Ondansetron Prescription for Home Use in a Pediatric Emergency Department.

OBJECTIVES: Ondansetron has been shown to decrease admission rate and the need for intravenous fluids among pediatric emergency department (ED) patients with acute gastroenteritis, but there is limited evidence regarding its use after ED discharge. This study describes prescribing patterns for ondansetron and assesses the effects of ondansetron home prescription on rate of return. METHODS: Data were gathered from the electronic health record on 2 separate but overlapping groups of patients seen in a pediatric ED from 2012 to 2014. The Gastroenteritis Group included all patients with a discharge diagnosis of gastroenteritis by International Classification of Diseases, Ninth Revision, code. The All Ondansetron Group included any child prescribed ondansetron at discharge. Patterns of ondansetron use and 3- and 7-day ED return rate were assessed for both groups. Discharge diagnosis was evaluated for the All Ondansetron Group. RESULTS: A total of 996 patients with acute gastroenteritis were identified during the study period. Of these, 76% received ondansetron in the ED, and 71% were discharged with prescriptions for ondansetron. Seven-day ED return rates were similar between groups (6% with prescription, 5% without, P = 0.66). A total of 2287 patients received home prescriptions for ondansetron. Fifty-four percent of these patients' discharge diagnoses were classed as gastrointestinal complaints, 14% other infectious conditions, 9% respiratory, and 4% injuries. Their return rate was 6%. There was wide variation in the number of doses prescribed. CONCLUSIONS: Home-use ondansetron is widely prescribed in this urban academic pediatric ED for a variety of indications, without effect on 3- or 7-day ED return. Further prospective studies are necessary to determine the efficacy of this practice.

A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients.

BACKGROUND: Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection. OBJECTIVE: Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate. METHODS: We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus. RESULTS: There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain. CONCLUSIONS: There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.

Use of a continual sweep motion to compare air polishing devices, powders and exposure time on unexposed root cementum.

Low abrasive air polishing powders are a viable method for subgingival biofilm removal. This in vitro study evaluated the effects of air polishing using a standard tip on cementum following clinically recommended protocols. Forty-eight teeth were randomly divided into eight groups with six teeth per group. Teeth were treated using either a Hu-Friedy EMS or DENTSPLY Cavitron® air polishing device. One of three glycine powders (Air-flow 25 µm, Clinpro 45 µm, Clinpro+TCP 45 µm) or a sodium bicarbonate powder (NaHCO3  85 µm) was sprayed on cementum using a clinically relevant sweeping motion. Volume and depth of cementum removed after 5 and 90 s exposures were calculated. Surface texture was evaluated using SEMs taken following the last exposure. After 5 s exposures, neither unit nor powder had a substantial effect on volume loss or defect depth. After 90 s exposures, differences between powders existed only for the DENTSPLY unit (p < 0.0001). Pairwise comparisons for this unit revealed mean volume loss and maximum defect depth were greater for NaHCO3 85 µm than the glycine powders (p < 0.0001). The 90 s exposure produced greater mean volume loss and defect depth for all powders (p < 0.0001). SEM images revealed dentinal tubule exposure with all powders; however, exposed tubules were larger and more prevalent for NaHCO3 85 µm. Root surface loss was similar for glycine powders evaluated in this study. Differences in powder performance between units may be related to tip apertures and spray patterns. Additional research is needed to determine if cementum loss is greater than what occurs with conventional biofilm removal methods, such as curets and ultrasonic scalers.

The novel LESS (low-cost entrainment syringe system) O2 blender for use in modified bubble CPAP circuits: a clinical study of safety.

Background: Bubble continuous positive airway pressure (bCPAP) is used in resource-limited settings for children with respiratory distress. Low-cost modifications of bCPAP use 100% oxygen and may cause morbidity from oxygen toxicity. We sought to test a novel constructible low-cost entrainment syringe system (LESS) oxygen blender with low-cost modified bCPAP in a relevant clinical setting. Methods: We conducted a clinical trial evaluating safety of the LESS O2 blender among hospitalized children under five years old in rural Cambodia evaluating the rate of clinical failure within one hour of initiation of the LESS O2 blender and monitoring for any other blender-related complications. Findings: Thirty-two patients were included. The primary outcome (clinical failure) occurred in one patient (3.1%, 95% CI = 0.1-16.2%). Clinical failure was defined as intubation, death, transfer to another hospital, or two of the following: oxygen saturation <85% after 30 min of treatment; new signs of respiratory distress; or partial pressure of carbon dioxide ≥60 mmHg and pH <7.2 on a capillary blood gas. Secondary outcomes included average generated FiO2's with blender use, which were 59% and 52% when a 5 mm entrainment was used vs. a 10 mm entrainment port with 5-7 cm H2O of CPAP and 1-7 L/min (LPM) of flow; and adverse events including loss of CPAP bubbling (64% of all adverse events), frequency of repair or adjustment (44%), replacement (25%), and median time of respiratory support (44 h). Interpretation: Overall the LESS O2 blender was safe for clinical use. The design could be modified for improved performance including less repair needs and improved nasal interface, which requires modification for the blender to function more consistently.

