Wrong-patient errors cause serious harm in newborns. These errors involve ordering and administering tests, procedures, medications, and breast milk to an unintended patient. Newborns receiving care in neonatal intensive care units (NICUs) are at particularly high risk. Although more distinct newborn naming conventions as recommended by the Joint Commission significantly reduce wrong-patient orders, name similarities among multiple-birth infants and truncation of differentiating information in some electronic health record (EHR) systems contribute to this persistent increased risk. Accordingly, novel newborn identifiers are urgently needed. We propose Pictographs - images that are appealing, recognizable, and appropriate - to serve as visual identifiers for newborns in NICUs. Pictographs are selected by caregivers, uploaded into the EHR, and displayed at bedside. As part of a multicenter randomized controlled trial assessing effectiveness of Pictographs to prevent wrong-patient order errors, we initially evaluated feasibility and acceptability of Pictographs at two study sites. Pictographs as novel visual identifiers for newborns in the NICU were generally well received by caregivers and clinicians, and the vast majority of caregivers selected a Pictograph for their infant(s), which was posted at the bedside and uploaded into the EHR. Ordering clinicians - the primary target of the intervention to prevent wrong-patient errors - recognized the potential for Pictographs to provide a visual cue when placing orders, particularly for multiple-birth infants. Here, we describe the rationale, implementation, framework, feasibility, usefulness, and acceptability of Pictographs among key stakeholders. If found effective for preventing wrong-patient errors, Pictographs could be adopted as a patient safety solution in hospitals worldwide.

Introduction Transfusion-dependent thalassemia (TDT) results in a severe phenotype with significantly impacted quality of life, shortened life expectancy, and high healthcare costs, driven primarily by the need for frequent transfusions and chelation therapy. Allogeneic blood and marrow transplantation (allo-BMT) is a curative option, but utilization is limited by donor availability, the toxicity of the preparative regimen, graft-vs-host disease (GVHD), and transplant-related mortality. Advances made by us and others have helped overcome these barriers. Methods We report our single-center experience, including the use of an augmented non-myeloablative (NMA) regimen (anti-thymocyte globulin, fludarabine, cyclophosphamide, total body irradiation 400 cGy) and post-transplant cyclophosphamide (PT-Cy). Results A total of 28 children and young adults (2-23 years of age, median 9) with TDT (beta thalassemia major n=24, hemoglobin E-beta thalassemia n=3, hemoglobin D-beta thalassemia n=1) underwent BMT from July 2013 to September 2025. Three had undergone a previous BMT at other institutions. Most (n=23, 82%) received our augmented NMA preparative regimen. For all but 2 patients (93%), GVHD prophylaxis included PT-Cy. While the majority of patients received a bone marrow graft (n=23, 82%) from a haplo-identical donor (n=19, 68%), transplant procedures were completed using a variety of donors (matched related n=6, unrelated n=3) and stem cell sources (peripheral blood n=3, cord blood ± BM n=2). Neutrophil and platelet recovery occurred at a median of 21 (13-38) and 27 days (13-88), respectively. Five patients (18%) developed grade I-II acute GVHD (skin or gut); all responded to steroids. No patients developed grade III-IV acute GVHD. Two patients developed mild chronic GVHD (7%). One patient developed VOD following myeloablation, and one developed idiopathic pneumonia syndrome both recovered fully after treatment with defibrotide and etanercept, respectively. At time of last follow-up (0.7-11 years, median 5.9) all patients were alive and transfusion independent, with the exception of one patient with near complete loss of donor chimerism and a single patient who died from a non-transplant related cause seven years post-BMT. Conclusion Allo-BMT is a safe, feasible, and highly effective therapy for TDT. The use of our established NMA platform, best available donor, and PT-Cy-based GVHD prophylaxis significantly abrogates the risk of post-BMT complications, mitigates GVHD, and is sufficient to provide ample donor-derived erythropoiesis resulting in long-term transfusion independence. Our experience has resulted in a paradigm shift regarding conditioning regimen intensity and donor selection for afflicted patients at our institution and highlights that all TDT patients should routinely be referred for consultation to a tertiary center with experience in BMT.

