Suzuki, Reina

ImportanceThere is limited evidence for therapeutic options for pediatric COVID-19 outside of multisystem inflammatory syndrome in children (MIS-C).ObjectiveTo determine whether the use of steroids within 2 days of admission for non–MIS-C COVID-19 in children is associated with hospital length of stay (LOS). The secondary objective was to determine their association with intensive care unit (ICU) LOS, inflammation, and fever defervescence.Design, Setting, and ParticipantsThis cohort study analyzed data retrospectively for children (<18 years) who required hospitalization for non–MIS-C COVID-19. Data from March 2020 through September 2021 were provided by 58 hospitals in 7 countries who participate in the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 registry.ExposureAdministration of steroids within 2 days of admission.Main Outcomes and MeasuresLength of stay in the hospital and ICU. Adjustment for confounders was done by mixed linear regression and propensity score matching.ResultsA total of 1163 patients met inclusion criteria and had a median (IQR) age of 7 years (0.9-14.3). Almost half of all patients (601/1163, 51.7%) were male, 33.8% (392/1163) were non-Hispanic White, and 27.9% (324/1163) were Hispanic. Of the study population, 184 patients (15.8%) received steroids within 2 days of admission, and 979 (84.2%) did not receive steroids within the first 2 days. Among 1163 patients, 658 (56.5%) required respiratory support during hospitalization. Overall, patients in the steroids group were older and had greater severity of illness, and a larger proportion required respiratory and vasoactive support. On multivariable linear regression, after controlling for treatment with remdesivir within 2 days, country, race and ethnicity, obesity and comorbidity, number of abnormal inflammatory mediators, age, bacterial or viral coinfection, and disease severity according to ICU admission within first 2 days or World Health Organization ordinal scale of 4 or higher on admission, with a random intercept for the site, early steroid treatment was not significantly associated with hospital LOS (exponentiated coefficient, 0.94; 95% CI, 0.81-1.09; P = .42). Separate analyses for patients with an LOS of 2 days or longer (n = 729), those receiving respiratory support at admission (n = 286), and propensity score–matched patients also showed no significant association between steroids and LOS. Early steroid treatment was not associated with ICU LOS, fever defervescence by day 3, or normalization of inflammatory mediators.Conclusions and RelevanceSteroid treatment within 2 days of hospital admission in a heterogeneous cohort of pediatric patients hospitalized for COVID-19 without MIS-C did not have a statistically significant association with hospital LOS.

ABSTRACT Background Implementation of checklists has been shown to be effective in improving patient safety. This study aims to evaluate the effectiveness of implementation of a checklist for daily care processes into clinical practice of pediatric intensive care units (PICUs) with limited resources. Methods Prospective before–after study in eight PICUs from China, Congo, Croatia, Fiji, and India after implementation of a daily checklist into the ICU rounds. Results Seven hundred and thirty-five patients from eight centers were enrolled between 2015 and 2017. Baseline stage had 292 patients and post-implementation 443. The ICU length of stay post-implementation decreased significantly [9.4 (4–15.5) vs. 7.3 (3.4–13.4) days, p = 0.01], with a nominal improvement in the hospital length of stay [15.4 (8.4–25) vs. 12.6 (7.5–24.4) days, p = 0.055]. The hospital mortality and ICU mortality between baseline group and post-implementation group did not show a significant difference, 14.4% vs. 11.3%; p = 0.22 for each. There was a variable impact of checklist implementation on adherence to various processes of care recommendations. A decreased exposure in days was noticed for; mechanical ventilation from 42.6% to 33.8%, p < 0.01; central line from 31.3% to 25.3%, p < 0.01; and urinary catheter from 30.6% to 24.4%, p < 0.01. Although there was an increased utilization of antimicrobials (89.9–93.2%, p < 0.01). Conclusions Checklists for the treatment of acute illness and injury in the PICU setting marginally impacted the outcome and processes of care. The intervention led to increasing adherence with guidelines in multiple ICU processes and led to decreased length of stay.

