Miranda C. Bradford

Resilience and psychosocial outcomes in parents of children with cancer

The psychosocial function of parents of children with cancer can impact the well‐being of the entire family. Resilience resources are likely related to psychosocial outcomes and may be amenable to intervention. We hypothesized that parents with lower resources would report worse outcomes.

Molecular epidemiology of human rhinovirus infections in the pediatric emergency department.

Abstract Background Human rhinovirus (HRV) infections are highly prevalent, genetically diverse, and associated with both mild upper respiratory tract and more severe lower tract illnesses (LRTI). Objective To characterize the molecular epidemiology of HRV infections in young children seeking acute medical care. Study design Nasal swabs collected from symptomatic children <3 years of age receiving care in the Emergency and Urgent Care Departments at Seattle Childrens Hospital were analyzed by a rapid polymerase chain reaction (PCR) system (FilmArray®) for multiple viruses including HRV/enterovirus. HRV-positive results were confirmed by laboratory-developed real-time reverse transcription PCR (LD-PCR). Clinical data were collected by chart review. A subset of samples was selected for sequencing using the 5′ noncoding region. Associations between LRTI and HRV species and genotypes were estimated using logistic regression analysis. Results Of 595 samples with HRV/enterovirus detected by FilmArray, 474 (80%) were confirmed as HRV by LD-PCR. 211 (96%) of 218 selected samples were sequenced; HRV species A, B, and C were identified in 133 (63%), 6 (3%), and 72 (34%), respectively. LRTI was more common in HRV-C than HRV-A illness episodes (adjusted OR [95% CI] 2.35[1.03–5.35). Specific HRV-A and HRV-C genotypes detected in multiple patients were associated with a greater proportion of LRTI episodes. In 18 patients with >1 HRV-positive illness episodes, a distinct genotype was detected in each. Conclusion Diverse HRV genotypes circulated among symptomatic children during the study period. We found an association between HRV-C infections and LRTI in this patient population and evidence of association between specific HRV genotypes and LRTI.

Adolescent and Young Adult Patient Engagement and Participation in Survey-Based Research: A Report From the "Resilience in Adolescents and Young Adults With Cancer" Study.

Conducting patient‐reported outcomes research with adolescents and young adults (AYAs) is difficult due to low participation rates and high attrition. Forty‐seven AYAs with newly diagnosed cancer at two large hospitals were prospectively surveyed at the time of diagnosis and 3–6 and 12–18 months later. A subset participated in 1:1 semistructured interviews. Attrition prompted early study closure at one site. The majority of patients preferred paper–pencil to online surveys. Interview participants were more likely to complete surveys (e.g., 93% vs. 58% completion of 3–6 month surveys, P = 0.02). Engaging patients through qualitative methodologies and using patient‐preferred instruments may optimize future research success.

Prevalence and outcomes of renal transplantation in children with intellectual disability.

To describe the prevalence and outcomes of renal transplantation in children with ID we performed a retrospective cohort analysis of all children receiving a first kidney‐alone transplant in the UNOS dataset from 2008 to 2011. Recipients with definite, probable, and without ID were compared using chi‐square tests. Kaplan–Meier curves were constructed for patient and graft survival. Cox proportional hazard models were used to estimate the association between ID and graft failure and patient survival. Over the study period, 332 children with definite (117) or probable (215) ID underwent first renal transplant, accounting for 16% of all first pediatric renal transplants (n = 2076). Children with definite ID were not significantly different from children without ID with respect to sex, ethnicity, or prevalence of acute rejection. ID was associated with increased likelihood of deceased donor source. ID was not significantly associated with decreased graft or patient survival. In this first large‐scale study, up to 16% of first pediatric renal transplants were performed in children with ID. Short‐term graft and patient survival after transplant were equivalent between children with and without ID. Further research is needed to examine long‐term outcomes of transplant in this population.