Introduction Outcomes for pediatric and AYA patients with advanced solid tumors remain dismal, with little improvement over decades. We developed a reduced-intensity haploidentical BMT (haploBMT) platform incorporating post-transplant cyclophosphamide (PTCy) to replace an incompetent, host, immune system with one from a healthy donor and limit GVHD followed by pre-emptive checkpoint inhibition to augment graft-versus-tumor (GVT) effects. Objectives To evaluate the safety and efficacy of haploBMT plus anti PD-1 therapy (aPD-1) as a consolidative intervention in high-risk solid tumors after achieving no evidence of disease or stable disease, and to define the immunologic mechanisms by which checkpoint blockade augments GVT. Methods Twelve patients (Ewing sarcoma n=5, rhabdomyosarcoma n=3, neuroblastoma n=3, medulloblastoma n=1) received haploBMT followed by aPD-1; 3 were treated at relapse and 9 received aPD-1 pre-emptively post-BMT (NCT03465592). Outcomes were compared with 25 haploBMT-only patients (Ewing n=5, rhabdomyosarcoma n=10, neuroblastoma n=3, desmoplastic small round cell n=3, other n=4). All patients were fully engrafted at the time of aPD-1 initiation and received 1-48 cycles. Peripheral blood and tumor specimens were analyzed with high-dimensional methods. Results (interim analysis) HaploBMT + aPD-1 significantly improved survival compared with haploBMT alone. Two-year OS rose from 25% with haploBMT alone to 65% with haploBMT + aPD-1 (p=0.03). Median OS was 1.0 vs 2.6 years, respectively (p=0.057). Survival curves diverged over time, with a subset of patients in the aPD-1 arm achieving a durable survival plateau beyond 3 years, consistent with sustained GVT activity. Treatment was well tolerated; one patient developed grade 3 GVHD (resolved) and two had serious immune-related events, managed with immunosuppression. Correlative analyses showed donor-derived lymphocytes remained checkpoint responsive, expanded in blood, and infiltrated tumors. Cytokine profiling revealed robust immune activation with increases in IFNγ, TNFα, and IL-12, consistent with Th1-skewed responses, together with modulation of PD-1, ICOS, and CCL5. Longitudinal profiling demonstrated expansion of cytotoxic CD8⁺ and effector CD4⁺ T cells with contraction of suppressive myeloid cells and Tregs, shifting the systemic milieu toward a pro-inflammatory state. Spatial multiplex immunofluorescence of tumor tissue revealed activated effector-like CD8⁺ and CD4⁺ T cells clustering with PD-L1⁺ myeloid subsets, reflecting a remodeled immune microenvironment conducive to antitumor responses. Conclusions HaploBMT plus aPD-1 is feasible, safe, and improves OS. Correlative studies show PD-1 blockade drives immune activation, effector T cell differentiation, and recruitment of tumor-reactive subsets, providing a mechanistic basis for durable GVT.

