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Background: Clinical Decision Support (CDS) tools have a mixed record of effectiveness, often due to inadequate alignment with clinical workflows and poor usability. While there's a consensus that usability testing methods address these issues, in practice, usability testing is generally only used for selected projects (such as funded research studies). There is a critical need for CDS operations to apply usability testing to all CDS implementations., Objectives: In this State of the Art / Best Practice paper, we share challenges with scaling usability in healthcare operations and alternative methods and CDS governance structures to enable usability testing as a routine practice., Methods: We coalesce our experience and results of applying guerilla in-situ usability testing to over 20 projects in 1 year period with the proposed solution., Results: We demonstrate the feasibility of adopting "guerilla in-situ usability testing" in operations and their effectiveness in incorporating user feedback and improving design., Conclusion: Although some methodological rigor was relaxed to accommodate operational speed, the benefits outweighed the limitations. Broader adoption of usability testing may transform CDS implementation and improve health outcomes., Competing Interests: Drs Evan Orenstein and Naveen Muthu are co-founders and has equity in Phrase Health a clinical decision support analytics company. They are Investigators on an R42 grant with Phrase Health from the National Library of Medicine (NLM) and National Center for Advancing Translational Science (NCATS). Both of them receive salary support from the NLM and NCATS, but no direct revenue from Phrase Health. Other authors have nothing to disclose., (Thieme. All rights reserved.)

Background:  Blood product ordering is a complex process and mistakes can harm patients and lead to poor outcomes. Orders and order sets can be designed to help mitigate errors, but major changes in design can unintentionally cause new errors., Objectives:  Our objective was as follows: (1) utilize formative in situ usability testing to iteratively improve the design of a redesigned blood product order set prior to go-live, (2) implement changes based on feedback derived from this testing, and (3) compare the error rate, system usability scale (SUS) score, time to task completion, and click counts between the prior order set in use at the time and the revised redesigned order set., Methods:  A multidisciplinary project team convened to redesign blood product orders and order sets from scratch based on a review of the literature and benchmarking against four pediatric academic institutions with the goal of addressing prior ordering errors. The newly redesigned blood product order set was iteratively updated via in situ formative usability testing performed with available clinical users using a concurrent think-aloud protocol in real clinical environments. Errors, SUS scores, time to task completion, and click counts were assessed for the revised redesigned order set using summative testing., Results:  Formative usability testing with 20 participants led to seven design changes in the redesigned order set which reduced the error rate at go-live. Summative usability testing showed that even though the usability scores were only slightly improved for the revised redesigned order set, the error rates in blood orders were significantly decreased., Conclusion:  Usability testing can identify design errors early in the process which can be rectified prior to implementation, thus avoiding unintended consequences of changes., Competing Interests: S.T. has nothing to disclose. H.W. has nothing to disclose. D.R. has nothing to disclose. E.O. has nothing to disclose. A.C. has nothing to disclose. M.R. has nothing to disclose. B.R. has nothing to disclose. S.K. has nothing to disclose. E.O. reports others from PhraseHealth outside the submitted work., (Thieme. All rights reserved.)

Background: Numerous programs have arisen to address interruptive clinical decision support (CDS) with the goals of reducing alert burden and alert fatigue. These programs often have standing committees with broad stakeholder representation, significant governance efforts, and substantial analyst hours to achieve reductions in alert burden which can be difficult for hospital systems to replicate., Objective:  This study aimed to reduce nursing alert burden with a primary nurse informaticist and small support team through a quality-improvement approach focusing on high-volume alerts., Methods:  Target alerts were identified from the period of January 2022 to April 2022 and four of the highest firing alerts were chosen initially, which accounted for 43% of all interruptive nursing alerts and an estimated 86 hours per month of time across all nurses occupied resolving these alerts per month. Work was done concurrently for each alert with design changes based on the Five Rights of CDS and following a quality-improvement framework. Priority for work was based on operational engagement for design review and approval. Once initial design changes were approved, alerts were taken for in situ usability testing and additional changes were made as needed. Final designs were presented to stakeholders for approval prior to implementation., Results:  The total number of interruptive nursing alert firings decreased by 58% from preintervention period (1 January 2022-30 June 2022) to postintervention period (July 1, 2022-December 31, 2022). Action taken on alerts increased from 8.1 to 17.3%. The estimated time spent resolving interruptive alerts summed across all nurses in the system decreased from 197 hours/month to 114 hours/month., Conclusion:  While CDS may improve use of evidence-based practices, implementation without a clear framework for evaluation and monitoring often results in alert burden and fatigue without clear benefits. An alert burden reduction effort spearheaded by a single empowered nurse informaticist efficiently reduced nursing alert burden substantially., Competing Interests: S.A.T. has nothing to disclose. S.K. has nothing to disclose. E.O. is a co-founder and holds equity in Phrase Health, a clinical decision support analytics company. He has also served as Principal Investigator on Phase 1 and Phase 2 STTR grants with Phrase Health from the National Library of Medicine (NLM) and National Center for the Advancement of Translational Science (NCATS). He receives no direct revenue from Phrase Health but has received salary support from NLM and NCATS., (Thieme. All rights reserved.)

