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OBJECTIVE: Use of telemedicine in pediatric gastroenterology has increased dramatically in response to the coronavirus disease 2019 (COVID-19) pandemic. The goal of this study was to systematically assess the usability of telemedicine in the field of pediatric gastroenterology. METHODS: The previously validated Telehealth Usability Questionnaire was distributed to physician pediatric gastroenterologist members of North American Society for Pediatric Gastroenterology Hepatology and Nutrition. Physician demographic and practice characteristics were collected. Data were analyzed using descriptive, linear mixed-effect, and ordinary least squares regression methods. RESULTS: One hundred sixty pediatric gastroenterologists completed the survey. The majority were from academic practice (77%) with experience ranging from trainee (11%) to over 20 years of clinical practice (34%). Most (82%) had no experience with telemedicine before the pandemic. The average usability score (scale 1-5) was 3.87 (σ = 0.67) with the highest domain in the usefulness of telemedicine (μ = 4.29, σ = 0.69) and physician satisfaction (μ = 4.13, σ = 0.79) and the lowest domain in reliability (μ = 3.02, σ = 0.87). When comparing trainees to attending physicians, trainees responses were almost one point lower on satisfaction with telemedicine (trainee effect = -0.97, Bonferroni adjusted 95% confidence interval = -1.71 to -0.23). CONCLUSION: Pediatric gastroenterologists who responded to the survey reported that the technology for telemedicine was usable, but trainees indicated lower levels of satisfaction when compared to attending physicians. Future study is needed to better understand user needs and the impacts of telemedicine on providers with different levels are experience to inform efforts to promote implementation and use of telemedicine beyond the pandemic.

Hypovitaminosis D is a prevalent micronutrient deficiency that can be severe and hard to treat in children with short bowel syndrome, a condition treated with substantial bowel resection. Surgically altered bowel anatomy then results in iatrogenic digestion and absorption limitations that require short- and long-term management and follow-up. Care of children with hypovitaminosis D standardly includes prescription dietary micronutrient supplementation, sometimes in irregularly high doses. This commentary responds to a pediatric case of vitamin D toxicity and suggests micronutrient-prescribing risk mitigation strategies in light of the absence of regulatory oversight of over-the-counter dietary supplements, inadequate insurance coverage, and easily available commercial retail products. [ABSTRACT FROM AUTHOR]

Introduction: Hospital‐acquired central line‐associated bloodstream infections (CLABSI) are "never events" in U.S. healthcare. National efforts to improve CLABSI rates are ongoing. Efforts are important for all patients with a central venous catheter (CVC) and critical to children with intestinal failure (IF) who depend on long‐term, daily use of a CVC and undergo extended hospitalizations. We describe outcomes of a multidisciplinary CLABSI elimination effort on a 24‐bed medical‐surgical unit caring for children with IF. Methods: Unit CLABSI events from 1/9/2012 to 4/16/2020 were evaluated with multiple improvement interventions. We leveraged prospectively maintained clinical registries and National Healthcare Safety Network (NHSN) reporting data to extract patient and unit demographics, ethanol lock utilization, and unit CVC days. Interventions were developed utilizing expert consensus and CDC guidelines with active frontline staff engagement. Descriptive statistics and tests of non‐parametric data were employed for analysis. Results: Ninety‐five patients with IF and 862 non‐IF patients experienced a total of 1,629 admissions with 20,372 CVC days. Twelve hospital‐acquired CLABSI events occurred during the study period, including 7 following NHSN definition change on 1/1/2015 (0.56 per 1,000 CVC days). After the last unit CLABSI on 12/5/2016, there were 7,117 CVC days through study conclusion. Conclusions: Described interventions with an enhanced culture of collaborative care profoundly improved hospital‐acquired CLABSI occurrence. Success in a specific population translated to all other unit patients with a CVC. Findings suggest elimination is not the result of a single new product or practice, but also includes support and empowerment of those caring for the patient and their CVC. [ABSTRACT FROM AUTHOR]