Background How best to efficiently reconstitute hematopoiesis in severe aplastic anemia (SAA) poses a challenge in pediatric hematology, with immunosuppressive therapy failing in 20–40% of patients and matched sibling donors (MSDs) available in only 25–30%. Haploidentical bone marrow transplantation (haploBMT) with post-transplant cyclophosphamide (PTCy) has expanded donor access and mitigated historical risks of graft failure and graft-versus-host disease (GVHD) in relapsed/refractory (R/R) and treatment-naïve (TN) SAA patients. However, pediatric data are only recently emerging. Objective To evaluate the safety and efficacy of PTCy-based, allogeneic (allo) BMT as a curative strategy for pediatric, adolescent, and young adult (AYA) SAA patients. Methods We conducted a single-center analysis of 31 consecutive pediatric and AYA patients (≤21 years, median age 10) with acquired SAA who underwent alloBMT from 2014–2024. Patients were enrolled on, or eligible for open institutional protocols. Twenty-three patients received reduced-intensity conditioning (RIC: fludarabine, low-dose cyclophosphamide, TBI 200-400 cGy) with haplo- or MSD-BMT plus PTCy (PTCy cohort), while eight received prior standard-of-care MSD-BMT with cyclophosphamide/ATG and calcineurin inhibitor-based GVHD prophylaxis (SOC cohort). Among PTCy recipients, 91% (21/23) received haploidentical grafts; 61% (14/23) were R/R and 39% (9/23) were TN. As expected, 88% (7/8) of SOC patients were TN. Median follow-up for the entire group was 27.4 months (range, 4–157). Results Overall survival was excellent at 97% (PTCy: 96%; SOC: 100%). In the PTCy cohort, count recovery was robust with median neutrophil, red cell, and platelet recovery by days 17, 19, and 25, respectively. All surviving PTCy patients—including all R/R cases—achieved full donor chimerism. SOC patients demonstrated faster count recovery (P<0.05); median neutrophil, red cell and platelet recovery was 13.5, 13, and 17.5 days respectively, but maintained uniformly mixed chimerism in whole blood and CD3 compartments throughout follow-up. Grade 1-2 acute GVHD was minimal across both cohorts (PTCy: 4%; SOC: 0%). No cases of grade ≥3 acute GVHD occurred, and each group experienced only one case of extensive chronic GVHD. Late complications were infrequent, with no cases of clonal evolution or secondary malignancy in the PTCy cohort, one desmoid tumor in the SOC group, and no significant organ toxicity in either cohort. Conclusions This decade-long experience further demonstrates that outcomes following RIC haploBMT with PTCy for pediatric patients with SAA are comparable to those of MSD-BMT, with high survival, minimal GVHD, and limited long-term toxicity, while maintaining full donor chimerism. These results strongly support the use of haploBMT for relapsed/refractory patients and as a frontline option if this is the best available donor.

Abstract Severe aplastic anemia (SAA) is a life-threatening bone marrow failure syndrome. Allogeneic bone marrow transplantation (allo-BMT) is the most definitive curative treatment for SAA and is prioritized when matched sibling donors (MSDs) are available. Haploidentical BMT (haplo-BMT) with posttransplant cyclophosphamide (PTCy) has emerged as a promising alternative, expanding donor access while mitigating historically high rates of graft failure and graft-versus-host disease (GVHD). We report the outcomes of 31 consecutive pediatric, adolescent, and young adult patients (aged ≤21 years) with acquired SAA who underwent allo-BMT at a single institution (2014-2024). Patients with treatment-naïve (TN) and relapsed/refractory (R/R) SAA were included. Patients received reduced-intensity conditioning (RIC) haplo-BMT or MSD-BMT with PTCy, mycophenolate mofetil, and tacrolimus (PTCy cohort, n = 23), or standard-of-care (SOC) MSD-BMT with cyclophosphamide/antithymocyte globulin conditioning and calcineurin inhibitor/methotrexate–based GVHD prophylaxis (SOC cohort, n = 8). Overall survival was 97% (PTCy, 96%; SOC, 100%). GVHD rates were low, with only 1 case of grade 2 acute GVHD and 1 case of extensive chronic GVHD (cGVHD) in the PTCy group, and 1 case of extensive cGVHD in the SOC group. No patients developed clonal hematopoiesis. Late effects were infrequent, and limited to menstrual dysfunction and BK virus–associated nephropathy in 1 patient. Robust donor chimerism was achieved in the PTCy cohort, in contrast to uniformly mixed chimerism in the SOC group. These findings demonstrate that RIC haplo-BMT with PTCy is a safe and effective curative approach for pediatric patients with both R/R and TN SAA, supporting its use as a frontline option even when MSDs are available.