Despite widespread adoption and maturity, paper persistence endures in many Electronic Health Record (EHR) systems, particularly for complex workflows involving multiple steps from different stakeholders separated in time. In our health system, Latent Tuberculosis Infection (LTBI) testing was one such workflow where a Tuberculin Skin Test (TST) must be administered and then correctly read 48-72 hours later and documented. This paper discusses a low-resource workflow analysis and clinical decision support approach to replace a paper workflow and garner the benefits of the EHR for clearer documentation and retrieval of LTBI results. Our approach resulted in a significant increase in completed TST documentation, 57% (24/42) to 95% (18/19), P < 0.003. Human-centered design practices such as work system analysis and formative usability testing are feasible with limited resources and improve the likelihood of success of electronic workflows by designing solutions that fit existing clinical workflows and automating processes wherever possible.

Pediatric patients are at high risk of peripheral intravenous infiltration or extravasation (PIVIE) leading to injury and increased costs. Most of the work in addressing PIVIE has focused on the implementation of workflow bundles and evidenced based guidelines. This project showed that Clinical Decision Support can be used to help support identification and treatment of Severe PIVIE through use of an interruptive alert that increases placement of vascular access team consults.

Background: General pediatric providers are the front line for early peanut introduction discussions, but many providers believe that they are ill-equipped to handle such discussions, as the guidelines have changed quickly., Objective: We hypothesized that a clinical decision support (CDS) tool could improve discussions of peanut introduction., Methods: CDS tools were designed by stakeholders, improved through usability testing, and integrated into the current note templates. On the basis of queries of electronic health records, we did a preperformance versus postperformance evaluation of conversations regarding peanut introduction, barriers to peanut introduction, and percentage of 12-month well-child checkups (WCCs) that resulted in successful introduction of peanut. Providers completed surveys before and after intervention to assess their awareness of early peanut introduction and comfort using the CDS tools., Results: Providers' awareness of early peanut introduction guidelines increased from 17.8% to 66.7% after the CDS tool was implemented; 79.1% of the providers were comfortable using the tool. The CDS tool improved peanut introduction conversations at the 4-month WCC from 2.4% to 81.2%, at the 6-month WCC from 3.0% to 84.2%, and at the 12-month WCC from 2.7% to 82.9%. In all, 56.6% of families had a plan to introduce peanut at the 4-month WCC. Of those who did not have a plan, the most common barrier was the family's unawareness of the benefits of early peanut introduction. At the 12-month WCC, 62.8% of families had introduced peanut without concerns., Conclusion: A point-of-care CDS tool encouraged more discussions of early peanut introduction between general pediatric providers and all patients. CDS tools should be considered in quality improvement projects as an implementation method for the most up-to-date guidelines., Competing Interests: Disclosure statement Disclosure of potential conflict of interest: E. Orenstein is a cofounder of Phrase Health, a company that provides clinical decision support analytics, and holds equity in the company but does not receive any direct revenue; in addition, he serves as the principal investigator for a phase 1 and phase 2 small business technology transfer grant awarded to Phrase Health by the National Library of Medicine and the National Center for Advancing Translational Science. The rest of the authors declare that they have no relevant conflicts of interest., (Copyright © 2024 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Wrong-patient order entry (WPOE) is a potentially dangerous medical error. It remains unknown if patient photographs reduce WPOE in the pediatric inpatient population., Materials and Methods: Order sessions from a single pediatric hospital system were examined for retract-and-reorder (RAR) events, a surrogate WPOE measure. We determined the association of patient photographs with the proportion of order sessions resulting in a RAR event, adjusted for patient, provider, and ordering context., Results: In multivariable analysis, the presence of a patient photo in the electronic health record was associated with 40% lower odds of a RAR event (aOR: 0.60, 95% CI: 0.48-0.75), while cardiac and ICU contexts had higher RAR frequency (aOR: 2.12, 95% CI: 1.69-2.67 and 2.05, 95% CI: 1.71-2.45, respectively)., Discussion and Conclusion: Patient photos were associated with lower odds of RAR events in the pediatric inpatient setting, while high acuity locations may be at higher risk. Patient photographs may reduce WPOE without interruptions., Competing Interests: E.O. is a co-founder and has equity in Phrase Health©, a clinical decision support analytics company. He received no direct revenue. He has also served as the principal investigator on an R41 and R42 grant with Phrase Health from the National Library of Medicine (NLM) and the National Center for Advancing Translational Science (NCATS). He has received salary support from NLM and NCATS. All other authors have no competing interests to declare., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Objective: To assess the relationship between the Child Opportunity Index (COI), a comprehensive measurement of social determinants of health, and specific COI domains on patient-specific outcomes following congenital cardiac surgery in the metropolitan region of Atlanta, Georgia., Study Design: In this retrospective chart review, we included patients who underwent an index operation for congenital heart disease between 2010 and 2020 in a single pediatric health care system. Patients' addresses were geocoded and mapped to census tracts. Descriptive statistics, univariable analysis, and multivariable regression models were employed to assess associations between variables and outcomes., Results: Of the 7460 index surgeries, 3798 (51%) met eligibility criteria. Presence of an adverse outcome, defined as either mortality or 1 of several other major postoperative morbidities, was significantly associated with COI in the univariable model (P = .008), but not the multivariable regression model (P = .39). Postoperative hospital length of stay was significantly associated with COI (P < .001) in univariable and multivariable regression models. There was no significant association between COI and readmission within 30 days of hospital discharge in univariable (P < .094) and multivariable (P = .49) models., Conclusion: COI is associated with postoperative hospital length of stay but not all outcomes in patients after congenital heart surgery. By understanding the role of COI in outcomes related to cardiac surgery, targeted interventions can be developed to improve health equity., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Published by Elsevier Inc.)