Matrix metalloproteinase-9 expression in alveolar extraction sockets of Zoledronic acid-treated rats.

PURPOSE: The use of nitrogen-containing bisphosphonates (n-bis) is associated with necrosis of the jaws, also known as bisphosphonate-related osteonecrosis of the jaws (BRONJ); however, the pathophysiology is unknown. Matrix metalloproteinase-9 (MMP-9) expression is essential for normal bone healing and is also required for angiogenesis. N-bis alters MMP-9 expression in vitro and in vivo; therefore, we hypothesized that n-bis alters MMP-9 expression during oral wound healing after tooth extraction. MATERIALS AND METHODS: A total accumulated dose of 2.25 mg/kg (n = 20) of Zoledronic acid (ZA) Zometa or saline (control, n = 20) was administered to Sprague-Dawley male rats. Next, both groups had maxillary molar teeth extracted. Rats were sacrificed at postoperative day 1, 3, 7, or 21. Western blotting or multiplex ELISA was used to evaluate proteins of interest. Real-time polymerase chain reaction was used to assess the relative quantities of target gene mRNA. MMP-9 enzymatic activity was assessed by zymography. RESULTS: The ZA group showed a statistically significant reduction in bone mineralization rate 21 days after tooth extraction compared with the control group (Student t test, P = .005). Moreover, ZA-treated animals showed a statistically significant increase in MMP-9-specific mRNA at postoperative days 3 (P = .003), 7 (P < .0001), and 21 (P < .0001) and protein on postoperative days 3 (P = .005) and 7 (P < .0001). MMP-9 enzymatic activity was also increased in ZA-treated rats compared with control animals (Student t test, P = .014). We also evaluated the extraction sockets for the presence of tissue inhibitor of MMP-1 (TIMP1), which is an inhibitor of MMP-9 enzymatic activity. TIMP1-specific mRNA and protein were not significantly altered by ZA treatment at the times tested (P > .05). Receptor of NF-κB ligand (RANKL) is known to regulate the expression of MMP-9; we therefore assessed the RANKL expression in our experimental oral wound-healing model. The ZA-treated animals had significantly increased RANKL mRNA at postoperative days 3 (P = .02) and 21 (P = .004), while the protein expression was significantly increased at postoperative days 1 (P < .0001), 7 (P = .02), and 21 (P = .03) compared with the control group. CONCLUSIONS: ZA reduced bone mineralization within tooth extraction sockets, suggesting aberrant bone healing. ZA increases the amount and enzymatic activity of MMP-9, while apparently not altering the amount of TIMP1 within extraction sockets. RANKL is increased in ZA-treated rats, which suggests that increased MMP-9 expression is due, in part, to augmented RANKL expression.

Efficacy of a Prototype Solution to Facilitate the Removal of Supragingival Dental Calculus: A proof of concept study.

Purpose: The purpose of this study was to determine whether the adjunctive use of an experimental calculus disruption solution (EXP-955), combined with the exclusive use of hand instruments, decreases the amount of time required to remove supragingival dental calculus deposits.Methods: A single-site, randomized, split-mouth clinical trial was conducted to compare the time needed to remove supragingival dental calculus on deposits pretreated with an experimental calculus disruption solution vs. calculus deposits that were not pretreated. Quadrants were randomized to either the treatment or control group and the principal investigator (PI) was timed while using hand instruments to remove the calculus. At the end of each session, both the subjects and the PI completed a questionnaire assessing their perceptions regarding the various aspects of the appointment and the solution. Descriptive statistics were used to analyze the data. Recurring themes from the questionnaire were examined.Results: Twenty-five healthy subjects, each having two quadrants matched for number of teeth and level of calculus deposits, completed the study (n=25). A statistically significant difference was found in in the supragingival calculus removal times between the control, (M=12.5 minutes; SD=6.0), and the treatment, (M=9.7; SD=4.6), quadrants; Mean difference (95% CI) = 2.8 (1.8-3.7), p<0.0001. Thematic analysis of the questionnaire responses showed that the perceptions of the principal investigator and subjects were positive towards the use of the solution with less pain being a common participant comment. The experimental calculus disruption solution was well tolerated by all subjects.Conclusions: Results from this proof of concept study provide preliminary evidence that use of an experimental calculus disruption solution (EXP-955) reduced the time needed to remove supragingival calculus while using hand instrumentation.