Background When implemented in both electronic health records (EHRs) and pharmacy management software, CancelRx communicates medication discontinuation in the EHR to pharmacies, which has been demonstrated to reduce medication discrepancies at pharmacies and the risk of medication dispensing after e-prescription discontinuation. Provider workflows for making medication changes and the configuration of CancelRx will affect whether a medication change (e.g., dose adjustment) is communicated to a pharmacy. Objective This study aimed to assess the effect of CancelRx configuration and the EHR tools used in provider workflows for medication changes on notification to health system and external community pharmacies. Methods We conducted a functionality analysis of prescriber workflows for documenting a medication change using “change,” “reorder,” “adjust sig,” “discontinue,” and “taking differently.” In the EHR test environment, we examined three outcomes of interest: communication of discontinuation of the old prescription (or cancellation); generation of a new prescription; and instructions to the patient. Results “Change” was the only single-step function that communicated medication discontinuation to both health system and external community pharmacies with default settings, although “discontinue” followed by a new prescription had the same results. “Reorder” and “adjust sig” functions had different cancellation outcomes for internal and external community pharmacies. “Adjust sig” also had different prescribing outcomes for internal and external pharmacies and “taking differently” did not result in communication of discontinuation or a new prescription at either pharmacy type. Conclusion Several workflows for dose changes did not communicate to external community pharmacies, resulting in different prescriptions at the health system and external community pharmacies. Health systems leaders should consider the implications of local EHR workflows and CancelRx configuration on communication of medication changes to pharmacies as part of CancelRx implementation. Multidisciplinary collaboration is needed to develop more effective strategies for communication of medication dose changes.

Background: Although electronic prescription cancellation such as via CancelRx can facilitate critical communication between prescribers and pharmacy staff about discontinued medications, there is little work that explores whether CancelRx meets the needs of pharmacy staff users. Objective: This study leverages qualitative interviews with pharmacy staff to address the following question: When medication changes are made by a prescriber using CancelRx, what information is needed by pharmacy staff to make correct and effective decisions in their roles in medication management? Methods: We conducted an inductive thematic analysis of interviews with 11 pharmacy staff members (pharmacists and pharmacy technicians) across three outpatient community pharmacy sites within an academic health care system. Results: Three information needs themes were consistently identified by both pharmacists and pharmacy technicians: prescriber intent when initiating the CancelRx, clinical rationale for the medication change, and intended medication regimen. Notably, both pharmacists and pharmacy technicians often reported seeking multiple information needs not fully addressed by CancelRx in the electronic health record (EHR) to achieve the shared goals of correct dispensing of medications and supporting patient self-management. Conclusions: Our qualitative analysis reveals that outpatient community pharmacy staff in an academic health care system often seek additional information from the (EHR) following medication changes communicated by CancelRx to meet their information needs. Ideally, the prescriber would provide sufficient information through CancelRx to automatically identify all discontinued prescriptions. These limitations highlight the need for design features that support routine communication of needed information at the time of a medication change, such as structured data elements.

Background Classically, urgent breast consults are seen by Breast Surgery or Surgical Oncology (BS/SO). At our safety net hospital, Acute Care Surgery (ACS) performs all urgent surgical consultations, including initial assessment of breast consults with coordinated BS/SO follow-up. The objective was to determine safety of ACS initial assessment of acute breast pathology. Methods All urgent breast-related consultations were included (2016-2019). Demographics, consult indications, and investigations/interventions were captured. Outcomes were compared between patients assessed by ACS versus both ACS and BS/SO at presentation. Results 234 patients met study criteria, with median age 39 years. Patients were primarily Hispanic (82%) women (96%). Most were not seen by BS/SO at presentation (69%), although BS/SO assessment was more frequent among patients ultimately diagnosed with cancer (8% vs 1%, P = .012). No patient had delay >90 days to core biopsy from presentation. Outcomes including time to cancer diagnosis (14 vs 8 days, P = .143) and outpatient BS/SO assessment (16 vs 13 days, P = .528); loss to follow-up (25% vs 21%, P = .414); and ED recidivism (24% vs 18%, P = .274) were comparable between patients seen by ACS versus ACS/BS/SO at index presentation. Conclusion Urgent breast consults at our safety net hospital typically underwent initial assessment by ACS with outpatient evaluation by BS/SO. Time to follow-up and cancer diagnosis, loss to follow-up, and ED recidivism were similar after index presentation assessment by ACS versus ACS and BS/SO. In a resource-limited environment, urgent breast consults can be safely managed in the acute setting by ACS with coordinated outpatient BS/SO follow-up.