We present 4k video and whole transcriptome data for seven deep-sea invertebrate animals collected in the Eastern Pacific Ocean during a research expedition onboard the Schmidt Ocean Institute's R/V Falkor in August of 2021. The animals include one jellyfish (Atolla sp.), three siphonophores (Apolemia sp., Praya sp., and Halistemma sp.), one larvacean (Bathochordaeus mcnutti), one tunicate (Pyrosomatidae sp.), and one ctenophore (Lampocteis sp.). Four of the animals were sequenced with long-read RNA sequencing technology, such that the reads themselves define a reference assembly for those animals. The larvacean tissues were successfully preserved in situ and has paired long-read reference data and short read quantitative transcriptomic data for within-specimen analyses of gene expression. Additionally, for three animals we provide quantitative image data, and a 3D model for one siphonophore. The paired image and transcriptomic data can be used for species identification, species description, and reference genetic data for these deep-sea animals., (© 2024. The Author(s).)

The American Academy of Pediatrics recommends utilizing hospitalizations as an opportunity to provide sexual health screenings for adolescents. This study aimed to describe the current practice of sexual history documentation (SHxD) and sexually transmitted infection (STI) testing among adolescents admitted to a pediatric hospital medicine service. Retrospective cross-sectional study of adolescents (14-19 years old) admitted to the PHM service from 2017-2019 was performed at an academic children's health system. Patient (demographics, history of complex chronic condition, and insurance), hospitalization (length of stay, diagnosis, STI tests ordered/results), and physician (level of training and gender) characteristics were extracted for each encounter. A natural language processing algorithm identified the presence of SHxD. Univariate analysis and multivariable analysis were performed to detect factors associated with SHxD and STI screening. The prevalence of STIs was calculated for those who were tested. Out of 2242 encounters, SHxD and STI testing rates were 40.9% and 17.2%, respectively. Patient gender, race, lack of complex chronic condition, and resident involvement were predictive of SHxD and STI testing. SHxD increased the odds of STI testing significantly (OR 5.06, CI 3.90-6.58). Among those who were tested, the prevalence of STIs was highest for chlamydia (37/329, 11.2%). Overall, sexual health screening rates remain low in the hospital setting and future improvement initiatives are needed., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Evan Orenstein is a co-founder and has equity in Phrase Health, a clinical decision support analytics company. He is also a PI on a phase 1 and phase 2 STTR grant with Phrase Health from the National Library of Medicine and the National Center for Advancing Translational Science. He receives salary support through these grants. The remaining authors have no conflicts of interest relevant to this article to disclose.

Introduction: Children are at increased risk of medication-associated adverse events, often due to weight-based dosing errors. We aimed to reduce the proportion of medications that were administered where the dosing weight was ≥ 10% different from the recorded weight., Methods: We adopted in-situ usability testing to iteratively improve design of clinical decision support that would enable accurate dosing weight documentation by prompting clinicians to update weight if recorded weight was > 10% different and it had been at least 7 days since the last dosing weight update., Results: The proportion of medication administrations with difference >10% between their recorded weight and dosing weight decreased from 13.1% (56,256/ 429,006) in the baseline period to 9.5% (35,560 / 372,443) in the intervention period (P < 0.001)., Discussion and Conclusion: User-centered design of an interruptive alert improved the accuracy of dosing weights during medication administrations without substantial alert burden. In-situ usability testing is an effective approach to rapidly obtain feedback from frontline users and iterate on the design to effect desired behavior changes.

Revolutionary advancements in underwater imaging, robotics, and genomic sequencing have reshaped marine exploration. We present and demonstrate an interdisciplinary approach that uses emerging quantitative imaging technologies, an innovative robotic encapsulation system with in situ RNA preservation and next-generation genomic sequencing to gain comprehensive biological, biophysical, and genomic data from deep-sea organisms. The synthesis of these data provides rich morphological and genetic information for species description, surpassing traditional passive observation methods and preserved specimens, particularly for gelatinous zooplankton. Our approach enhances our ability to study delicate mid-water animals, improving research in the world's oceans.

