OBJECTIVE To determine whether intrapleural tissue plasminogen activator (TPA) reduces hospital length of stay (LOS) vs intrapleural normal saline in children with complicated parapneumonic effusion or empyema. METHODS A retrospective cohort study at a tertiary pediatric referral hospital in Iran, comparing children aged 1 month to 18 years treated during TPA unavailability (2012–2015; intrapleural saline, 40 mL, 1-hour dwell, daily ×3 days) with those treated after TPA became available (2015–2018; TPA 4 mg in 40 mL saline, same protocol). The primary outcome was hospital LOS, and the secondary outcomes were intensive care unit (ICU) stay, fever duration, chest-tube duration, and ICU admission. Multivariable linear regression was adjusted for baseline imbalances between cohorts. RESULTS Of 85 patients, 61 received TPA and 24 saline. The cohorts were comparable at baseline, except for higher pleural fluid adenosine deaminase and shorter time to first instillation in the saline group (medium and very large effects). The mean hospital LOS was 20.28 ± 5.53 days (TPA) vs 19.17 ± 3.60 days (saline). The unadjusted difference was 1.11 days (95% CI, −1.14 to 3.36; P = .366). The adjusted mean difference was 0.36 days (95% CI, −2.91 to 3.63; P = .826). Secondary outcomes showed similarly small differences, with CI ranges compatible with no clinically important effect. CONCLUSIONS Intrapleural TPA showed no detectable benefit over saline in this retrospective comparison. The wide CI ranges indicate insufficient evidence to reject the null hypothesis and not equivalence. Our findings raise, but do not confirm, the hypothesis that mechanical lavage contributes to clinical improvement. Residual confounding and selection bias cannot be excluded. Adequately powered, prospective randomized trials are needed to establish the incremental value of fibrinolysis in children.
In pediatric hospital medicine (PHM), effective interventions often fail to reach the bedside or are significantly delayed, contributing to gaps in quality, outcomes, and value. Dissemination and implementation (D&I) science addresses this evidence-to-practice gap by studying methods to promote the uptake, integration, and sustainment of evidence-based interventions in real-world settings. In this methodology article, we apply a PHM lens to D&I science, outlining when D&I is most useful and how it differs from quality improvement and traditional efficacy and effectiveness research. We introduce core D&I terminology and commonly used theories, models, and frameworks and describe key steps in conducting D&I studies, including identifying contextual barriers, selecting theory-informed implementation strategies, assessing appropriate implementation outcomes, applying rigorous study designs, and planning for dissemination and sustainment. We highlight practical tools and examples from PHM literature to support application in inpatient pediatric settings. We also discuss key limitations, including methodological complexity and challenges with measurement and reproducibility. By providing a pragmatic overview, this article aims to equip pediatric hospitalists and researchers with foundational D&I knowledge to accelerate translation of evidence into practice and improve care for hospitalized children.
OBJECTIVE To examine how parents experience and navigate prognostic uncertainty following a diagnosis of congenital cytomegalovirus (cCMV) and identify implications for clinical communication and newborn screening. METHODS We conducted in-depth qualitative interviews with 41 birth parents of children with cCMV. Interviews explored diagnosis, communication with health care practitioners, health care navigation, and perceptions of child development. Transcripts were analyzed using inductive reflexive thematic analysis. RESULTS Prognostic uncertainty emerged as a central and enduring feature of parents’ experiences. Five themes characterized how families navigated uncertainty: (1) families live with the burden of an unpredictable future, (2) families struggle to make meaning from incomplete and inconsistent information, (3) families become drivers of the diagnostic journey to gain clarity and control, (4) knowledge provides families direction even when certainty is impossible, and (5) families value early diagnosis because it makes uncertainty more manageable. Uncertainty contributed to anxiety, information seeking, and ongoing monitoring. However, parents consistently valued early diagnosis because it provided direction, facilitated treatment and developmental surveillance, supported access to intervention, and informed decision-making. Rather than eliminating uncertainty, diagnosis transformed an unpredictable future into possibilities on which families could monitor and act. CONCLUSIONS Prognostic uncertainty is an inherent and longitudinal feature of cCMV and should be acknowledged in counseling following the diagnosis. Despite persistent uncertainty, parents valued early identification because it provided direction and opportunities for surveillance and intervention. As cCMV screening expands, family-centered communication, anticipatory guidance, care coordination, and longitudinal support can help families navigate uncertainty over time.