Background: Atopic dermatitis (AD) is a chronic inflammation of the skin. Many patients who are severely affected by AD are children and young adults, when social interactions contribute substantially to their overall health related quality of life. We hypothesize that children and adults with atopic dermatitis are less satisfied with their social activities and relationships as compared to those without atopic dermatitis. Data from the 2010 National Health Interview Survey (NHIS), which was conducted by the National Center for Health Statistics and focused on health for the noninstitutionalized civilian population of the United States, was used. STATA was used to perform logistical regression models among AD and social interaction variables accounting for age, sex, race, educational attainment, and income. For the independent variables: participate in social activities (OR=9, P<0.001), activity limitation from fatigue (OR=1.47, P<0.001), and worry or anxiety interferes with life (OR=6.11, P<0.001); there was an odds ratio greater than 1 showing decreased social interactions for individuals who had atopic dermatitis. These data show that individuals with atopic dermatitis were less satisfied with their social activities and relationships as compared to those without atopic dermatitis. Possible reasons for decreased social activities include early childhood onset of disease and other comorbidities including mental health issues/ cardiovascular risk factors leading to a sedentary lifestyle with less interactions with others. Study limitations include retrospective review of survey data. Future studies may involve analysis of other data sets.

Abstract Background Oncofertility is a developing field of increasing importance, particularly in pediatric oncology, where most patients are likely to survive long‐term and have not yet had the opportunity to have children. Aims We performed a quality improvement initiative to increase our rates of fertility preservation counseling and referral through the implementation of a pediatric oncofertility team, and we report outcomes 7 years following implementation of our initiative. Methods and results We compare our baseline oncofertility survey to 44 post‐intervention survey respondents and electronic medical record documentation for 149 patients treated in 2019. Ninety‐five percent of post‐intervention survey respondents recalled fertility counseling (baseline 70%, p = .004) and 89.3% were appropriately referred for fertility preservation (baseline 50%, p = .017). Counseling was documented in 60.4% of charts; 81% of patients analyzed by chart review were appropriately referred for fertility preservation. Fertility preservation outcomes differed by sex assigned at birth. Conclusion Creation of an oncofertility team produced improvements in fertility counseling and fertility preservation referral across an extended period of time.

