Inpatient Bronchiolitis Guideline Implementation and Resource Utilization abstract BACKGROUND: Provider-dependent practice variation in children hospitalized with bronchiolitis is not uncommon. Clinical practice guidelines (CPGs) can streamline practice and reduce utilization however, CPG implementation is complex. METHODS:A multidisciplinary team developed and implemented CPGs for management of bronchiolitis for children ,2 years old. Children with comorbidities, ICU admissions, and outside hospital transfers were excluded. Implementation involved teamwork and collaboration, provider education, online access to CPGs, order sets, data sharing, and monthly team meetings. Resource utilization was defined as use of chest x-rays (CXRs), antibiotics, steroids, and more than 2 doses of inhaled bronchodilator use. Outcome metrics included length of stay (LOS) and readmission rate. Bronchiolitis season was defined as September to April. Data were collected for 2 seasons post implementation. RESULTS:The number CPG-eligible patients in the pre-and 2 postimplementation periods were similar (1244, preimplementation; 1159, postimplementation season 1; 1283 postimplementation season 2). CXRs decreased from 59.7% to 45.1% (P , .0001) in season 1 to 39% (P , .0001) in season 2. Bronchodilator use decreased from 27% to 20% (P , .01) in season 1 to 14% (P , .002) in season 2. Steroid use significantly reduced from 19% to 11% (P , .01). Antibiotic use did not change significantly (P = .16). LOS decreased from 2.3 to 1.8 days (P , .0001) in season 1 and 1.9 days (P , .05) in season 2. All-cause 7-day readmission rate did not change (P = .45).CONCLUSIONS: Bronchiolitis CPG implementation resulted in reduced use of CXRs, bronchodilators, steroids, and LOS without affecting 7-day all-cause readmissions. Pediatrics 2014;133:e730-e737 Bronchiolitis is a common cause of pediatric hospitalization. Variation in the use of tests and treatments for management of bronchiolitis exists, some of which may contribute to increased health care costs that are estimated to be $545 million annual total direct expenditure nationally. 1 In 2006, the American Academy of Pediatrics published a national clinical practice guideline (CPG) for management of children with bronchiolitis. 2 The CPG does not recommend routine tests and treatments, emphasizing a diagnosis of bronchiolitis based on history and physical examination, and supportive management. Nevertheless, nationally, there is a wide variation in use of tests and treatments in the management of bronchiolitis. [2][3][4] CPGs can be a powerful resource to reduce variation and help providers deliver disease-specific best practice. 5,6 Therefore, many national organizations support development of CPGs. [7][8][9] Integrating a CPG into practice requires changes in physician behaviors and remains a significant challenge. 10 Studies suggest that locally developed CPGs affect patient outcomes more than those developed nationally. 11 At Children' s Medical Center (CMC) Dallas, we noted variation in practice ...

Extracorporeal life support is used to support patients of all ages with refractory cardiac and/or respiratory failure. Extracorporeal membrane oxygenation (ECMO) has been used to rescue patients whose predicted mortality would have otherwise been high. It is associated with acute central nervous system (CNS) complications and with long- term neurologic morbidity. Many patients treated with ECMO have acute neurologic complications, including seizures, hemorrhage, infarction, and brain death. Various pre-ECMO and ECMO factors have been found to be associated with neurologic injury, including acidosis, renal failure, cardiopulmonary resuscitation, and modality of ECMO used. The risk of neurologic complication appears to vary by age of the patient, with neonates appearing to have the highest risk of acute central nervous system complications. Acute CNS injuries are associated with increased risk of death in a patient who has received ECMO support. ECMO is increasingly used during cardiopulmonary resuscitation when return of spontaneous circulation is not achieved rapidly and outcomes may be good in select populations. Economic analyses have shown that neonatal and adult respiratory ECMO are cost effective. There have been several intriguing reports of active physical rehabilitation of patients during ECMO support that is well tolerated and may improve recovery. Although there is evidence that some patients supported with ECMO appear to have very good outcomes, there is limited understanding of the long-term impact of ECMO on quality of life and long-term cognitive and physical functioning for many groups, especially the cardiac and pediatric populations. This deserves further study.

Ten of the 14 patients with an abscess size > or =3 cm had an invasive intervention, but only 1 of these 10 had an initial 48-hour trial of antibiotics alone. In contrast, only 2 of the 22 patients who had an abscess size <3 cm received an invasive intervention (Fisher P= .0002). We conclude that conservative treatment with intravenous antibiotics may be a reasonable initial approach.

Background & Aims: Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. Methods:We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death.