JoAnna K. Leyenaar

The role of cognitive deficits in the development of eating disorders.

Eating disorders (ED), including anorexia and bulimia nervosa, are chronic illnesses with periods of symptom exacerbation and remission. Because symptoms are usually present from 6 to 24 months before a diagnosis is made, aetiological agents are believed to be active well before symptoms appear. It is proposed that neuropsychological deficits in various cognitive domains preexist and underlie the aetiology of ED. This paper provides a comprehensive review of the literature relevant to neuropsychological deficits in ED patients and explores the relationship between cognitive deficits, psychosocial development, and the development of ED. Although the role of neuropsychological deficits in the evolution of ED requires further research, the proposed association has significant implications for clinical practice.

Early clinical outcomes in children enrolled in human immunodeficiency virus infection care and treatment in lesotho.

Background: Children are largely underrepresented among those accessing treatment of HIV infection in Africa. Reported outcomes of children enrolled in national care and treatment programs are needed to inform the widespread scale-up of pediatric HIV care in resource-limited settings. Methods: The objective of this article is to report on the early outcomes of a pediatric HIV infection care and treatment program in Lesotho during its first 14 months of operation. Clinical protocols are described, and characteristics and outcomes of the first cohort of children enrolled in care are reported, derived from a retrospective review of medical records. Results: In the programs first 14 months, 1566 children and adolescents aged between 0 and 16 years were evaluated for HIV, with 567 (36%) confirmed to be infected. Of infected patients, 61% presented with advanced or severe symptoms of HIV disease and 65% presented with CD4 profiles consistent with advanced or severe immunodeficiency, based on World Health Organization 2006 guidelines. Two hundred and eighty four children received highly active antiretroviral therapy. The mortality rate was 18.6 deaths per 100 patient years of follow-up. Ninety-nine percent of deaths occurred within 90 days of enrollment. Deceased patients were significantly younger, had higher rates of stunting and wasting, and were more likely to present with low CD4 cell counts. Conclusion: Highly active antiretroviral therapy was well tolerated, but the early mortality rate was high despite concurrent management of HIV and comorbidities. Given that hundreds of thousands of children remain without access to HIV care, renewed efforts are needed to reach this underserved population.

The reproductive performance of sows after PRRS vaccination depends on stage of gestation.

In order to minimize the effects of porcine reproductive and respiratory syndrome (PRRS) on stillbirth, mummification, and neonatal mortality in swine herds, many producers have vaccinated their herds using a modified-live virus vaccine. The purpose of this study was to determine the association of the PRRS modified-live vaccine and reproductive performance by stage of gestation when the vaccine was administered. A total of 47 swine herds from Ontario and Manitoba, Canada, and from the mid-western USA were included in the study. Participating farms had vaccinated all of their sows at one point in time when they used the vaccine for the first time. The reproductive performance of sows that farrowed in the year prior to use of the vaccine was compared to that of sows vaccinated in each of five stages of gestation and in the gestation that followed the initial use of the vaccine. Sows vaccinated at any time during gestation had a reduced number of pigs born alive, a reduced number of pigs weaned per litter, and increased number of stillborn pigs and an increased number of mummified pigs compared to the sows that farrowed prior to use of the vaccine. The largest association was seen in sows that were vaccinated in the last four weeks of gestation. The largest losses were observed in those herds that were vaccinated concurrently with the initial PRRS herd outbreak. These results suggest that the modified-live vaccine should only be administered to non-gestating sows.

Variation in Resource Utilization for the Management of Uncomplicated Community-Acquired Pneumonia across Community and Children's Hospitals

OBJECTIVE To describe patterns of diagnostic testing and antibiotic management of uncomplicated pneumonia in general community hospitals and childrens hospitals within hospitals and to determine the association between diagnostic testing and length of hospital stay. STUDY DESIGN We conducted a retrospective cohort study of children 1-17 years of age hospitalized with the diagnosis of pneumonia from 2007 to 2010 to hospitals contributing data to Perspective Database Warehouse, assessing patterns of diagnostic testing and antibiotic management. We constructed logistic regression models of log-transformed length of stay (LOS) and grouped treatment models to ascertain whether performance of blood cultures and viral respiratory testing were associated with LOS. RESULTS A total of 17 299 pneumonia cases occurred at 125 hospitals, with considerable variability in pneumonia management. Only 40 (0.2%) received ampicillin/penicillin G alone or in combination with other antibiotics, and 1318 (7.4%) received macrolide monotherapy as initial antibiotic management. Performance of blood culture and testing for respiratory viruses was associated with a statistically significant longer LOS, but these differences did not persist in grouped treatment models. CONCLUSIONS We observed greater rates of diagnostic testing in this cohort of structurally diverse hospitals than previously reported at freestanding childrens hospitals, with extremely low rates of narrow-spectrum antibiotic use. Tailored antibiotic stewardship initiatives at these hospitals are needed to achieve adherence to national guideline recommendations.