Importance:An estimated 1.5% to nearly 5% of medications are dispensed after discontinuation in the electronic health record (EHR), with 34% meeting criteria for high risk of potential harm. Objective:To evaluate the association of the implementation of e-prescription cancellation messaging (CancelRx) with medication dispensing after discontinuation of e-prescriptions in the EHR. Design, Setting, and Participants:This case series with interrupted time series analysis included patients who had at least 1 medication e-prescribed in ambulatory care to a health system pharmacy and discontinued in the 2-year study period from 1 year prior to approximately 1 year after CancelRx implementation (January 15, 2018, to December 7, 2019). Prior to CancelRx implementation, changes to e-prescribed medications within the EHR were not electronically communicated to health system pharmacies, which used separate pharmacy management software. Statistical analysis was performed from November 2020 to June 2023 (primary analysis from March 2021 to May 2022). Exposure:Implementation of CancelRx. Main Outcomes and Measures:The primary outcome was the proportion of e-prescribed medications dispensed and sold to patients by pharmacies within 6 months after discontinuation in the EHR. A medication was defined as dispensed after discontinuation if the timestamp of dispensing was at least 1 minute and less than 6 months after the timestamp of discontinuation in the EHR. A secondary outcome was the proportion of discontinued medications that was reordered within 120 days. Results:A total of 53 298 qualifying e-prescriptions that were discontinued were identified for 17 451 unique patients (mean [SD] age, 50.6 [18.2] years; 9332 women [53.5%]). After CancelRx implementation, 22 443 (85.9%) of the 26 127 discontinued e-prescriptions resulted in a CancelRx transaction. In interrupted time series analysis, the proportion of prescriptions dispensed after discontinuation decreased from a baseline of 8.0% (2162 of 27 171) to 1.4% (369 of 26 127; P < .001), without a significant week-to-week trend (β = 0.000158; P = .37). Conclusions and Relevance:In this case series with interrupted time series analysis, findings suggest that CancelRx implementation was associated with an immediate and persistent reduction in the proportion of e-prescriptions sold after discontinuation in the EHR. Widespread implementation of CancelRx may significantly improve medication safety through the reduction of medication dispensing after discontinuation by prescribers.

Objectives Wrong-patient errors are common and have the potential to cause serious harm. The Office of the National Coordinator for Health Information Technology Patient Identification SAFER Guide recommends displaying patient photographs in electronic health record (EHR) systems to facilitate patient identification and reduce wrong-patient errors. A potential barrier to implementation is patient refusal; however, patients’ perceptions about having their photograph captured during registration and integrated into the EHR are unknown. Methods The study was conducted in an emergency department (ED) and primary care outpatient clinic within a large integrated health system in New York City. The study consisted of 2 components: (1) direct observation of the registration process to quantify the frequency of patient refusals and (2) semistructured interviews to elicit patients’ feedback on perceived benefits and barriers to integrating their photograph into the EHR. Results Of 172 registrations where patients were asked to take a photograph for patient identification, 0 refusals were observed (ED, 0 of 87; primary care outpatient clinic, 0 of 85). A convenience sample of 30 patients were interviewed (female, 70%; age ≥55 years, 43%; Hispanic/Latino, 67%; Black, 23%). Perceived benefits of integrating patient photographs into the EHR included improved security (40%), improved patient identification (23%), and ease of registration (17%). A small proportion of patients raised privacy concerns. Conclusions Patient refusal was not found to be a barrier to implementation of patient photographs in the EHR. Efforts to identify and address other potential barriers would help ensure that the highest proportion of patients has photographs in their medical record.

Electronic communication of prescription discontinuation, or CancelRx, has the potential to improve medication safety. We aimed to describe the proportion of discontinued outpatient medications that would result in a CancelRx message to understand its impact on medication safety. We used a data report to identify all outpatient medications discontinued in the electronic health record (EHR) of an academic health system in 1 month (October 2018). Among all 63 485 medications discontinued, 23 118 (36.4%) were e-prescribed, 25 982 (40.9%) were patient-reported or reconciled, and the remainder prescribed nonelectronically. Discontinued high-risk medications were more likely to be e-prescribed (2768 of 5896, 47.0%). A discontinuation reason was specified in 37 353 (58.9%) of all discontinued medications. Approximately one-third to one-half of discontinued medications were e-prescribed within the same EHR and would result in a CancelRx message to the pharmacy. Extension of this functionality to medications reconciled in the EHR could significantly expand the impact of CancelRx on medication safety. In addition, complete and accurate discontinuation reasons are needed to optimize CancelRx implementation.

