The primary aim of this study was to reduce duration of continuous albuterol and hospital length of stay in critically ill children with severe status asthmaticus.
Observational prospective study ...from September 2012 to May 2016.
Medicine ICU and intermediate care unit.
Children greater than 2 years old with admission diagnosis of status asthmaticus admitted on continuous albuterol and managed via a standardized protocol.
The protocol was an iterative algorithm for escalation and weaning of therapy. The algorithm underwent three revisions. Iteration 1 concentrated on reducing duration on continuous albuterol; iteration 2 concentrated on reducing hospital length of stay; and iteration 3 concentrated on reducing helium-oxygen delivered continuous albuterol. Balancing measures included adverse events and readmissions.
Three-hundred eighty-five patients were treated as follows: 123, 138, and 124 in iterations 1, 2, and 3, respectively. Baseline data was gathered from an additional 150 patients prior to protocol implementation. There was no difference in median age (6 vs 8 vs 7 vs 7 yr; p = 0.130), asthma severity score (9 vs 9 vs 9 vs 9; p = 0.073), or female gender (42% vs 41% vs 43% vs 48%; p = 0.757). Using statistical process control charts, the mean duration on continuous albuterol decreased from 24.9 to 17.5 hours and the mean hospital length of stay decreased from 76 to 49 hours. There was no difference in adverse events (0% vs 1% vs 4% vs 0%; p = 0.054) nor in readmissions (0% vs 0% vs 1% vs 2%; p = 0.254).
Implementation of a quality improvement protocol in critically ill patients with status asthmaticus was associated with a decrease in continuous albuterol duration and hospital length of stay.
Background: Frontline healthcare safety leaders require expertise and confidence to manage local safety programs effectively yet are confronted with substantial challenges in identifying risk and ...reducing harm. Methods: We convened a multidisciplinary safety learning collaborative in a children’s hospital pediatric department and used the Institute for Healthcare Improvement’s Breakthrough Series model. Participants attended four virtual education sessions over 13 months (September 2020–September 2021) focused on identifying harm and using tools to improve safety. We analyzed departmental safety data monthly throughout the collaborative. The primary outcome was the development of improvement projects using direct application of the session content. The secondary outcome was participant confidence in improving safety via pre- and postsurveys. Results: Seventy clinicians and quality consultants participated. Fifteen divisional safety improvement projects were initiated. The percentage of survey respondents who reported feeling “completely confident” in their ability to improve safety increased from 26% (n = 39) to 58% (n = 26) from September 2020 to September 2021 ( P = 0.01) and maintained at 65% 1 year after the end of the collaborative. We observed a decrease in the mean rate of reported inpatient preventable and possibly preventable moderate/serious/catastrophic events per 1000 bedded days from 1.10 (baseline) to 0.71 (intervention period). Conclusions: Through a collaborative effort in a virtual learning environment, we facilitated the development of fifteen safety projects, increased leaders’ confidence in improving safety, and saw improved inpatient safety. This approach, which involves healthcare professionals from various disciplines, may be effectively adapted to other settings.
Oral food challenges (OFCs) are routinely used to confirm ongoing food allergy. Serum-specific IgE (sIgE) and skin prick testing (SPT) are imperfect predictors of which patients will pass OFCs.
The ...objective of this study was to describe the design and implementation of a Standardized Clinical Assessment and Management Plan (SCAMP) to study and iteratively improve sIgE and SPT thresholds to determine when and where to conduct OFCs for patients.
Allergists consulted recommended sIgE and SPT thresholds when ordering challenges although diversions were permitted. Criteria were iteratively improved after periodic analyses of challenge outcome and diversions.
Over 3 years, allergists ordered 2368 food challenges for 1580 patients with histories of IgE-mediated reactions to food: 1386 in an outpatient clinic and 945 in a higher resource infusion center. Reactions to challenge were observed in 13% of clinic and 23% of infusion center challenges. Six patients challenged in clinic required treatment with epinephrine compared with 22 in the infusion center. The need for epinephrine was more common in patients with asthma-5% of asthmatic patients required epinephrine compared with 1% of nonasthmatic patients (P < .01). Recommended sIgE and SPT thresholds were incrementally changed and, using the control chart methodology, a significant decrease was noted in the proportion of challenges ordered in the higher resource location.
By setting and continually refining sIgE and SPT recommendations using the SCAMP method, allergists can better determine the risk of severe reaction and triage patients to the appropriate setting for an OFC.
Conclusions By setting and continually refining ssIgE and skin prick test recommendations using the SCAMP method, allergists can better determine the risk of severe reactions and triage patients to ...the appropriate resource setting for an OFC.
Background Asthma is an inflammatory disease of the airways that can lead to impaired arterial blood oxygenation during exercise. Objective We asked whether treatment of airway inflammation in ...asthmatic subjects would improve arterial blood gases during whole-body exercise. Methods By using a double-blind parallel-group design, 19 asthmatic subjects completed treadmill exercise to exhaustion on 2 occasions: (1) before and (2) after 6 weeks' treatment with an inhaled corticosteroid (ICS; n = 9) or placebo (n = 10). Results The ICS group had improved resting pulmonary function, decreased exercise-induced bronchospasm, and decreased postexercise sputum histamine during the posttreatment study compared with that during the pretreatment study. In the ICS group exercise Pa o2 was significantly increased after treatment (84.8 to 93.8 mm Hg). Increased alveolar ventilation (arterial P co2 decreased from 36.9 to 34.1 mm Hg) accounted for 37% of the increased Pa o2 and improved gas exchange efficiency (alveolar-to-arterial P o2 difference decreased from 22.5 to 16.3 mm Hg) accounted for the remaining 63% of the increased Pa o2 after treatment. In the ICS group exercise time to exhaustion was increased from 9.9 minutes during the pretreatment study to 14.8 minutes during the posttreatment study. Conclusion Treatment of airway inflammation in asthmatic subjects can improve arterial blood oxygenation during exercise by (1) improving airway function, thereby allowing increased alveolar ventilation during exercise, and (2) improving the efficiency of alveolar-to-arterial blood O2 exchange. Clinical implications In asthmatic patients ICSs not only attenuate exercise-induced bronchospasm but also improve arterial blood oxygenation during exercise.