Prescribing Video-Based Patient Education in the Hospital Setting: Can Bedside Breastfeeding Videos Affect Exclusive Breastfeeding at Postpartum Discharge?

BACKGROUND AND OBJECTIVES: Evaluate the impact of a standardized bundle of educational videos delivered via the bedside television to postpartum mothers on exclusive breastfeeding rates. Despite the growing use of videos for hospital discharge education, there is a paucity of literature evaluating their effectiveness. METHODS: In November 2015, we began ordering 4 externally produced, peer-reviewed breastfeeding education videos for all postpartum mothers to view via their bedside televisions. Mothers could choose whether to watch the videos, and if they did, this was automatically documented in the electronic health record. We then performed a retrospective chart review generating a data set focusing on newborns who were healthy, term, and appropriate for gestational age, born in the year pre- and postintervention, and compared exclusive breastfeeding rates at the time of discharge among both groups. RESULTS: Our data set included 3115 newborns (1467 pre- and 1648 postintervention). In the postintervention year, the exclusive breastfeeding rate at discharge was 69.5% vs 68.4% preintervention (P value: .80). Most mothers (81.3%; 1339) watched all 4 videos, and 308 mothers (18.7%) watched none. The mothers who watched all 4 videos were more likely to breastfeed exclusively (72.7% vs 55.3%) and less likely to exclusively formula feed than the mothers who watched none (1.1% vs 19.8%; P < .0001). CONCLUSIONS: There was no change in exclusive breastfeeding rates pre- versus post-video education intervention. However, most mothers watched all 4 videos, and those who did were significantly more likely to engage in any breastfeeding (98.9%) compared with those who watched none (80.2%) during the postpartum hospitalization.

The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication.

Optimizing information sharing at transfer of care between teams is an important target for the improvement of patient safety. Traditional emergency department (ED)-to-floor handoffs do not support a shared mental model between physicians, residents, and nurses. This report describes and evaluates acceptance of a novel process for coordinating physician and nursing handoff calls for patients being admitted to an inpatient floor from a children's hospital ED. METHODS: The Admission Conference Call (ACC) is a single conference call including attendings, residents, and nurses from the ED and inpatient teams, currently used for 29.8% of admissions from one ED. Physicians and nurses were surveyed to assess perception of its effects on patient care. RESULTS: A total of 653 ACCs were conducted during 2017. The survey was completed by 43 nurses and 89 physicians. Mean Likert scale findings were in favor of the process supporting safe patient care (4.5/5; standard deviation [SD], 0.6); none said it increased risk. Ratings favored the process improving interdisciplinary alignment (4.0/5; SD, 0.8) and the benefits outweighing the inconvenience (3.9/5; SD, 0.9). Respondents were neutral on the effect of the ACC on throughput time (3.0/5; SD, 1.0). Logistical concerns were expressed; mean satisfaction was 6.8/10 (SD, 2.1). Free text comments varied widely, from pride to frustration. CONCLUSION: The Admission Conference Call is a well-accepted alternative to a traditional multiple call process. Most participants believe it supports safe patient care. Further research is necessary to confirm measurable effects on patient outcomes, but this project provides encouragement to institutions considering innovative approaches.

Choosing the perfect shot - The loaded narrative of imagery in online news coverage of vaccines.

Images in health communication have been shown to affect perspectives and attitudes towards health issues including vaccination. We seek to quantify the frequency of images used in online news coverage of vaccines that may convey varying sentiments about vaccination. To capture a breadth of vaccine-related news coverage, including international sources, we searched the following terms in Google News Archives: "autism and vaccine", "flu and vaccine", and "measles and Disneyland". We developed a coding tool that classified images as negative (eg, screaming child), positive (eg, happy child), neutral (eg, vaccine vial), or irrelevant (eg, picture of journalist). All images were coded independently by two researchers and discussed for consensus. We analyzed 734 images. Of the images which featured vaccines and/or a medical encounter (322), 28% had negative features and 30% had positive features. The remaining 137 images (43%) were neutral. There was no statistically significant difference between proportions of negative and positive imagery for each pair of search terms, which may be a reflection of random image selection. Ultimately, nearly one in eight images included in vaccine-related news coverage contains negative features which may be selected without careful consideration of the potential negative impact on public health initiatives regarding vaccination.