Management of refractory pain in pediatric sickle cell disease (SCD) and oncology is reliant on opioids though high opioid dosing increases side effects and tachyphylaxis. We introduced low-dose ketamine infusion (LDKI) to our inpatient unit to determine if LDKI was tolerable. We subsequently hypothesized that LDKI would improve pain scores. We reviewed inpatients from LDKI initiation in March 2014 through October 2017, with the day before LDKI initiation compared with the day of LDKI initiation and 2 subsequent days. For patients with SCD, the LDKI admission was compared with up to 3 admissions in the prior year for a vaso-occlusive event. Nineteen patients (12 oncology, 7 SCD) with a median age of 14.6 years received LDKI for a median of 6 days at a median initial dose of 0.06 mg/kg/h (1.1 µg/kg/min). There was no change in pain scores or opioid utilization when comparing the day before LDKI initiation with subsequent days. No patient discontinued LDKI because of intolerability. For patients with SCD, there was a median 32% reduction in cumulative pain scores when comparing the LDKI admission with prior admissions. LDKI is well tolerated for refractory pediatric cancer-related and sickle cell-related pain.

Objectives This study aimed to evaluate the impact of electronic communication of medication discontinuation from prescribers to pharmacies (CancelRx) on medication safety. Methods We used electronic health record (EHR) data to identify medications that were e-prescribed from a pilot practice to a health system pharmacy and subsequently discontinued before or after CancelRx implementation (January 16–April 15, 2018 versus 2019). We matched these EHR data to pharmacy management software data to identify medications that were sold to patients in the 6 months after discontinuation. As a surrogate for unintended cancellation, we also identified medications refilled within 120 days of discontinuation. We conducted a medical record review to identify documentation of prescriber intent to discontinue these medications. Results CancelRx implementation prevented prescriptions from being sold after discontinuation in the EHR (42 of 392 [10.7%] versus 0 of 387 [0.0%], P < 0.0001), but only 15 of 42 (35.7%) had documented intent to discontinue the medication (15 of 392, or 3.8% overall). There was a nonsignificant increase in the proportion of discontinued medications reordered within 120 days (10.0% versus 12.7%, P = 0.23). Medical record review of reordered prescriptions after CancelRx implementation found that 10 of 49 (10 of 387, or 2.6% overall) might have been unintentionally canceled. Conclusions Implementation of CancelRx eliminated the sale of e-prescribed medications after discontinuation in the EHR but might result in the unintentional cancellation of some prescriptions. Strategies to increase situational awareness of providers and pharmacy staff, including increased visibility of CancelRx, clear distinctions between active and expired prescriptions, and transmission of the reason for discontinuation, might reduce the risk of unintentional cancellations.

Introduction: Meaningful engagement in quality improvement (QI) projects by trainees is often challenging. A fellow-led QI project aimed to improve adherence to a blood culture clinical decision algorithm and reduce unnecessary cultures in pediatric oncology inpatients. Methods: We visualized preintervention rates of blood cultures drawn on pediatric oncology inpatients using a control chart. Following the introduction of the algorithm to our division, an Ishikawa fishbone diagram of cause-and-effect identified two areas for improvement: prescriber education on the algorithm and targeted feedback on its use. We developed two interventions to support algorithm awareness and use: (1) bundled educational interventions and (2) targeted chart review and feedback. Fellows reviewed >750 blood culture episodes and adjudicated each as "adherent" or "nonadherent" to the algorithm. In addition, fellows provided direct feedback to prescribers regarding nonadherent episodes and discussed strategies for algorithm adherence. Results: Blood culture rates in preintervention, intervention, and follow-up periods were 33.35, 25.24, and 22.67 cultures/100 patient-days, respectively. The proportion of nonadherent culture episodes decreased from 47.14% to 11.11%. The use of the algorithm did not prolong the time to cultures drawn on patients with new fever. Seventy-five percent of fellows provided feedback to inpatient teams on algorithm use. Following this project, trainees reported feeling more qualified to apply QI principles to patient care. Conclusions: Implementation of a clinical decision algorithm reduced the rate of cultures drawn on pediatric oncology inpatients. Fellow-led education of the care team decreased the proportion of nonadherent culture episodes and provided active engagement in QI.