ABSTRACT In the summer of 2012, during a Pulsar Search Collaboratory workshop, two high-school students discovered J1930-1852, a pulsar in a double neutron star (DNS) system. Most DNS systems are ...characterized by short orbital periods, rapid spin periods, and eccentric orbits. However, J1930-1852 has the longest spin period ( 185 ms) and orbital period ( 45 days) yet measured among known, recycled pulsars in DNS systems, implying a shorter than average and/or inefficient recycling period before its companion went supernova. We measure the relativistic advance of periastron for J1930-1852, (4) deg yr−1, which implies a total mass ( (4) ) consistent with other DNS systems. The constraints on place limits on the pulsar and companion masses ( and respectively). J1930-1852's spin and orbital parameters challenge current DNS population models and make J1930-1852 an important system for further investigation.
We observed the Ultraluminous X-ray Source (ULX) IC 342 X-1 simultaneously in X-ray and radio with Chandra and the JVLA to investigate previously reported unresolved radio emission coincident with ...the ULX. The Chandra data reveal a spectrum that is much softer than observed previously and is well modelled by a thermal accretion disc spectrum. No significant radio emission above the rms noise level was observed within the region of the ULX, consistent with the interpretation as a thermal state though other states cannot be entirely ruled out with the current data. We estimate the mass of the black hole using the modelled inner disc temperature to be
$30 \,\mathrm{M_{{\odot }}} \lesssim M\sqrt{\mathrm{cos}i}\lesssim 200 \,\mathrm{M_{{\odot }}}$
based on a Shakura–Sunyaev disc model. Through a study of the hardness and high-energy curvature of available X-ray observations, we find that the accretion state of X-1 is not determined by luminosity alone.
The evidence base for the optimal laboratory diagnosis of
(
)
in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic ...review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of
The systematic review and meta-analysis included eligible studies (those that had PICO population, intervention, comparison, outcome elements) that assessed the diagnostic accuracy of NAAT alone or following glutamate dehydrogenase (GDH) enzyme immunoassays (EIAs) or GDH EIAs plus
toxin EIAs (toxin). The diagnostic yield of NAAT for repeat testing after an initial negative result was also assessed. Two hundred thirty-eight studies met inclusion criteria. Seventy-two of these studies had sufficient data for meta-analysis. The strength of evidence ranged from high to insufficient. The uses of NAAT only, GDH-positive EIA followed by NAAT, and GDH-positive/toxin-negative EIA followed by NAAT are all recommended as American Society for Microbiology (ASM) best practices for the detection of the
toxin gene or organism. Meta-analysis of published evidence supports the use of testing algorithms that use NAAT alone or in combination with GDH or GDH plus toxin EIA to detect the presence of
in adults. There is insufficient evidence to recommend against repeat testing of the sample using NAAT after an initial negative result due to a lack of evidence of harm (i.e., financial, length of stay, or delay of treatment) as specified by the Laboratory Medicine Best Practices (LMBP) systematic review method in making such an assessment. Findings from this systematic review provide clarity to diagnostic testing strategies and highlight gaps, such as low numbers of GDH/toxin/PCR studies, in existing evidence on diagnostic performance, which can be used to guide future clinical research studies.
The European HIV Drug Resistance Guidelines Panel, established to make recommendations to clinicians and virologists, felt that sufficient new information has become available to warrant an update of ...its recommendations, explained in both pocket guidelines and this full paper. The Panel makes the following recommendations concerning the indications for resistance testing: for HIV-1 (i) test earliest sample for protease and reverse transcriptase drug resistance in drug-naive patients with acute or chronic infection; (ii) test protease and reverse transcriptase drug resistance at virologic failure, and other drug targets (integrase and envelope) if such drugs were part of the failing regimen; (iii) consider testing for CCR5 tropism at virologic failure or when a change of therapy has to be made in absence of detectable viral load, and in the latter case test DNA or last detectable plasma RNA; (iv) consider testing earliest detectable plasma RNA when a successful nonnucleoside reverse transcriptase inhibitor-containing therapy was inappropriately interrupted; (v) genotype source patient when postexposure prophylaxis is considered; for HIV-2, (vi) consider resistance testing where treatment change is needed after treatment failure. The Panel recommends genotyping in most situations, using updated and clinically evaluated interpretation systems. It is mandatory that laboratories performing HIV resistance tests take part regularly in external quality assurance programs, and that they consider storing samples in situations where resistance testing cannot be performed as recommended. Similarly, it is necessary that HIV clinicians and virologists take part in continuous education and discuss problematic clinical cases. Indeed, resistance test results should be used in the context of all other clinically relevant information for predicting therapy response.
PDF