Abstract Background: The Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) study is a before-and-after clinical quality improvement study involving 20 countries. Our aim was to describe the challenges and solutions for study implementation across various intensive care units.Methods: After local institutional review board approval, each study center had a setup period before patient data were collected. Each center was required to accomplish 4 stages: baseline data collection, remote simulation training, local implementation, and postimplementation data collection and maintenance of process of care. We measured the time required to complete each study stage and used the Define, Measure, Analyze, Improve, and Control (DMAIC) framework to identify the challenges encountered during each stage and guide improvement strategies to facilitate implementation of CERTAIN.Results: Between June 2012 and December 2017, 55 centers from 20 countries were recruited to participate. The time to complete each stage at different centers varied significantly. The most common domains in which challenges occurred were 1) leadership support and team building, 2) communication, 3) work environment culture, 4) language barriers, 5) infrastructure and technology, and 6) sustainability. Obstacles in these 6 areas delayed reaching major milestones of the study. Different strategies were deployed to overcome these barriers: engaging leadership for support, using native-speaking clinicians during training sessions, using various communication platforms, providing personal computers to local hospitals, making in-person site visits, offering flexible training time, and supporting local centers’ grant applications. Centers that enrolled during the control phase, compared with those that enrolled earlier, had significantly shorter times and less variation in times for each study stage and for the total study time.Conclusions: By using the DMAIC method, we identified the predominant 6 domains in which challenges occurred during implementation of the global CERTAIN study and developed targeted strategies to overcome the challenges and shorten the duration of the study. The DMAIC method would be useful in improving the efficiency of other large-scale multinational quality improvement projects.

Background: Telemedicine as a technology is expected to resolve issues such as doctor shortages and disparities in medical services. However, high costs of system installation and maintenance inhibit its widespread use. Introduction: This study involved a cost minimization analysis for installation of a teleradiology system in the Hokkaido prefecture of Japan. Conditions under which system utilization is cost-efficient and system utilization is effective for cost reduction were analyzed. Materials and Methods: A cost minimization analysis was conducted using three geospatial points of 50, 100, and 200 km from Sapporo city, the prefectural capital of Hokkaido, assuming a central imaging diagnosis center in Sapporo. The analysis was conducted from the standpoint of both patients and requesting hospitals. Results: From the patient's standpoint, a cost reduction effect was observed at all three distances from system installation. In contrast, from the hospital's standpoint, a cost reduction effect was found only when teleradiology examination was conducted from a distance of at least 100 km from Sapporo. Discussion: Results show that the cost reduction effect for patients increased as the travel distance increased. Although the teleradiology service is beneficial for a wide range of patients, the financial burden on requesting hospitals is significant. Conclusions: The following conditions were found necessary to reduce the requesting hospital's financial burden: the hospital should be far from the imaging diagnosis center, an inexpensive system is to be selected, and the system needs to be utilized continuously.

ObjectiveTo investigate clinical and pathologic aspects of IgG4‐related disease (IgG4‐RD) in non‐Asian populations.MethodsWe conducted a retrospective review of the medical records of patients with IgG4‐RD who presented to an academic medical center from January 1994 to September 2012.ResultsAmong 166 patients identified, the median age at diagnosis was 61 years (interquartile range [IQR] 49–70 years), 75% were male, and 80% were white. The median number of organs involved was 2 (IQR 2–3). When organs were grouped according to anatomic system, the hepatopancreaticobiliary system was most commonly involved (77%). The median highest serum IgG4 level during the clinical course was 215 mg/dl (IQR 122–466). Forty‐three patients (26%) had a normal serum IgG4 level. Seventy‐nine pathology specimens were available for immunostaining. The median number of IgG4+ cells was 37 (IQR 25–82) per high‐power field, with an IgG4+:IgG+ ratio of 0.50 (IQR 0.32–0.68). Among 151 patients who received medical therapy, 72 (48%) received steroid‐sparing agents because of relapse, recurrence, or corticosteroid intolerance. Of the 66 patients who were newly diagnosed, started on corticosteroid monotherapy as the initial treatment, and followed up at our institution, 30 (45%) experienced relapse or recurrence despite an initial favorable response. The number of organs involved had a significant impact on time to relapse or recurrence, with a hazard ratio of 1.48 (95% confidence interval [95% CI] 1.12–1.93) (P < 0.01) in multivariate analysis. The standardized incidence ratio of malignancy was 4.5 (95% CI 1.5–7.5).Conclusion. IgG4‐RD is a multisystem disorder that commonly affects older men and has a propensity for relapse, recurrence, and malignancy.