Introduction: Central line–associated bloodstream infections (CLABSIs) lead to significant morbidity and mortality in children with intestinal failure (IF). Ethanol lock prophylaxis (ELP) greatly reduces CLABSI frequency with minimal side effects. However, in the United States, a recently approved orphan drug designation for dehydrated alcohol has greatly increased 70% ethanol cost from about $10/day to $1000/day. We examined the cost‐effectiveness of ELP in relation to these changes. Methods: We simulated a previously developed IF Markov model over 1 year. Costs were measured in 2020 US dollars and effectiveness in quality‐adjusted life‐years (QALYs). CLABSI rate with and without ELP was estimated from the largest available comparative observational study. The primary outcome was incremental cost‐effectiveness ratio (ICER) between treatments. Secondary outcomes included CLABSI frequency. Sensitivity analyses on all model parameters were performed. Results: In the base model, children with IF not using ELP accumulated $131,815 in costs and 0.32 QALYs per patient compared with $437,884 and 0.33 QALYs per patient in those using ELP. The ICER was nearly $17 million/QALY gained. ELP resulted in a 40% reduction in CLABSI frequency. ELP became cost‐effective at $68/day and cost‐saving at $63/day. Sensitivity analysis identified no other plausible parameter variation to reach the benchmark of $100,000/QALY gained. Conclusions: At the current price, ELP is not cost‐effective for CLABSI prevention in children with IF in the United States. This study highlights the critical need for the approval of an affordable lock therapy option to prevent CLABSIs in these children. [ABSTRACT FROM AUTHOR]

Background: Ethanol lock use has been associated with significantly lower rates of central line–associated bloodstream infection (CLABSI) in children with intestinal failure. Concerns have been raised among intestinal rehabilitation program providers regarding the impact of recent changes in cost and availability of ethanol locks in the US. Methods: We conducted a survey among the members of the North American Society For Pediatric Gastroenterology, Hepatology & Nutrition Intestinal Rehabilitation Special Interest Group (NASPGHAN IR‐SIG) regarding practice changes among providers to tackle this issue and the anticipated effect on CLABSI rates. Results: The results show that the vast majority of US participants use ethanol locks in their population with intestinal failure, with most anticipating or already experiencing reduction in access to ethanol locks. Most worrisome is that more than half of participating programs expect an increase in CLABSI rates in this vulnerable patient population as a consequence of limited access to ethanol locks. Conclusion: Further multicenter prospective studies to assess the efficacy of alternative locking agents, besides ethanol, are needed in order to have readily available and affordable options for CLABSI prevention in the future. [ABSTRACT FROM AUTHOR]

Background: We determined qualitative and quantitative serum unconjugated bile acid (SUBA) levels among children with history of intestinal failure (IF) and suspected small bowel bacterial overgrowth (SBBO).Methods: This was a single-center, case-control pilot study conducted at Cincinnati Children's Hospital Medical Center. Children with history of IF and suspected SBBO were enrolled as subjects. Age-matched children without IF or suspected SBBO served as controls. All participants underwent small bowel fluid sampling for microbial culture analysis. Additionally, serum fractionated and total bile acids were measured by liquid chromatography-mass spectrometry at enrollment and following treatment for SBBO.Results: SUBA concentrations were elevated in IF subjects (median 1.16 μM, range 0.43-10.65 μM) compared with controls (median 0.10 μM, range 0.05-0.18 μM, P = 0.001). Among SUBA, chenodeoxycholic acid (CDCA) was significantly elevated in subjects (median 0.8 μM, range 0-7.08 μM) compared with controls (median 0 μM, range 0-0.03 μM, P = 0.012). When controls were excluded from analysis, IF subjects with positive aspirates for SBBO demonstrated higher concentration of CDCA (median 7.36 μM, range 1.1-8.28 μM) compared with IF subjects with negative aspirates (median 0.18 μM, range 0-1.06 μM, P = 0.017). Treatment for SBBO did not alter SUBA concentration.Conclusions: SUBA concentrations are elevated in children with history of IF and presumed SBBO compared with non-IF controls. CDCA was more prevalent in IF subjects with positive aspirates for SBBO compared with IF subjects with negative aspirates. The determination of SUBA concentration may be a useful surrogate to small bowel fluid aspiration in the diagnosis of SBBO in children with history of IF. [ABSTRACT FROM AUTHOR]