Faculty Bibliography

CONTEXT: Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review. OBJECTIVE: To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions. DATA SOURCES: We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017). STUDY SELECTION: We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated. DATA EXTRACTION: Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form. RESULTS: Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0). LIMITATIONS: The studies were primarily observational in nature. CONCLUSIONS: Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

OBJECTIVES: To compare pediatric respiratory syncytial virus (RSV) hospitalizations in the United States to regional RSV activity and inpatient palivizumab administration. METHODS: We characterized inpatients, excluding newborns, with RSV from the Pediatric Health Information System (July 2010-June 2013). RSV regional activity timing was defined by the National Respiratory and Enteric Virus Surveillance System. RSV hospitalization season (defined by at least 3 SDs more than the mean regional baseline number of RSV hospitalizations for 3 consecutive weeks) was compared with RSV regional activity season (2 consecutive weeks with >/=10% RSV-positive testing). Logistic regression was used to determine predictors of hospitalization timing (ie, during or outside of regional activity season). We also assessed the timing of inpatient palivizumab administration. RESULTS: There were 50 157 RSV hospitalizations. Mean RSV hospitalization season onset (early November) was 3.3 (SD 2.1) weeks before regional activity season onset (early December). Hospitalization season offset (early May) was 4.4 (SD 2.4) weeks after activity season offset (mid-April). RSV hospitalization and activity seasons lasted 18 to 32 and 13 to 23 weeks, respectively. Nearly 10% of hospitalizations occurred outside of regional activity season (regional ranges: 5.6%-22.4%). Children with chronic conditions were more likely to be hospitalized after regional activity season, whereas African American children were more likely to be hospitalized before. Inpatient palivizumab dosing was typically initiated before the start of RSV hospitalizations. CONCLUSIONS: There is regional variation in RSV hospitalization and activity patterns. Many RSV hospitalizations occur before regional activity season; high-risk infants may require RSV immunoprophylaxis sooner.

OBJECTIVE: Asthma is a leading cause of pediatric admissions. While several factors including race have been linked to increased overall asthma morbidity and mortality, few studies have explored factors associated with inpatient asthma outcomes. We examined factors associated with mortality and morbidity in children admitted for asthma. DESIGN/METHODS: Data were obtained from the US Nationwide Inpatient Sample for 2007-2011. Patients 2-18 years old with a primary diagnosis of asthma were included. Predictor variables were sociodemographic and hospital factors and acute/chronic secondary diagnoses. Outcomes were mortality, intubation, length of stay (LOS), and costs. Weighted national estimates were calculated. Multivariable analyses were performed. RESULTS: There were 97,379 (478,546 weighted) asthma admissions. Most patients were male (60.6%); 30% were white, 28% black, and 18% Hispanic. Mortality rate was 0.03%. 0.3% were intubated. Median (IQR) LOS was 2 (1-3) days. Median (IQR) costs were $2760 ($1860-4320). Native American race, older age (13-18 years), and West region were significant independent predictors of mortality. Intubation rate was lower in Hispanic compared to white children (p=0.028). LOS was shorter in Asian compared to white children (p=0.022) but longer in children with public insurance and from low income areas (p <0.001). Average costs were higher in black, Hispanic, and Asian compared to white children (p<0.05). CONCLUSIONS: With the exception of Native Americans, race/ethnicity is not associated with inpatient asthma mortality and has varied effects on morbidity. Recognition of factors associated with increased asthma mortality and morbidity may allow for earlier, more effective treatment and avoidance of complications.

BACKGROUND: The incidence and growth of cancer has been reported to increase with age and/or impaired T lymphocyte function. RESULTS: Consistent with these observations, we found that a monoclonal serum immunoglobulin (mIgG2b), rarely detectable after the injection of 5T33 murine multiple myeloma (MMM) cells into 3-4 month old wild-type C57BL/6 mice was seen more frequently in 18-20 month old wild-type C57BL/6 mice and in 3-4 month old Rag1-deficient C57BL/6 mice. These observations were confirmed and extended using more sensitive assays such as quantitation of splenic mRNA specific for the canonical 5T33 monoclonal IgG2b produced by 5T33 myeloma cells and the most sensitive assay, photon-imaging of mice injected with 5T33 cells, stably transfected with fire-fly luciferase gene (5T33L cells), which emit photons after the injection of luciferin. Furthermore, the proliferation of 5T33L myeloma cells in Rag1-deficient C57BL/6 mice was greater in mice which also received spleen T cells from 18-20 month old C57BL/6 wild-type mice compared to mice which received splenic T cells from 3-4 month old C57BL/6 wild-type mice. Thus, immune reconstitution of C57BL/6 mice with splenic T cells from young wild-type mice offered greater protection from progressive growth of 5T33L myeloma cells than did reconstitution with splenic T cells from old mice. CONCLUSIONS: Our findings support the hypothesis that age-associated changes in splenic T cell function contribute to the increased growth of 5T33 MMM cells in old compared to young C57BL/6 mice. Should similar processes occur in humans, increasing the anti-myeloma activity of T cells in old patients with multiple myeloma or transferring cryopreserved, young, autologous, T cells might benefit elderly patients with multiple myeloma.