Thanks very much. Oh, it is so nice to see all of you We really thought we were going to be talking to an empty room because everyone went to lunch So we're really happy to see this big group As dr. Hall said I'm Charlene I'm a nurse practitioner from UF Gainesville, and I'm also a clinical researcher and I'm going to talk to you about the past publications from 2022 in clinical science Maybe Okay Now it's working I have no financial disclosures to make because as already mentioned we didn't write these papers We're just sharing with you things that we hoped you haven't missed over the past year the objective of this presentation was to gather the relevant publications from January through November of 2022 and Collate a list of them that we thought were important to share and briefly appraise them and Discuss our applicability to clinical practice to do this I did a PubMed search with the search terms that you see there Excluding guidelines as they're already talked about in other forums during Congress and other sources Excluding reviews and non-clinical papers. I then looked at altmetric scores Website page views and citations as markers of impact if you're not familiar with the altmetric score for research output it's basically a weighted score of the impact and sharing of the paper and it takes into account factors such as news media and Social media and things like how many people have been sharing or talking about that particular paper? And we'll talk we'll show the altmetric scores of the papers as I move forward Not sure why that's happening, but that's okay The first paper I'm going to share is epidemiology and outcomes of SARS-CoV-2 infection or multi-inflammatory syndrome in children first influenza Among critically ill children which published in JAMA Open Network in June By Steve Schein, Chris Carroll, Ken Ramey et al. You'll see the altmetric score Which is the thing inside the colorful circle down there to the right of 413. That's super high if you're not familiar with those scores That is in the top 5% of all altmetric scores for the year And there were over as of end of November when I put this together there were over 15,000 page views of this study Sorry, this was a Study using the virtual pediatric systems database and they were comparing epidemiology and outcomes of almost 2,000 PICU patients with SARS-CoV-2 disease both COVID and MIS-C during the first 15 months of the pandemic versus about 1,500 patients with critical flu prior to the pandemic and that was a group from Spring of 2018 to spring of 2020 just before the pandemic Those graphics there. I know you can't read but you can see the colors and basically on the The The dark blue are the flu patients and the light blue are the influenza patients and on the top graphic the y-axis has the quarterly patient volumes admitted and on the x-axis, they have kind of breakdowns view of With and without comorbidities and Hospital length of stay is on the bottom graphic on the y-axis, etc The to be included in the study you had to contribute all 13 quarters of data collection so it ended up being 66 centers that were included in the analysis and You can see that all of the light blue bars are higher than all of the dark blue bars So basically their results were that there was a higher volume per center per quarter of the SARS-CoV-2 related illness than Influenza related illness and There were twice as many admissions a third more intubations Both PICU and hospital length of stay were longer and there were similar patterns with and without comorbidities The mortality risk was higher for SARS-CoV-2 by PIM-2 scores, but the actual mortality did not differ and The what prompted them to do this study would have kind of reading between the lines were the early Comparisons in the media and from the public of you know, is this just the flu quote-unquote? So I think they've successfully answered that question Limitations, of course as a database study. They only had data available in the database and that may have been a little bit skewed because Theoretically Centers may have not been as comfortable early particularly early in the pandemic taking care of the kovat patients or the early miss see Patients so it may reflect a little bit of a disproportionate referral to the participating hospitals impact on clinical practice It's just support for ongoing public health mitigation members measures and for vaccine advocacy The second paper is a follow-up the pre-work for this study was presented at last year's peds in review and Now this is the result of the of that so in case anybody caught this during last year's peds in review Just giving the second half basically of the results And this is the Association of Diagnostic Stewardship for blood cultures and critically ill children with culture rates antibiotic use and patient outcomes and it's the result of the bright star collaborative which was published in GM a pediatrics in May of 2022 By dr. Woods Hill Elizabeth Cullen Tony Danielle Coons at all You'll see another super high altmetric score down there of 365 which was also in the top 5% of all scores There were over 4,000 page views And already this should be a for for citations Of this study so far even though it was recently published There were also 43 media outlet sharings of this Paper so it was very popular. I Don't expect you to be able to read this But I'll kind of talk you through it so that if you choose to read the paper if you haven't already read the paper You'll know what these graphics are and kind of what to look for. So Bacterial cultures as we know are often associated with starting antibiotics So this project aimed at focus stewardship of microbiology testing as a strategy