Reducing Head CT Use for Children With Head Injuries in a Community Emergency Department

This QI initiative significantly reduced the rate of unnecessary head CTs obtained in a community ED for pediatric patients with head injuries. BACKGROUND AND OBJECTIVE: Clinical decision rules have reduced use of computed tomography (CT) to evaluate minor pediatric head injury in pediatric emergency departments (EDs). CT use remains high in community EDs, where the majority of children seek medical care. We sought to reduce the rate of CT scans used to evaluate pediatric head injury from 29% to 20% in a community ED. METHODS: We evaluated a quality improvement (QI) project in a community ED aimed at decreasing the use of head CT scans in children by implementing a validated head trauma prediction rule for traumatic brain injury. A multidisciplinary team identified key drivers of CT use and implemented decision aids to improve the use of prediction rules. The team identified and mitigated barriers. An affiliated children’s hospital offered Maintenance of Certification credit and QI coaching to participants. We used statistical process control charts to evaluate the effect of the intervention on monthly CT scan rates and performed a Wald test of equivalence to compare preintervention and postintervention CT scan proportions. RESULTS: The baseline period (February 2013–July 2014) included 695 patients with a CT scan rate of 29.2% (95% confidence interval, 25.8%–32.6%). The postintervention period (August 2014–October 2015) included 651 patients with a CT scan rate of 17.4% (95% confidence interval, 14.5%–20.2%, P < .01). Barriers included targeting providers with variable pediatric experience and parental imaging expectations. CONCLUSIONS: We demonstrate that a Maintenance of Certification QI project sponsored by a children’s hospital can facilitate evidence-based pediatric care and decrease the rate of unnecessary CT use in a community setting.

Parental vaccine hesitancy and acceptance of seasonal influenza vaccine in the pediatric emergency department

BACKGROUND Providing influenza vaccine to patients in the pediatric emergency department (PED) is one strategy to increase childhood influenza vaccine uptake. The Parent Attitudes about Childhood Vaccines (PACV) survey is a new tool to identify vaccine-hesitant parents that may facilitate influenza vaccine uptake in the PED. OBJECTIVE To assess the feasibility of administering the PACV modified for influenza vaccination in the PED setting and to determine whether parental PACV scores are associated with patient receipt of influenza vaccine in the PED. METHODS We conducted a cross-sectional study in the PED of a tertiary pediatric hospital in Seattle, WA during the 2013-2014 influenza season. English-speaking parents of children aged 6 months to 7 years who were afebrile, medically stable to be discharged home from the PED, and had not already received an influenza vaccine this season were administered a modified version of the PACV. PACV scores (0-100, higher score=higher hesitancy) were dichotomized (<50 and ≥50) consistent with previous validation studies. Feasibility was assessed by determining time to complete the PACV. Our primary outcome was influenza vaccine refusal in the PED. We used multivariable logistic regression to estimate unadjusted and adjusted odds ratios for association between vaccine refusal and dichotomized PACV scores. RESULTS 152 parent participants were included in the analysis. The median time for administering the PACV was 7 min. The median PACV score was 28, with 74% scoring <50. Parents who scored ≥50 on the PACV had increased odds of refusing the influenza vaccine compared to parents who scored <50 (adjusted OR [95% CI]: 6.58 [2.03-21.38]). CONCLUSION Administration of the PACV in the PED is feasible, and higher PACV scores in this setting are associated with increased influenza vaccine refusal.

Rhinovirus Disease in Children Seeking Care in a Tertiary Pediatric Emergency Department

BACKGROUND Rhinovirus is the most common cause of viral respiratory tract infections in children. Virologic predictors of lower respiratory tract infection (LRTI), such as viral load and the presence of another respiratory virus (coinfection), are not well characterized in pediatric outpatients. METHODS Mid-nasal turbinate samples were collected from children presenting for care to the Seattle Childrens Hospital emergency department (ED) or urgent care with a symptomatic respiratory infection between December 2011 and May 2013. A subset of samples was tested for rhinovirus viral load by real-time polymerase chain reaction. Clinical data were collected by chart reviews. Multivariate logistic regression was used to evaluate the relationship between viral load and coinfection and the risk for LRTI. RESULTS Rhinovirus was the most frequent respiratory virus detected in children younger than 3 years. Of 445 patients with rhinovirus infection, 262 (58.9%) had LRTIs, 231 (51.9%) required hospital admission and 52 (22.5%) were hospitalized for 3 days or longer. Children with no comorbidities accounted for 142 (54%) of 262 rhinovirus LRTIs. Higher viral load was significantly associated with LRTI among illness episodes with rhinovirus alone (OR, 2.11; 95% confidence interval [CI], 1.24-3.58). Coinfection increased the risk of LRTI (OR, 1.83; 95% CI, 1.01-3.32). CONCLUSIONS Rhinovirus was the most common pathogen detected among symptomatic young children in a pediatric ED who had respiratory viral testing performed, with the majority requiring hospitalization. Higher rhinovirus viral load and coinfection increased disease severity. Virologic data may assist clinical decision making for children with rhinovirus infections in the pediatric ED.