Effects of a Telehealth Care Coordination Intervention on Perceptions of Health Care by Caregivers of Children With Medical Complexity: A Randomized Controlled Trial.

INTRODUCTION: The purpose of this study was to evaluate the effect of advanced practice registered nurse (APRN) telehealth care coordination for children with medical complexity (CMC) on family caregiver perceptions of health care. METHOD: Families with CMC ages 2 to 15 years (N = 148) were enrolled in a three-armed, 30-month randomized controlled trial to test the effects of adding an APRN telehealth care coordination intervention to an existing specialized medical home for CMC. Satisfaction with health care was measured using items from the Consumer Assessment of Healthcare Providers and Systems survey at baseline and after 1 and 2 years. RESULTS: The intervention was associated with higher ratings on measures of the child's provider, provider communication, overall health care, and care coordination adequacy, compared with control subjects. Higher levels of condition complexity were associated with higher ratings of overall health care in some analyses. DISCUSSION: APRN telehealth care coordination for CMC was effective in improving ratings of caregiver experiences with health care and providers. Additional research with CMC is needed to determine which children benefit most from high-intensity care coordination.

Endoscopic vs. tactile evaluation of subgingival calculus.

PURPOSE: Endoscopic technology has been developed to facilitate imagery for use during diagnostic and therapeutic phases of periodontal care. The purpose of this study was to compare the level of subgingival calculus detection using a periodontal endoscope with that of conventional tactile explorer in periodontitis subjects. METHODS: A convenience sample of 26 subjects with moderate periodontitis in at least 2 quadrants was recruited from the University of Minnesota School of Dentistry to undergo quadrant scaling and root planing. One quadrant from each subject was randomized for tactile calculus detection alone and the other quadrant for tactile detection plus the Perioscope ™ (Perioscopy Inc., Oakland, Cali). A calculus index on a 0 to 3 score was performed at baseline and at 2 post-scaling and root planing visits. Sites where calculus was detected at visit 1 were retreated. T-tests were used to determine within-subject differences between Perioscope™ and tactile measures, and changes in measures between visits. RESULTS: Significantly more calculus was detected using the Perioscope™ vs. tactile explorer for all 3 subject visits (p<0.005). Mean changes (reduction) in calculus detection from baseline to visit 1 were statistically significant for both the Perioscope™ and tactile quadrants (p<0.0001). However, further reductions in calculus detection from visit 1 to visit 2 was only significant for the Perioscope™ quadrant (p<0.025), indicating that this methodology was able to more precisely detect calculus at this visit. CONCLUSION: It was concluded that the addition of a visual component to calculus detection via the Perioscope™ was most helpful in the re-evaluation phase of periodontal therapy.

Accumulation of VEGFR2 in zoledronic acid-treated endothelial cells.

Nitrogen-containing bisphosphonates (BIS) are potent inhibitors of bone resorption and are used in the treatment of a number of medical conditions, including multiple myeloma, breast cancer and osteoporosis. Recent experimental evidence demonstrates that BIS also affect endothelial cell functions and angiogenesis; however, the molecular mechanism(s) are unclear. Vascular endothelial growth factor (VEGF) is a potent pro-angiogenic signal for endothelial cells. BIS inhibit VEGF responses in endothelial cells. The VEGF receptor-2 (VEGFR2) is the main signaling receptor for VEGF in endothelial cells. We hypothesized that altered VEGFR2 expression in BIS-treated endothelial cells may account for these attenuated responses to VEGF. The affect of the BIS zoledronic acid (ZOL) was investigated in human umbilical vein endothelial cells using confocal microscopy, Western blotting, real-time PCR and flow cytometry. VEGFR2 accumulated within the ZOL-treated endothelial cells (p=0.0002), though not on the cell surface (p>0.05). ZOL did not induce VEGFR2-specific mRNA (p>0.05). ZOL inhibited endothelial cell chemotaxis towards VEGF (p=0.001). VEGF stimulation significantly reduced the amount of VEGFR2 in the endothelial cells (p=0.01). This response to VEGF was reduced by ZOL (p>0.05). The effects of ZOL on endothelial cell migration, VEGFR2 protein expression and response to VEGF were attenuated by geranylgeranyl pyrophosphate. Two- and one-way ANOVAs with Tukey or Dunnett's multiple comparison adjustments were used. The data suggest that ZOL induces aberrant VEGFR2 accumulation. This is not likely due to the induction of mRNA transcription, but rather to the disruption of the mevalonate pathway.