Abstract Purpose: We report findings from the first-in-human study of [ 11 C]MDTC, a radiotracer developed to image the cannabinoid receptor type 2 (CB2R) with positron emission tomography (PET). Methods: Ten healthy adults were imaged according to a 90 min dynamic PET protocol after bolus intravenous injection of [ 11 C]MDTC. Five participants also completed a second [ 11 C]MDTC PET scan to assess test-retest reproducibility of receptor-binding outcomes. The kinetic behavior of [ 11 C]MDTC in human brain was evaluated using a metabolite-corrected arterial plasma input function with compartmental modeling and graphical analysis approaches. Four additional healthy adults completed whole-body [ 11 C]MDTC PET/CT to calculate organ doses and the whole-body effective dose. Results: [ 11 C]MDTC brain PET and [ 11 C]MDTC whole body PET/CT was well-tolerated. The model of choice for fitting the time activity curves (TACs) across brain regions of interest was a two-tissue compartment model with the blood volume fraction included as a fitting parameter (2TCM-vB). Regional distribution volume (V T ) values computed from Logan graphical analysis correlated well with those estimated using the 2TCM-vB model. Cortical regions and thalamus had higher V T than brainstem, striatum, hippocampus, and corpus callosum. Test-retest reliability of V T demonstrated a mean absolute variability of 7.13%, with an intraclass correlation coefficient 0.91. The measured effective dose of [ 11 C]MDTC was 5.29 µSv/MBq. Conclusion: These data support use of [ 11 C]MDTC PET for in vivo neuroimaging of CB2R in humans. Future in vivo studies using [ 11 C]MDTC PET in neuroinflammatory conditions are needed to assess the detection of high expression of the CB2R by activated microglia in human brain.

Microbial sharing between humans and animals has been demonstrated in a variety of settings. However, the extent of microbial sharing that occurs within the healthcare setting during animal-assisted intervention programs is unknown. Understanding microbial transmission between patients and therapy dogs can provide important insights into potential health benefits for patients, in addition to addressing concerns regarding potential pathogen transmission that limits program utilization. This study evaluated for potential microbial sharing between pediatric patients and therapy dogs and tested whether patient–dog contact level and a dog decolonization protocol modified this sharing. Patients, therapy dogs, and the hospital environment were sampled before and after every group therapy session and samples underwent 16S rRNA sequencing to characterize microbial communities. Both patients and dogs experienced changes in the relative abundance and overall diversity of their nasal microbiome, suggesting that the exchange of microorganisms had occurred. Increased contact was associated with greater sharing between patients and therapy dogs, as well as between patients. A topical chlorhexidine-based dog decolonization was associated with decreased microbial sharing between therapy dogs and patients but did not significantly affect sharing between patients. These data suggest that the therapy dog is both a potential source of and a vehicle for the transfer of microorganisms to patients but not necessarily the only source. The relative contribution of other potential sources (e.g., other patients, the hospital environment) should be further explored to determine their relative importance.

Therapy animals in hospital animal-assisted intervention programs are an invaluable part of holistic patient care. However, therapy dogs may be exposed to hospital-associated pathogens through these activities. This pilot study sought to examine the effect of topical chlorhexidine application, used as an infection control measure, on the microbial composition of the skin and mucous membranes of therapy dogs. We found that the chlorhexidine decolonization intervention altered microbial alpha diversity and shifted microbial structures in these therapy dogs, and particularly influenced more phylogenetically rare taxa. Specifically, the intervention reduced the abundance of Staphylococcus pseudintermedius , the archetypal canine commensal and a frequent cause of opportunistic infections. However, it did not reduce levels of S. aureus , which is a common hospital-associated pathogen of people. These preliminary findings highlight the importance of considering holistic microbial communities when undertaking infection control strategies, and stress the need for further research to understand the unintended consequences of antiseptic use on therapy dogs.