Hope, distress, and later quality of life among adolescent and young adults with cancer

ABSTRACT We aimed to explore the predictive value of screening for distress alone, hope alone, or a combination of both. In a multicenter prospective study, 37 English-speaking adolescents and young adults with cancer and 40 parents completed validated instruments at diagnosis (“baseline”) and 3–6 months later (“follow-up”). Correlated regression models described associations. Within each instrument, baseline and follow-up scores were associated. However, only a composite hope/distress score predicted all three patient-centered outcomes. Multidimensional screens incorporating positive and negative psychosocial constructs may predict patient-centered outcomes better than isolated, single-construct instruments.

Empiric Antibiotic Use and Susceptibility in Infants With Bacterial Infections: A Multicenter Retrospective Cohort Study

OBJECTIVES To assess hospital differences in empirical antibiotic use, bacterial epidemiology, and antimicrobial susceptibility for common antibiotic regimens among young infants with urinary tract infection (UTI), bacteremia, or bacterial meningitis. METHODS We reviewed medical records from infants <90 days old presenting to 8 US childrens hospitals with UTI, bacteremia, or meningitis. We used the Pediatric Health Information System database to identify cases and empirical antibiotic use and medical record review to determine infection, pathogen, and antimicrobial susceptibility patterns. We compared hospital-level differences in antimicrobial use, pathogen, infection site, and antimicrobial susceptibility. RESULTS We identified 470 infants with bacterial infections: 362 (77%) with UTI alone and 108 (23%) with meningitis or bacteremia. Infection type did not differ across hospitals (P = .85). Empirical antibiotic use varied across hospitals (P < .01), although antimicrobial susceptibility patterns for common empirical regimens were similar. A third-generation cephalosporin would have empirically treated 90% of all ages, 89% in 7- to 28-day-olds, and 91% in 29- to 89-day-olds. The addition of ampicillin would have improved coverage in only 4 cases of bacteremia and meningitis. Ampicillin plus gentamicin would have treated 95%, 89%, and 97% in these age groups, respectively. CONCLUSIONS Empirical antibiotic use differed across regionally diverse US childrens hospitals in infants <90 days old with UTI, bacteremia, or meningitis. Antimicrobial susceptibility to common antibiotic regimens was similar across hospitals, and adding ampicillin to a third-generation cephalosporin minimally improves coverage. Our findings support incorporating empirical antibiotic recommendations into national guidelines for infants with suspected bacterial infection.

Prospective Observational Study on High-Value Care Topics Discussed on Multidisciplinary Rounds

OBJECTIVES Establishing a high-value care (HVC) culture within an institution requires a multidisciplinary commitment and participation. Bedside rounds provide an ideal environment for role modeling and learning behaviors that promote an HVC culture. However, little is understood regarding the types of HVC discussions that take place at the bedside and who participates in those discussions. METHODS A prospective observational study at a tertiary-care, university-affiliated, free-standing childrens hospital. The prevalence of HVC discussions was captured by using the HVC Rounding Tool, a previously developed instrument with established validity evidence. For each observed HVC discussion, raters recorded who initiated the discussion and a description of the topic. RESULTS Raters observed 660 patient encounters over 59 separate dates. Of all patient encounters, 29% (191 of 660; 95% confidence interval: 26%-33%) included at least 1 observed HVC discussion. The attending physician or fellow initiated 41% of all HVC discussions, followed by residents or medical students (31%), families (12%), and nurses (7%). CONCLUSIONS Despite a recent focus on improving health care value and educating trainees in the practice of HVC, our study demonstrated that bedside discussions of HVC are occurring with a limited frequency at our institution and that attending physicians initiate the majority of discussions. The capacity of the nonphysician team members to contribute to establishing and sustaining an HVC culture may be underused. Multi-institutional studies are necessary to determine if this is a national trend and whether discussions have an impact on patient outcomes and hospital costs.