Background: Childhood-onset systemic lupus erythematosus (cSLE) is an autoimmune disease with variable disease expression but noted association with significant disease-related damage, morbidity, and mortality. The European Alliance of Associations for Rheumatology (EULAR) recommends routine monitoring of SLE through validated disease activity and chronicity indices, including the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Despite this, physician adherence with SLEDAI documentation remains elusive at various academic institutions. The aim of our study was to determine baseline SLEDAI documentation rates at our center and assess the change in adherence in SLEDAI documentation rate with electronic clinical decision support (CDS) reminders facilitated through the electronic medical record (EMR) over a 2-year period., Methods: All SLE encounters over a 24-month period at a pediatric academic center were reviewed in order to obtain baseline SLEDAI documentation percentages. Physicians subsequently received monthly email reminders, initiated at month 4 of project initiation, with subsequent CDS reminder 13 months after project initiation prompted by anti-dsDNA lab result. Chart review was repeated continuously for each provider, and SLEDAI documentation rates were emailed to each provider monthly. Physicians completed a post-intervention survey regarding barriers to SLEDAI documentation at the end of the study., Results: A total of 1980 SLE encounters were reviewed for this study. Baseline SLEDAI documentation rates were 10%. Following the introduction of monthly emails reminding physicians to document SLEDAI, rates increased to 55%. After the initiation of electronic in-basket reminders prompted by lab results, rates increased to 60%. Noted barriers to documentation were cited to be forgetfulness (67%) and lack of time (33%)., Conclusion: Our study demonstrates that monthly email reminders as well as EMR-mediated electronic in-basket reminders increased SLEDAI documentation rates at an academic center. Noted barriers to documentation were reported to be forgetfulness (67%) and lack of time (33%)., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Asthma is a common cause of morbidity and mortality in children. Predictive models may help providers tailor asthma therapies to an individual's exacerbation risk. The effectiveness of asthma risk scores on provider behavior and pediatric asthma outcomes remains unknown., Objective: Determine the impact of an electronic health record (EHR) vendor-released model on outcomes for children with asthma., Methods: The Epic Systems Risk of Pediatric Asthma Exacerbation model was implemented on February 24, 2021, for volunteer pediatric allergy and pulmonology providers as a noninterruptive risk score visible in the patient schedule view. Asthma hospitalizations, emergency department (ED) visits, or oral steroid courses within 90 days of the index visit were compared from February 24, 2019, to February 23, 2022, using a difference-in-differences design with a control group of visits to providers in the same departments. Volunteer providers were interviewed to identify barriers and facilitators to model use., Results: In the intervention group, asthma hospitalizations within 90 days decreased from 1.4% (54/3,842) to 0.7% (14/2,165) after implementation with no significant change in the control group (0.9% [171/19,865] preimplementation to 1.0% [105/10,743] post). ED visits in the intervention group decreased from 5.8% (222/3,842) to 5.5% (118/2,164) but increased from 5.5% (1,099/19,865) to 6.8% (727/10,743) in the control group. The adjusted difference-in-differences estimators for hospitalization, ED visit, and oral steroid outcomes were -0.9% (95% confidence interval [CI]: -1.6 to -0.3), -2.4% (-3.9 to -0.8), and -1.9% (-4.3 to 0.5). In qualitative analysis, providers understood the purpose of the model and felt it was useful to flag high exacerbation risk. Trust in the model was calibrated against providers' own clinical judgement., Conclusion: This EHR vendor model implementation was associated with a significant decrease in asthma hospitalization and ED visits within 90 days of pediatric allergy and pulmonology clinic visits, but not oral steroid courses., Competing Interests: E.O. is a co-founder and has equity in Phrase Health, a clinical decision support analytics company. He receives no direct revenue. He has also served as the principal investigator on an R41 and R42 grant with Phrase Health from the National Library of Medicine (NLM) and the National Center for Advancing Translational Science (NCATS). He has received salary support from NLM and NCATS., (Thieme. All rights reserved.)

Background: The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown., Objective: To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department., Methods: This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients., Results: Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed., Conclusions: After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged., Competing Interests: Disclosure: Evan Orenstein is a cofounder and has equity in Phrase Health, a clinical decision support analytics company. He receives no direct revenue. He is also a principal investigator on a phase 1 and phase 2 Small Business Technology Transfer grant with Phrase Health from the National Library of Medicine and the National Center for Advancing Translational Science. He receives salary support through these grants. The other authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities., Objective: In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting., Methods: We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS., Results: Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary., Conclusions: User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation., (©Thinh Hoang Nguyen, Priscila Pereira Cunha, Annabelle Friedman Rowland, Evan Orenstein, Tricia Lee, Swaminathan Kandaswamy. Originally published in JMIR Formative Research (https://formative.jmir.org), 22.08.2023.)