to reduce antibiotic Overuse and development of resistance and the star in the bright star stood for a testing stewardship for antibiotic reduction This was a multidisciplinary Collaborative quality improvement effort and super interesting organization of This so they had experts at each site in pediatric infectious disease critical care quality improvement human factors engineering and statistics And each site had a similar makeup team at their sites The each site did a pre-assessment of their current practices And then they developed a site-specific clinical decision support tool and an implementation plan The left figure there is their timeline so you can see that this takes a good while to do this figure represents an 18 month time period and The outcomes are on the right the things I really want to highlight from that table Which I know you can't read but I'll just tell you are that they had a 33% relative reduction in blood culture rate as well As a 13% relative reduction in broad-spectrum antibiotic use overall 8% relative reduction in new initiation of broad-spectrum antibiotics their rates of CLABSI Which we all know are super important markers to keep our hospital administrators happy were 36% reduced Balancing measures for their project included mortality PICU length of stay readmission rates and all forms of sepsis And those were similar before and after implementation There were some technical limitations and those are detailed in the manuscript But the main thing I want to highlight is that all of these sites were really experienced and resourced So this could certainly impact generalizability The clinical applicability part is the really interesting part here so They focused on patients that were admitted for more than three days recognizing that within the first 48 hours patients getting cultures and antibiotics are It's very high risk that they have sepsis or someone's concerned that they're high risk for sepsis So why not focus on the patients that have been minimal for more than three days already in your ICU who are not? Super high risk for sepsis in your opinion who have spiked this new fever and you want to investigate whether or not They need cultures and that's sort of the the The target of the study that I think in Relatively stable patients who have been in your ICU for more than three days who have a fever But don't have other signs of sepsis Can we impact our care and it seems that even if we don't have the resources to put together this Strong team like they do like I know I don't have access to human systems engineers or human factors engineers But I certainly could take pieces of this approach and implement it in my own unit Moving on to a paper that was published in JAMA of June of 2022 We have the effect of high flow nasal cannula therapy versus continuous positive airway pressure therapy on liberation from respiratory support In acutely ill children admitted to pediatric critical care units a randomized clinical trial This was from Padma Dabhan, Radmarayan, Alvin Richards-Bell, Laura Druckett and all Representing the first ABC step-up RCT investigators and the Pediatric Critical Care Society study group from the UK This has another high altmetric score of 119, which again is in the top 5% of all scores had over 11,000 page views and Rather Than make my own side about this study the journal provided a handy infographic which I'll just quickly walk through So at the top of the infographic the research question is there It is an acutely ill children who require non-invasive respiratory support is first-line use of high flow nasal cannula and non-inferior to CPAP for time to liberation for all forms of Respiratory support so to answer this question they conducted a pragmatic randomized non-inferiority clinical trial 600 patients were randomized in 24 units in the UK they were randomized one-to-one to commence either high flow, which was weight-based or CPAP which started at seven to eight centimeters of water the primary outcome again was the medium median time to liberation from support and they defined that as The first hour they were off of any support for a 48 hour period The high flow subjects did meet the non-inferiority margin criteria As you can see there on the right There were seven secondary outcomes and the top three which were mortality at critical care discharge intubation within 48 hours and use of sedation Were all lower in actually the high flow group Which is interesting For Limitations the study was not blinded which raised some interesting Aspects so that may have influenced decisions to Switch or escalate treatment remember this was only the initial treatment randomization Or to start treatment at all there was a high rate of switching from CPAP to high flow for perceived patient discomfort as well as a large number who were Randomized to CPAP who never ended up starting therapy at all. So That's an interesting limitation of the study as far as the potential Sorry before I move to the clinical practice I do want to mention the authors mentioned That there were a thousand children that were not able to be included because they had already received prior non-invasive support which is a pretty big number and then Data related to feeding were not collected as part of the trial and the authors mentioned that this made it not possible to assess the effect of feeding on patient comfort And then impact of clinical practice really just reassurance that whatever your modality of preference is is not inferior So carry on as you were basically And with that I'll wrap it up for the clinical portion of the year

clinical science

PubMed search

altmetric scores

SARS-CoV-2 infection

diagnostic stewardship