Patient Care

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Can a collaborative quality improvement project improve the quality and efficiency of pediatric hospital discharges?

Background: Transitions of care, including at the time of hospital discharge, are a potential source of risk and can be associated with adverse events including medication errors and preventable readmissions. Some studies have shown that 10–20% of patients had an adverse event after discharge, and half of those were preventable; one adult study found nearly half of the discharged patients had at least one medication error.1,2 Although multiple projects to improve the discharge process have been published in adult literature, few have focused on the pediatric population. In this study, the Children’s Hospital Association (CHA) formed a pediatric quality improvement collaborative across multiple facilities to examine whether shared improvement strategies would affect failures of discharge-related care, parent-reported readiness for discharge, and readmission rates.

Study Design: Multicenter quality improvement collaborative.

Setting: 11 freestanding tertiary-care children’s hospitals in the United States.

Synopsis: Each of the 11 participating sites chose a specific target population, such as patients with sickle cell disease, asthma, or all discharged pediatric patients. Populations were selected at the discretion of the sites. A multidisciplinary expert advisory panel reviewed literature and developed a change package that included being proactive about discharge planning during hospitalization; improving throughput; arranging post-discharge treatment and support; and communicating post-discharge plan with patients, families, and providers. Each site selected elements of the change package to implement based on individual needs and preferences and incorporated via plan-do-study-act cycles during three action periods. Elements that were implemented by most or all sites included family education on diagnosis and discharge plans, use of discharge checklists, improvement of written discharge instructions, post-discharge follow-up phone calls to reinforce discharge instructions, and identifying and obtaining medications. Virtual learning conferences and monthly Web conferences were held for participants in the collaborative, and experienced improvement coaches guided teams through implementation.

The primary aim of the study was to reduce discharge-related care failures by 50% in 12 months. Failures were measured by phone calls to families two to seven days following discharge, and if any problem related to discharge occurred, the discharge was considered a failure (all-or-none measure). Components of this measure included understanding the diagnosis, receiving discharge instructions and education, complying with instructions, receiving necessary equipment, planning for follow-up pending tests, receiving help with appointments, and not requiring a related unplanned medical visit. Other measures evaluated in this study included patient/family readiness for discharge and unplanned readmission rates (72 hours and 30 days).

Overall, the rate of failures of discharge care was 34% at baseline, which decreased to 21% at the end of the collaborative, for a reduction of 40%. Some individual hospitals exceeded this mark as well. Among the hospitals reporting data on family readiness for discharge, there was a statistically significant improvement, with 85% of families at baseline rating readiness in the highest category and 91% in the last quarter of the study. There was no improvement in rates of unplanned readmission, with 72-hour readmission rates steady across the project (0.7% at onset, 1.1% at end of study; P = 0.29) and slight worsening of the 30-day rate (4.5% to 6.3%; P = 0.05).

Potential explanations for the findings related to readmission rates include seasonal variability in readmissions as well as high variability in patients included in the study. For example, one site focused on patients with sickle cell disease, another on patients with asthma, and others included all diagnoses. Overall, unplanned readmission rates were low (around 1% for 72-hour, 5% for 30-day), which is consistent with other pediatric studies.

Bottom Line: In this study, institutions using a collaborative approach improved the quality of inpatient discharges by using an intervention bundle in pediatric hospital settings. There was no improvement noted in readmission rates, although these rates were low.

Citation: Wu S, Tyler A, Logsdon T, et al. A quality improvement collaborative to improve the discharge process for hospitalized children. Pediatrics. 2016;138(2). pii:e20143604.

References:

1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
2. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.

Clinical Question: Can a collaborative quality improvement project improve the quality and efficiency of pediatric hospital discharges?

Background: Transitions of care, including at the time of hospital discharge, are a potential source of risk and can be associated with adverse events including medication errors and preventable readmissions. Some studies have shown that 10–20% of patients had an adverse event after discharge, and half of those were preventable; one adult study found nearly half of the discharged patients had at least one medication error.1,2 Although multiple projects to improve the discharge process have been published in adult literature, few have focused on the pediatric population. In this study, the Children’s Hospital Association (CHA) formed a pediatric quality improvement collaborative across multiple facilities to examine whether shared improvement strategies would affect failures of discharge-related care, parent-reported readiness for discharge, and readmission rates.

Study Design: Multicenter quality improvement collaborative.

Setting: 11 freestanding tertiary-care children’s hospitals in the United States.

Synopsis: Each of the 11 participating sites chose a specific target population, such as patients with sickle cell disease, asthma, or all discharged pediatric patients. Populations were selected at the discretion of the sites. A multidisciplinary expert advisory panel reviewed literature and developed a change package that included being proactive about discharge planning during hospitalization; improving throughput; arranging post-discharge treatment and support; and communicating post-discharge plan with patients, families, and providers. Each site selected elements of the change package to implement based on individual needs and preferences and incorporated via plan-do-study-act cycles during three action periods. Elements that were implemented by most or all sites included family education on diagnosis and discharge plans, use of discharge checklists, improvement of written discharge instructions, post-discharge follow-up phone calls to reinforce discharge instructions, and identifying and obtaining medications. Virtual learning conferences and monthly Web conferences were held for participants in the collaborative, and experienced improvement coaches guided teams through implementation.