Hospitalized children experience frequent sleep disruptions. We aimed to reduce caregiver-reported sleep disruptions of children hospitalized on the pediatric hospital medicine service by 10% over 12 months., Methods: In family surveys, caregivers cited overnight vital signs (VS) as a primary contributor to sleep disruption. We created a new VS frequency order of "every 4 hours (unless asleep between 2300 and 0500)" as well as a patient list column in the electronic health record indicating patients with this active VS order. The outcome measure was caregiver-reported sleep disruptions. The process measure was adherence to the new VS frequency. The balancing measure was rapid responses called on patients with the new VS frequency., Results: Physician teams ordered the new VS frequency for 11% (1,633/14,772) of patient nights on the pediatric hospital medicine service. Recorded VS between 2300 and 0500 was 89% (1,447/1,633) of patient nights with the new frequency ordered compared to 91% (11,895/13,139) of patient nights without the new frequency ordered ( P = 0.01). By contrast, recorded blood pressure between 2300 and 0500 was only 36% (588/1,633) of patient nights with the new frequency but 87% (11,478/13,139) of patient nights without the new frequency ( P < 0.001). Overall, caregivers reported sleep disruptions on 24% (99/419) of reported nights preintervention, which decreased to 8% (195/2,313) postintervention ( P < 0.001). Importantly, there were no adverse safety issues related to this initiative., Conclusion: This study safely implemented a new VS frequency with reduced overnight blood pressure readings and caregiver-reported sleep disruptions., Competing Interests: Dr. Evan Orenstein is a co-founder and holds equity in Phrase Health©, a clinical decision support analytics company. He receives no direct revenue and is the principal investigator on an R42 grant with Phrase Health funded by the National Library of Medicine (NLM) and the National Center for Advancing Translational Sciences (NCATS). He receives salary support from NLM and NCATS. The other authors have no financial interest to declare., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rituximab, used in the treatment of some rheumatic and kidney diseases, can lead to hepatitis B virus (HBV) reactivation; HBV screening is recommended for those starting this medication. We aimed to improve by 50% the proportion of patients undergoing HBV screening by implementing multimodal interventions to support clinicians in this evidence-based practice. We conducted a quality improvement project from November 2020 to June 2022 at a tertiary care pediatric hospital system, including patients with rheumatic and/or kidney diseases starting rituximab. Multimodal interventions targeting clinicians included electronic health tools (dot phrase, display of screening recommendations and screening results in rituximab order sets/therapy plans), educational meetings, and e-mail/paper reminders. The primary outcome was the proportion of patients with complete HBV screening, while the secondary outcome was utilization of each laboratory component, tracked using statistical process control charts. Pre- and post-intervention data were compared using Fisher's test. One hundred eighty-two patients who had been prescribed rituximab were included, of which 98 (54%) were post-intervention. The proportions of patients undergoing complete HBV screening (6% vs. 44%; p < 0.001), HBsAg collection (60% vs. 79%; p = 0.006), anti-HBsAb collection (14% vs. 54%; p < 0.001), and total anti-HBcAb collection (8% vs. 52%; p < 0.001) were significantly higher in the post-intervention period. Improvement was sustained over 18 months, with shifts and/or data points above the control limits in all measures. Forty-five patients were HBV-non-immune. In this study, multimodal interventions including electronic health tools and education of the provider significantly increased the proportion of patients screened for HBV prior to rituximab and identified immunization opportunities.

Background: Therapeutic duplication, the presence of multiple agents prescribed for the same indication without clarification for when each should be used, can contribute to serious medical errors. Joint Commission standards require that orders contain clarifying information about when each order should be given. In our system, as needed (PRN) acetaminophen and ibuprofen orders are major contributors to therapeutic duplication., Objective: The objective of this study is to design and evaluate effectiveness of clinical decision support (CDS) to reduce therapeutic duplication with acetaminophen and ibuprofen orders., Methods: This study was done in a pediatric health system with three freestanding hospitals. We iteratively designed and implemented two CDS strategies aimed at reducing the therapeutic duplication with these agents: (1) interruptive alert prompting clinicians for clarifying PRN comments at order entry and (2) addition of discrete "first-line" and "second-line" PRN reasons to orders. Therapeutic duplications were measured by manual review of orders for 30-day periods before and after each intervention and 6 months later., Results: Therapeutic duplications decreased from 1,485 in the 30 days prior to the first alert implementation to 818 in the 30 days after but rose back to 1,208 in the 30 days prior to the second intervention. After discrete reasons were added to the order, therapeutic duplication decreased to 336 in the immediate 30 days and 6 months later remained at 277. Alerts firing rates decreased from 76.0 per 1,000 PRN acetaminophen or ibuprofen orders to 42.9 after the second intervention., Conclusion: Interruptive alerts may reduce therapeutic duplication but are associated with high rates of user frustration and alert fatigue. Leveraging discrete PRN reasons for "first line" and "second line" produced a greater reduction in therapeutic duplication as well as fewer interruptive alerts and less manual entry for providers., Competing Interests: E.W.O. is a cofounder and has equity in Phrase Health. He is also the Principal Investigator on an R42 grant from the National Library of Medicine (NLM) and National Center for Advancing Translational Science (NCATS). He receives salary support from the NLM and NCATS but no direct revenue from Phrase Health. Other authors have nothing to disclose., (Thieme. All rights reserved.)

Background: Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs' impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations., Objective: We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service., Methods: We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission., Results: CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (28/227, 12.3% vs 19/81, 23.4%)., Conclusions: The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set., (©Justine Mrosak, Swaminathan Kandaswamy, Claire Stokes, David Roth, Jenna Gorbatkin, Ishaan Dave, Scott Gillespie, Evan Orenstein. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 21.03.2023.)