Variation and Outcomes Associated With Direct Hospital Admission Among Children With Pneumonia in the United States

IMPORTANCE Although the majority of children with an unplanned admission to the hospital are admitted through the emergency department (ED), direct admissions constitute a significant proportion of hospital admissions nationally. Despite this, past studies of children have not characterized direct admission practices or outcomes. Pneumonia is the leading cause of pediatric hospitalization in the United States, providing an ideal lens to examine variation and outcomes associated with direct admissions. OBJECTIVES To describe rates and patterns of direct admission in a large sample of US hospitals and to compare resource utilization and outcomes between children with pneumonia admitted directly to a hospital and those admitted from an ED. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of children 1 to 17 years of age with pneumonia who were admitted to hospitals contributing data to Perspective Data Warehouse. We developed hierarchical generalized linear models to examine associations between admission type and outcomes. MAIN OUTCOMES AND MEASURES Outcome measures included (1) length of stay, (2) high turnover hospitalization, (3) total hospital cost, (4) transfer to the intensive care unit, and (5) readmission within 30 days of hospital discharge. RESULTS A total of 19,736 children from 278 hospitals met eligibility criteria, including 7100 (36.0%) who were admitted directly and 12,636 (64.0%) through the ED. Rates of direct admission varied considerably across hospitals, with a median direct admission rate of 33.3% (interquartile range, 11.1%-50.0%). Children admitted directly were more likely to be white, to have private health insurance, and to be admitted to small, general community hospitals. In adjusted models, children admitted directly had a 9% higher length of stay (risk ratio, 1.09 [95% CI, 1.07-1.11]), 39% lower odds of high turnover hospitalization (odds ratio [OR], 0.61 [95% CI, 0.56-0.66]), and 12% lower cost (risk ratio, 0.88 [95% CI, 0.87-0.90]) than those admitted through the ED, with no significant differences in transfers to the intensive care unit (OR, 1.29 [95% CI, 0.83-2.00]) or 30-day readmissions (OR, 0.80 [95% CI, 0.57-1.13]). CONCLUSIONS AND RELEVANCE Increasing rates of direct admission among children with access to outpatient care might be an effective strategy to reduce hospital costs and the volume of patients in the ED. Additional research is needed to establish direct admission policies and procedures that are safe and cost-effective.

Pediatric discharge content: a multisite assessment of physician preferences and experiences.

BACKGROUND AND OBJECTIVES Professional medical societies endorse prompt, consistent discharge communication to primary care providers (PCPs) on discharge. However, evidence is limited about what clinical elements to communicate. Our main goal was to identify and compare the clinical elements considered by PCPs and pediatric hospitalists to be essential to communicate to PCPs within 2 days of pediatric hospital discharge. A secondary goal was to describe experiences of the PCPs and pediatric hospitalists regarding sending and receiving discharge information. METHODS A survey of physician preferences and experiences regarding discharge communication was sent to 320 PCPs who refer patients to 16 hospitals, with an analogous survey sent to 147 hospitalists. Descriptive statistics were calculated, and χ² analyses were performed. RESULTS A total of 201 PCPs (63%) and 71 hospitalists (48%) responded to the survey. Seven clinical elements were reported as essential by >75% of both PCPs and hospitalists: dates of admission and discharge; discharge diagnoses; brief hospital course; discharge medications; immunizations given during hospitalization; pending laboratory or test results; and follow-up appointments. PCPs reported reliably receiving discharge communication significantly less often than hospitalists reported sending it (71.8% vs 85.1%; P < .01), and PCPs considered this communication to be complete significantly less often than hospitalists did (64.9% vs 79.1%; P < .01). CONCLUSIONS We identified 7 core clinical elements that PCPs and hospitalists consider essential in discharge communication. Consistently and promptly communicating at least these core elements after discharge may enhance PCP satisfaction and patient-level outcomes. Reported rates of transmission and receipt of this information were suboptimal and should be targeted for improvement.

Comparative Effectiveness of Ceftriaxone in Combination With a Macrolide Compared With Ceftriaxone Alone for Pediatric Patients Hospitalized With Community-acquired Pneumonia

Background: Guidelines for management of community-acquired pneumonia recommend empiric therapy with a macrolide and beta-lactam when infection with Mycoplasma pneumoniae is a significant consideration. Evidence to support this recommendation is limited. We sought to determine the effectiveness of ceftriaxone alone compared with ceftriaxone combined with a macrolide with respect to length of stay and total hospital costs. Methods: We conducted a retrospective cohort study of children 1–17 years with pneumonia, using Poisson regression and propensity score analyses to assess associations between antibiotic and length of stay. Multivariable linear regression and propensity score analyses were used to assess log-treatment costs, adjusting for patient and hospital characteristics and initial tests and therapies. Results: A total of 4701 children received combination therapy and 8892 received ceftriaxone alone. Among children 1–4 years of age, adjusted models revealed no significant difference in length of stay, with significantly higher costs in the combination therapy group [cost ratio: 1.08 (95% confidence interval: 1.05–1.11)]. Among children 5–17 years of age, children receiving combination therapy had a shorter length of stay [relative risk: 0.95 (95% confidence interval: 0.92–0.98)], with no significant difference in costs [cost ratio: 1.01 (95% confidence interval: 0.98–1.04)]. Conclusions: Combination therapy did not appear to benefit preschool children but was associated with higher costs. Among school-aged children, combination therapy was associated with a shorter length of stay without a significant impact on cost. Development of sensitive point-of-care diagnostic tests to identify children with M. pneumoniae infection may allow for more focused prescription of macrolides and enable comparative effectiveness studies of targeted provision of combination therapy.

