Quality improvement in immunization delivery following an unsuccessful immunization recall.

OBJECTIVES: Within a clinic serving disadvantaged children, 1) to evaluate a multifaceted quality improvement (QI) project to improve immunization (IZ) up-to-date (UTD) rates and 2) to assess the efficacy of IZ reminder/recall performed following QI. METHODS: A year-long QI project followed by a trial of reminder/recall. QI interventions were targeted at previously identified barriers to IZ and were designed specifically to improve the efficacy of reminder/recall. QI interventions were designed to 1) increase the use of medical record releases to document IZs received elsewhere; 2) improve the accuracy of parental contact information; and 3) reduce missed opportunities by utilizing chart prompts, provider education, and provider reminders. Following QI, we conducted a randomized trial of reminder/recall. RESULTS: UTD rates for 7-11 month olds increased from 21% before the QI project to 52% after (P <.0001); rates for 12-18 month olds increased from 16% before QI to 44% after (P <.0001); 19-25 month olds 18% before to 33% after (P <.001). After QI, an average of 61 records per month were updated with IZs received elsewhere. However, the accuracy of parental contact information worsened (29% unreachable before QI vs 44% after, P <.001) and missed opportunities did not improve (8% before vs 6% after, P = not significant [NS]). A subsequent trial of reminder/recall did not increase UTD rates, with 17% of recalled children brought UTD vs 16% of controls (P = NS). CONCLUSIONS: Clinic-based QI increased documented UTD rates in a disadvantaged patient population. However, IZ reminder/recall did not further increase UTD rates above the rates achieved by the QI process.     

Peroneal latency in normal and injured ankles at varying angles of perturbation

The aim of this study was to determine whether there was a difference in latency of the peroneus longus muscle at varying amplitudes of ankle inversion perturbation and between individuals with and without a history of ankle injury. Thirty-four male athletes from different football codes (soccer, rugby) received four random tilts to their left ankles at 5 degrees, 10 degrees, and 15 degrees in the frontal plane on a dual platform trap door. Peroneal latency was defined as the time difference between onset of the trap door movement, as detected by an accelerometer, and the onset of muscle activation above a resting baseline, as recorded using surface electromyography. Latency was determined using an algorithm. A series of repeated measures analyses of variance indicated that the latency was reliable between trials. There was no statistical evidence that history of injury or subjective ankle instability influenced the latency; however, there was a systematic difference between dominant and nondominant legs (dominant, 6.3 ms faster), and there was a small systematic effect (3 ms) for the angle of inversion perturbation. Muscle latency responses in male football players are thought to be influenced more by dominance than by history of injury or amplitude of perturbation.     

Contribution of edema and cerebral blood volume to traumatic brain swelling in head-injured patients

OBJECT: The pathogenesis of traumatic brain swelling remains unclear. The generally held view is that brain swelling is caused primarily by vascular engorgement and that edema plays a relatively minor role in the swelling process. The goal of this study was to examine the roles of cerebral blood volume (CBV) and edema in traumatic brain swelling. METHODS: Both brain-tissue water and CBV were measured in 76 head-injured patients, and the relative contribution of edema and blood to total brain swelling was determined. Comparable measures of brain-tissue water were obtained in 30 healthy volunteers and CBV in seven volunteers. Brain edema was measured using magnetic resonance imaging, implementing a new technique for accurate measurement of total tissue water. Measurements of CBV in a subgroup of 31 head-injured patients were based on consecutive measures of cerebral blood flow (CBF) obtained using stable xenon and calculation of mean transit time by dynamic computerized tomography scanning after a rapid bolus injection of iodinated contrast material. The mean (+/- standard deviation) percentage of swelling due to water was 9.37+/-8.7%, whereas that due to blood was -0.8+/-1.32%. CONCLUSIONS: The results of this study showed that brain edema is the major fluid component contributing to traumatic brain swelling. Moreover, CBV is reduced in proportion to CBF reduction following severe brain injury.     

Higher executive abilities following a blood transfusion in children and young adults with sickle cell disease

Individuals with sickle cell disease (SCD) experience cognitive deficits; however, it remains unclear whether medical treatments for SCD improve cognition. Given that executive abilities are typically impaired in individuals with SCD, they were the focus of the current study. Our primary hypothesis was that executive abilities would be higher acutely soon after a blood transfusion in children and young adults with SCD. We used tests from the NIH Toolbox to assess executive abilities in 27 participants with SCD receiving chronic transfusion in comparison to 34 participants with SCD receiving hydroxyurea (HU) and 41 non‐SCD demographically matched controls, all of whom were tested at two time points. Participants in the transfusion group completed cognitive testing within 3 days after a transfusion (soon after transfusion) and then within 3 days before their next transfusion (long after transfusion) over an interval of 3‐7 weeks. We found that executive abilities were significantly poorer for the transfusion and HU groups than for the control group. In support of our primary hypothesis, executive abilities for the transfusion group were significantly better soon after a transfusion compared to long after a transfusion, χ²(1) = 17.8, P < .0001. Our results demonstrate that executive abilities were higher acutely following a blood transfusion. These findings have implications for daily functioning, medical decision making, and academic achievement in children and young adults with SCD.     

Explaining the Varying Patterns of COVID-19 Deaths Across the United States: 2-Stage Time Series Clustering Framework

BackgroundSocially vulnerable communities are at increased risk for adverse health outcomes during a pandemic. Although this association has been established for H1N1, Middle East respiratory syndrome (MERS), and COVID-19 outbreaks, understanding the factors influencing the outbreak pattern for different communities remains limited.ObjectiveOur 3 objectives are to determine how many distinct clusters of time series there are for COVID-19 deaths in 3108 contiguous counties in the United States, how the clusters are geographically distributed, and what factors influence the probability of cluster membership.MethodsWe proposed a 2-stage data analytic framework that can account for different levels of temporal aggregation for the pandemic outcomes and community-level predictors. Specifically, we used time-series clustering to identify clusters with similar outcome patterns for the 3108 contiguous US counties. Multinomial logistic regression was used to explain the relationship between community-level predictors and cluster assignment. We analyzed county-level confirmed COVID-19 deaths from Sunday, March 1, 2020, to Saturday, February 27, 2021.ResultsFour distinct patterns of deaths were observed across the contiguous US counties. The multinomial regression model correctly classified 1904 (61.25%) of the counties’ outbreak patterns/clusters.ConclusionsOur results provide evidence that county-level patterns of COVID-19 deaths are different and can be explained in part by social and political predictors.