Background: Influenza causes greater morbidity in children with cancer or sickle cell disease (SCD). Literature on influenza vaccination receipt for these populations is limited in low-vaccination states. Outpatient interventions improve vaccine receipt but isolated inpatient interventions remain unstudied., Procedure: We reviewed influenza vaccine receipt of children with cancer or SCD treated at Children's Healthcare of Atlanta during three influenza seasons. We implemented a clinical decision support intervention during an influenza season and compared influenza vaccine receipt preintervention and postintervention among admitted children., Results: The oncology cohort (N=1548, 60% to 62%) and the SCD cohort (N=2549, 61% to 65%) had similar-to-higher vaccination receipt to the United States (58% to 64%, P =0.01 to 0.79) and Georgia (51% to 56%, P <0.01). The intervention did not significantly improve vaccination receipt for admitted children with cancer (40% vs. 56%, P =0.05 to 0.88) or SCD (44% vs. 56%, P =0.01). Regression modeling also found no significant increase in vaccine receipt (hematologic malignancy: 0.8 [0.73 to 0.98], solid tumor: 0.9 [0.80 to 1.90], central nervous system tumor: 0.9 [0.71 to 1.14], SCD: 0.9 [0.85 to 0.99])., Conclusions: Children with cancer and SCD have similar-to-greater influenza vaccination receipt compared with Georgia and the United States. An inpatient intervention did not significantly improve influenza vaccine receipt in these patient cohorts. Future studies are needed to identify alternative approaches to improving vaccine receipt in these cohorts., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The ocean is experiencing unprecedented rapid change, and visually monitoring marine biota at the spatiotemporal scales needed for responsible stewardship is a formidable task. As baselines are sought by the research community, the volume and rate of this required data collection rapidly outpaces our abilities to process and analyze them. Recent advances in machine learning enables fast, sophisticated analysis of visual data, but have had limited success in the ocean due to lack of data standardization, insufficient formatting, and demand for large, labeled datasets. To address this need, we built FathomNet, an open-source image database that standardizes and aggregates expertly curated labeled data. FathomNet has been seeded with existing iconic and non-iconic imagery of marine animals, underwater equipment, debris, and other concepts, and allows for future contributions from distributed data sources. We demonstrate how FathomNet data can be used to train and deploy models on other institutional video to reduce annotation effort, and enable automated tracking of underwater concepts when integrated with robotic vehicles. As FathomNet continues to grow and incorporate more labeled data from the community, we can accelerate the processing of visual data to achieve a healthy and sustainable global ocean., (© 2022. The Author(s).)

Background: We aimed to develop and validate a rule-based Natural Language Processing (NLP) algorithm to detect sexual history documentation and its five key components [partners, practices, past history of sexually transmitted infections (STIs), protection from STIs, and prevention of pregnancy] among adolescent encounters in the pediatric emergency and inpatient settings., Methods: We iteratively designed a NLP algorithm using pediatric emergency department (ED) provider notes from adolescent ED visits with specific abdominal or genitourinary (GU) chief complaints. The algorithm is composed of regular expressions identifying commonly used phrases in sexual history documentation. We validated this algorithm with inpatient admission notes for adolescents. We calculated the sensitivity, specificity, negative predictive value, positive predictive value, and F1 score of the tool in each environment using manual chart review as the gold standard., Results: In the ED test cohort with abdominal or GU complaints, 97/179 (54%) provider notes had a sexual history documented, and the NLP algorithm correctly classified each note. In the inpatient validation cohort, 97/321 (30%) admission notes included a sexual history, and the NLP algorithm had 100% sensitivity and 98.2% specificity. The algorithm demonstrated >97% sensitivity and specificity in both settings for detection of elements of a high quality sexual history including protection used and contraception. Type of sexual practice and STI testing offered were also detected with >97% sensitivity and specificity in the ED test cohort with slightly lower performance in the inpatient validation cohort., Conclusion: This NLP algorithm automatically detects the presence of sexual history documentation and its key components in ED and inpatient settings., (Copyright © 2022 Robertson, Mukherjee, Gooding, Kandaswamy and Orenstein.)

Every heatlhcare encounter is an opportunity to provide both acute care and health maintenance to children. A Clinical Decision Support (CDS) intervention was instituted in a tertiary pediatric health system to improve influenza vaccination rates during the 2019-2020 season among eligible children receiving care in an acute care inpatient healthcare setting. This study explores reasons for low vaccine uptake following implementation of a CDS aimed at improving vaccine administration as well as identifying possible solutions to improve flu vaccine coverage.