Quality measures to assess care transitions for hospitalized children

BACKGROUND: Transitions between sites of care are inherent to all hospitalizations, yet we lack pediatric-specific transitions-of-care quality measures. We describe the development and validation of new transitions-of-care quality measures obtained from medical record data. METHODS: After an evidence review, a multistakeholder panel prioritized quality measures by using the RAND/University of California, Los Angeles modified Delphi method. Three measures were endorsed, operationalized, and field-tested at 3 children’s hospitals and 2 community hospitals: quality of hospital-to-home transition record content, timeliness of discharge communication between inpatient and outpatient providers, and ICU-to-floor transition note quality. Summary scores were calculated on a scale from 0 to 100; higher scores indicated better quality. We examined between-hospital variation in scores, associations of hospital-to-home transition quality scores with readmission and emergency department return visit rates, and associations of ICU-to-floor transition quality scores with ICU readmission and length of stay. RESULTS: A total of 927 charts from 5 hospitals were reviewed. Mean quality scores were 65.5 (SD 18.1) for the hospital-to-home transition record measure, 33.3 (SD 47.1) for the discharge communication measure, and 64.9 (SD 47.1) for the ICU-to-floor transition measure. The mean adjusted hospital-to-home transition summary score was 61.2 (SD 17.1), with significant variation in scores between hospitals (P < .001). Hospital-to-home transition quality scores were not associated with readmissions or emergency department return visits. ICU-to-floor transition note quality scores were not associated with ICU readmissions or hospital length of stay. CONCLUSIONS: These quality measures were feasible to implement in diverse settings and varied across hospitals. The development of these measures is an important step toward standardized evaluation of the quality of pediatric transitional care.

Epidemiology of Bacteremia in Previously Healthy Febrile Infants: A Follow-up Study

OBJECTIVE Describe the etiology of bacteremia among a geographically diverse sample of previously well infants with fever admitted for general pediatric care and to characterize demographic and clinical characteristics of infants with bacteremia according to bacterial etiology. We hypothesized that the epidemiology of bacteremia in febrile infants from a geographically diverse cohort would show similar results to smaller or single-center cohorts previously reported. METHODS This was a retrospective review of positive, pathogenic blood cultures in previously healthy, febrile infants≤90 days old admitted to a general unit. In total, there were 17 participating sites from diverse geographic regions of the United States. Cultures were included if the results were positive for bacteria, obtained from an infant 90 days old or younger with a temperature≥38.0°C, analyzed using an automated detection system, and treated as pathogenic. RESULTS Escherichia coli was the most prevalent species, followed by group B Streptococcus, Streptococcus viridans, and Staphylococcus aureus. Among the most prevalent bacteria, there was no association between gender and species (Ps>.05). Age at presentation was associated only with Streptococcus pneumoniae. There were no cases of Listeria monocytogenes. CONCLUSIONS Our study confirms the data from smaller or single-center studies and suggests that the management of febrile well-appearing infants should change to reflect the current epidemiology of bacteremia. Further research is needed into the role of lumbar puncture, as well as the role of Listeria and Enterococcus species in infantile bacteremia.

Families' Priorities Regarding Hospital-to-Home Transitions for Children With Medical Complexity.

BACKGROUND: National health care policy recommends that patients and families be actively involved in discharge planning. Although children with medical complexity (CMC) account for more than half of pediatric readmissions, scalable, family-centered methods to effectively engage families of CMC in discharge planning are lacking. We aimed to systematically examine the scope of preferences, priorities, and goals of parents of CMC regarding planning for hospital-to-home transitions and to ascertain health care providers’ perceptions of families’ transitional care goals and needs. METHODS: We conducted semistructured interviews with parents and health care providers at a tertiary care hospital. Interviews were continued until thematic saturation was reached. Interviews were audio recorded, transcribed verbatim, and analyzed to identify emergent themes via a general inductive approach. RESULTS: Thirty-nine in-depth interviews were conducted, including 23 with family caregivers of CMC and 16 with health care providers. Families’ priorities, preferences, and goals for hospital-to-home transitions aligned with 7 domains: effective engagement with health care providers, respect for families’ discharge readiness, care coordination, timely and efficient discharge processes, pain and symptom control, self-efficacy to support recovery and ongoing child development, and normalization and routine. These domains also emerged in interviews with health care providers, although there were minor differences in themes discussed. CONCLUSIONS: Although CMC have diverse transitional care needs, their families’ priorities, preferences, and goals aligned with 7 domains that bridged their hospital admission with reestablishment of a home routine. This research provides essential foundational data to engage families in discharge planning, guiding the operationalization of national health policy recommendations.