Search

Importance: Adolescents and young adults (AYA) who have complex chronic disease (CCD) are a growing population that requires hospitalization to treat severe, acute health problems. These patients may have increased risk of readmission as demands on their self-management increase and as they transfer care from pediatric to adult health care practitioners., Objective: To assess variation across CCDs in the likelihood of readmission for AYA with increasing age., Design, Setting, and Participants: Retrospective 1-year cross-sectional study of the 2014 Agency for Healthcare Research and Quality Nationwide Readmissions Database for all US hospitals. Participants were 215 580 hospitalized individuals aged 15 to 30 years with cystic fibrosis (n = 15 213), type 1 diabetes (n = 86 853), inflammatory bowel disease (n = 48 073), spina bifida (n = 7819), and sickle cell anemia (n = 57 622) from January 1, 2014, to December 1, 2014., Exposures: Increasing age at index admission., Main Outcomes and Measures: Unplanned 30-day hospital readmission. Readmission odds were compared by patients' ages in 2-year epochs (with age 15-16 years as the reference) using logistic regression, accounting for confounding patient characteristics and data clustering by hospital., Results: Of 215 580 participants, 115 982 (53.8%) were female; the median (interquartile range) age was 24 (20-27) years. Across CCDs, multimorbidity was common; the percentages of index hospitalizations with 4 or more coexisting conditions ranged from to 33.4% for inflammatory bowel disease to 74.2% for spina bifida. Thirty-day hospital readmission rates varied significantly across CCDs: 20.2% (cystic fibrosis), 19.8% (inflammatory bowel disease), 20.4% (spina bifida), 22.5% (type 1 diabetes), and 34.6% (sickle cell anemia). As age increased from 15 to 30 years, unadjusted, 30-day, unplanned hospital readmission rates increased significantly for all 5 CCD cohorts. In multivariable analysis, age trends in the adjusted odds of readmission varied across CCDs. For example, for AYA who had cystic fibrosis, the adjusted odds of readmission increased to 1.9 (95% CI, 1.5-2.3) by age 21 years and remained elevated through age 30 years. For AYA who had type 1 diabetes, the adjusted odds of readmission peaked at ages 23 to 24 years (odds ratio, 2.3; 95% CI, 2.1-2.6) and then declined through age 30 years., Conclusions and Relevance: These findings suggest that hospitalized AYA who have CCDs have high rates of multimorbidity and 30-day readmission. The adjusted odds of readmission for AYA varied significantly across CCDs with increasing age. Further attention is needed to hospital discharge care, self-management, and prevention of readmission in AYA with CCD.

Objective: Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project., Materials and Methods: We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled "Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE)." The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics., Results: Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]., Discussion: We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects., Conclusions: ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools' impact on medical decision making, clinical practice, and health outcomes.

Antisera prepared against strains of Streptococcus mutans, particularly strain BHT, contain antibodies to the membrane lipoteichoic acid component that will cross-react with lipoteichoic acids from three species of lactobacilli. A more detailed study of the antibodies to strain BHT confirmed that the antibodies are specific for the polyglycerol phosphate component common to the lipoteichoic acids. Sera with a higher hemagglutinating titer could be obtained by injecting disrupted organisms. The partially purified lipoteichoic acid isolated from the culture fluid of S. mutans BHT was also immunogenic antibodies; antibodies were also formed against another unidentified component in this extracellular fraction.

Examination of the culture fluids from a number of strains of oral streptococci and latobacilli has shown the presence of an erythrocyte-sensitizing antigen with the properties of lipoteichoic acid. The antigen was isolated from the culture fluids of Lactobacillus casei and Lactobacillus fermentum and characterized chemically and serologically, For other strains, serological evidence for the presence of lipoteichoic acid depends on the reactivity with antiserum specific for the glycerol phosphate backbone. The relative concentrations of the antigen in culture fluids from different organisms, in culture fluids from different stages of growth, and in extracts of organisms was estimated by determining the maximum dilution that fully sensitized erythrocytes; the culture fluid titer, which is the reciprocal of the dilution, varied from 4 to 320. Strains of Streptococcus mutans were generally characterized by a high level of extracellular lipoteichoic acid, the amount being greater than that detectable in cell extracts; this conclusion was confirmed by using the quantitative precipitin method. A high-molecular-weight fraction obtained from S. mutans BHT culture fluid was effective in sensitizing erythrocytes at a concentration of 1 mug/ml, compared with 2 mug/ml required for cellular lipoteichoic acid from L. casei. The detecting procedure depends on the teichoic acid sensitizing erythrocytes but, as shown with L. fermentum, low-molecular-weight nonsensitizing teichoic acid may also be present in culture fluid.