Objective: Safe care of central venous access devices (CVAD) requires clinicians be able to identify key CVAD properties from insertion until safe removal. Our objective was to design and evaluate interfaces to improve CVAD documentation quality and information retrieval., Materials and Methods: We applied user-centered design (UCD) to CVAD property documentation interfaces. We measured expert agreement and front-line clinician accuracy in retrieving key properties in CVADs documented pre- and postimplementation., Results: The new approach (1) optimized searches for line types, (2) enabled discrete entry of key properties which propagated to the display name, and (3) facilitated error correction by experts. Expert agreement on key CVAD properties improved from 42% to 83% ( P  < 0.01). Frontline nurses' perception of key CVAD properties improved from 31% to 86% ( P  < 0.01). Ease of use scores improved from 15/100 to 80/100 ( P  < 0.01)., Conclusions: UCD significantly improved data quality and nurse perception of CVAD properties to guide subsequent care., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Purpose: Sexually transmitted infections (STIs) are disproportionally prevalent in adolescents, and adolescents often present to the pediatric emergency department (PED) for STI care. Prior studies have found low rates of sexual history documentation and STI testing in the PED. However, these studies have had limited sample sizes because of the burden of manual chart review. We aimed to estimate the rate of sexual history documentation and identify factors associated with STI testing in a large cohort of adolescents using natural language processing (NLP)., Methods: We applied a validated NLP algorithm to all adolescent visits over a three-year period to the PED at a single large children's health care organization with a chief complaint potentially related to an STI. We utilized NLP to determine the prevalence of sexual history documentation in these patients. We applied logistic regression models to determine associations between sexual history documentation, patient demographic factors, and STI testing., Results: Of the 1,987 patient encounters included, only 56% had a sexual history documented, and only 40% of all patients were tested for STIs. Patients were more likely to have a sexual history documented and to be tested for STIs if they were of non-Hispanic black race/ethnicity, were >15 years of age, and had nonprivate insurance. Patients with a sexual history documented were seven times more likely to have STI testing ordered. Of patients tested (n = 728), 25% were positive for an STI., Conclusions: Despite presenting to the PED with symptoms potentially related to an STI, many adolescents are not receiving recommended sexual health care. Rates of sexual history documentation and STI testing varied by demographic factors including race, age, and insurance status. Utilizing NLP technology allowed us to examine a larger sample size than previously documented in the adolescent sexual history and PED literature. This study highlights critical opportunities to improve sexual health provision and equity of care provided in the PED., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives of this study were to (1) describe barriers to using clinical practice guideline (CPG) admission order sets in a pediatric hospital and (2) determine if integrating CPG order bundles into a general admission order set increases adoption of CPG-recommended orders compared to standalone CPG order sets. We identified CPG-eligible encounters and surveyed admitting physicians to understand reasons for not using the associated CPG order set. We then integrated CPG order bundles into a general admission order set and evaluated effectiveness through summative usability testing in a simulated environment. The most common reasons for the nonuse of CPG order sets were lack of awareness or forgetting about the CPG order set. In usability testing, CPG order bundle use increased from 27.8% to 66.6% while antibiotic ordering errors decreased from 62.9% to 18.5% with the new design. Integrating CPG-related order bundles into a general admission order set improves CPG order set use in simulation by addressing the most common barriers to CPG adoption., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Plankton interact with the environment according to their size and three-dimensional (3D) structure. To study them outdoors, these translucent specimens are imaged in situ. Light projects through a specimen in each image. The specimen has a random scale, drawn from the population's size distribution and random unknown pose. The specimen appears only once before drifting away. We achieve 3D tomography using such a random ensemble to statistically estimate an average volumetric distribution of the plankton type and specimen size. To counter errors due to non-rigid deformations, we weight the data, drawing from advanced models developed for cryo-electron microscopy. The weights convey the confidence in the quality of each datum. This confidence relies on a statistical error model. We demonstrate the approach on live plankton using an underwater field microscope.

Introduction: Communication between pediatric hospitalists and primary care physicians (PCPs) at discharge is an essential part of a successful transition to home. While many hospitals require communicating with PCPs for all admitted patients, it is unknown if PCPs find such communication valuable or if it improves outcomes. Our global aim was to improve discharge communication for patients that pediatric hospitalists and PCPs deemed appropriate., Methods: We sent surveys to 422 outpatient pediatricians in our care network to understand their communication preferences. Survey results informed local guidelines for when hospitalists should directly contact PCPs. We determined the proportion of inpatient discharges meeting those guidelines and set a target for our primary process metric: the proportion of discharges with attempted direct PCP contact. We engaged in Plan-Do-Study-Act cycles, including a discharge documentation tool in the electronic health record, education of inpatient teams, email reminders including group performance data, asynchronous Health Insurance Portability and Accountability Act-compliant messaging application, and competitions that shared blinded individual data., Results: We increased the percentage of documented direct communication with the PCPs from 2% to 33% and from 4% to 65% for those who met guidelines for direct communication., Conclusions: PCPs only want direct communication on a subset of discharges. Interventions focused on high-yield populations improved discharge communication in our institution., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

III-V materials such as indium arsenide (InAs) and gallium arsenide (GaAs) are increasingly used in electronic and photovoltaic devices. The extensive application of these materials may lead to release of III-V ionic species during semiconductor manufacturing or disposal of decommissioned devices into the environment. Although arsenic is recognized as an important contaminant due to its high toxicity, there is a lack of information about the toxic effects of indium and gallium ions. In this study, acute toxicity of As(III), As(V), In(III) and Ga(III) species was evaluated using two microbial assays testing for methanogenic activity and O 2 uptake, as well as two bioassays targeting aquatic organisms, including the marine bacterium Aliivibrio fischeri (bioluminescence inhibition) and the crustacean Daphnia magna (mortality). The most noteworthy finding was that the toxicity is mostly impacted by the element tested. Secondarily, the toxicity of these species also depended on the bioassay target. In(III) and Ga(III) were not or only mildly toxic in the experiments. D. magna was the most sensitive organism for In(III) and Ga(III) with 50% lethal concentrations of 0.5 and 3.4mM, respectively. On the other hand, As(III) and As(V) caused clear inhibitory effects, particularly in the methanogenic toxicity bioassay. The 50% inhibitory concentrations of both arsenic species towards methanogens were about 0.02mM, which is lower than the regulated maximum allowable daily effluent discharge concentration (2.09mg/L or 0.03mM) for facilities manufacturing electronic components in the US. Overall, the results indicate that the ecotoxicity of In(III) and Ga(III) is much lower than that of the As species tested. This finding is important in filling the knowledge gap regarding the ecotoxicology of In and Ga., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: There is evidence to suggest that people with aphasia (PWA) may have deficits in attention stemming from the inefficient allocation of resources. The inaccurate perception of task demand, or sense of effort, may underlie the misallocation of the available attention resources. Given the lack of treatment options for improving attention in aphasia, Mindfulness Meditation, shown to improve attention in neurologically intact individuals, may prove effective in increasing attention in PWA., Aims: The purpose of the present study was to determine if Mindfulness Meditation improves divided attention or language in PWA and if it affects the overall sense of effort., Methods & Procedures: A multiple baseline single-subject design was used to determine the effects of Mindfulness Meditation on divided attention for three PWA. Divided attention was measured using a non-linguistic divided attention task. Visual inspection of the data was used to determine changes in performance (sense of effort, reaction time and accuracy, language) over time., Outcomes & Results: High performance observed on the attention measures suggests that PWA have varying degrees of attentional impairment that may surface when certain demands are presented. There were no observable changes in the performance on the sense of effort or language measures; however, measures of reaction time may indicate Mindfulness Meditation improved efficiency of task completion., Conclusions & Implications: All three participants reported that Mindfulness Meditation was easy to learn and carry out on a daily basis, and reported feeling more 'relaxed' and 'peaceful' after Mindfulness Meditation training than before. With the knowledge that PWA can learn meditative practices, and with such successful findings in neurologically intact individuals, it is important to continue evaluating the benefits of Mindfulness Meditation in PWA., (© 2012 Royal College of Speech and Language Therapists.)

Background: Emerging research suggests that genetically distinct strains of Mycobacterium tuberculosis may modulate the immune system differently. This may be of importance in high-burden settings where > or =1 genetic group of M. tuberculosis confers significant morbidity., Methods: A dynamic mathematical model was constructed to evaluate how different degrees of cross-immunity among M. tuberculosis groups could affect epidemics of drug-resistant tuberculosis (TB)., Results: Simulated populations with immunogenically distinct TB strain groups experienced a heightened risk of drug-resistant TB, compared with populations without such strain diversity, even when the same rates of case detection and treatment success were achieved. The highest risks of infection were observed in populations in which HIV was prevalent. Drug-resistant strains with very low transmission fitness could still propagate in environments with reduced cross-immunity among different strain groups, even after common targets for case detection and treatment success are reached., Conclusions: It is possible that the propagation of drug-resistant strains could depend not only on the rate of development of resistance and the fitness of the drug-resistant strains but, also, on the diversity of the strains in the region. The risk of infection with drug-resistant strains could be amplified in locations where there is reduced cross-immunity between originating strain groups. This amplification may be most profound during the first few decades of TB treatment expansion.

Measures to decrease contact between persons during an influenza pandemic have been included in pandemic response plans. We used stochastic simulation models to explore the effects of school closings, voluntary confinements of ill persons and their household contacts, and reductions in contacts among long-term care facility (LTCF) residents on pandemic-related illness and deaths. Our findings suggest that school closings would not have a substantial effect on pandemic-related outcomes in the absence of measures to reduce out-of-school contacts. However, if persons with influenzalike symptoms and their household contacts were encouraged to stay home, then rates of illness and death might be reduced by approximately 50%. By preventing ill LTCF residents from making contact with other residents, illness and deaths in this vulnerable population might be reduced by approximately 60%. Restricting the activities of infected persons early in a pandemic could decrease the pandemic's health effects.

Anterior repositioning appliances are commonly used for treating patients with an anterior disk displacement with reduction. The goal is to regain a proper disk to condyle relationship. Several questions immediately arise: Does the absence of joint noise indicate that the disk is properly positioned over the head of the condyle? Does this anterior position promote healing of the ligaments surrounding the disk?; and, is this anterior position merely therapeutic, or should the mandible be kept in this forward position? This review of the literature is intended to explore how anterior repositioning appliances are used in temporomandibular joint dysfunction (TMD) patients. Hopefully, it will answer questions and also raise more questions about our treatment objectives when dealing with dysfunctional patients.