The primary aim of the study was to reduce discharge-related care failures by 50% in 12 months. Failures were measured by phone calls to families two to seven days following discharge, and if any problem related to discharge occurred, the discharge was considered a failure (all-or-none measure). Components of this measure included understanding the diagnosis, receiving discharge instructions and education, complying with instructions, receiving necessary equipment, planning for follow-up pending tests, receiving help with appointments, and not requiring a related unplanned medical visit. Other measures evaluated in this study included patient/family readiness for discharge and unplanned readmission rates (72 hours and 30 days).

Overall, the rate of failures of discharge care was 34% at baseline, which decreased to 21% at the end of the collaborative, for a reduction of 40%. Some individual hospitals exceeded this mark as well. Among the hospitals reporting data on family readiness for discharge, there was a statistically significant improvement, with 85% of families at baseline rating readiness in the highest category and 91% in the last quarter of the study. There was no improvement in rates of unplanned readmission, with 72-hour readmission rates steady across the project (0.7% at onset, 1.1% at end of study; P = 0.29) and slight worsening of the 30-day rate (4.5% to 6.3%; P = 0.05).

Potential explanations for the findings related to readmission rates include seasonal variability in readmissions as well as high variability in patients included in the study. For example, one site focused on patients with sickle cell disease, another on patients with asthma, and others included all diagnoses. Overall, unplanned readmission rates were low (around 1% for 72-hour, 5% for 30-day), which is consistent with other pediatric studies.

Bottom Line: In this study, institutions using a collaborative approach improved the quality of inpatient discharges by using an intervention bundle in pediatric hospital settings. There was no improvement noted in readmission rates, although these rates were low.

Citation: Wu S, Tyler A, Logsdon T, et al. A quality improvement collaborative to improve the discharge process for hospitalized children. Pediatrics. 2016;138(2). pii:e20143604.

References:

1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
2. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.

Clinical Question: Can a collaborative quality improvement project improve the quality and efficiency of pediatric hospital discharges?

Background: Transitions of care, including at the time of hospital discharge, are a potential source of risk and can be associated with adverse events including medication errors and preventable readmissions. Some studies have shown that 10–20% of patients had an adverse event after discharge, and half of those were preventable; one adult study found nearly half of the discharged patients had at least one medication error.1,2 Although multiple projects to improve the discharge process have been published in adult literature, few have focused on the pediatric population. In this study, the Children’s Hospital Association (CHA) formed a pediatric quality improvement collaborative across multiple facilities to examine whether shared improvement strategies would affect failures of discharge-related care, parent-reported readiness for discharge, and readmission rates.

Study Design: Multicenter quality improvement collaborative.

Setting: 11 freestanding tertiary-care children’s hospitals in the United States.

Synopsis: Each of the 11 participating sites chose a specific target population, such as patients with sickle cell disease, asthma, or all discharged pediatric patients. Populations were selected at the discretion of the sites. A multidisciplinary expert advisory panel reviewed literature and developed a change package that included being proactive about discharge planning during hospitalization; improving throughput; arranging post-discharge treatment and support; and communicating post-discharge plan with patients, families, and providers. Each site selected elements of the change package to implement based on individual needs and preferences and incorporated via plan-do-study-act cycles during three action periods. Elements that were implemented by most or all sites included family education on diagnosis and discharge plans, use of discharge checklists, improvement of written discharge instructions, post-discharge follow-up phone calls to reinforce discharge instructions, and identifying and obtaining medications. Virtual learning conferences and monthly Web conferences were held for participants in the collaborative, and experienced improvement coaches guided teams through implementation.

The primary aim of the study was to reduce discharge-related care failures by 50% in 12 months. Failures were measured by phone calls to families two to seven days following discharge, and if any problem related to discharge occurred, the discharge was considered a failure (all-or-none measure). Components of this measure included understanding the diagnosis, receiving discharge instructions and education, complying with instructions, receiving necessary equipment, planning for follow-up pending tests, receiving help with appointments, and not requiring a related unplanned medical visit. Other measures evaluated in this study included patient/family readiness for discharge and unplanned readmission rates (72 hours and 30 days).

Overall, the rate of failures of discharge care was 34% at baseline, which decreased to 21% at the end of the collaborative, for a reduction of 40%. Some individual hospitals exceeded this mark as well. Among the hospitals reporting data on family readiness for discharge, there was a statistically significant improvement, with 85% of families at baseline rating readiness in the highest category and 91% in the last quarter of the study. There was no improvement in rates of unplanned readmission, with 72-hour readmission rates steady across the project (0.7% at onset, 1.1% at end of study; P = 0.29) and slight worsening of the 30-day rate (4.5% to 6.3%; P = 0.05).

Potential explanations for the findings related to readmission rates include seasonal variability in readmissions as well as high variability in patients included in the study. For example, one site focused on patients with sickle cell disease, another on patients with asthma, and others included all diagnoses. Overall, unplanned readmission rates were low (around 1% for 72-hour, 5% for 30-day), which is consistent with other pediatric studies.

Bottom Line: In this study, institutions using a collaborative approach improved the quality of inpatient discharges by using an intervention bundle in pediatric hospital settings. There was no improvement noted in readmission rates, although these rates were low.

Citation: Wu S, Tyler A, Logsdon T, et al. A quality improvement collaborative to improve the discharge process for hospitalized children. Pediatrics. 2016;138(2). pii:e20143604.

References:

1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
2. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.

Clinical Question: What is the performance of the Step-by-Step approach to evaluate febrile infants, and how does it compare to other existing criteria?

Background: Multiple studies have been performed to find the best set of criteria to identify febrile infants at low risk for bacterial infection in order to manage them in a less invasive manner. Common criteria used in the United States include Rochester, Philadelphia, and Boston criteria, initially published in the early 1990s. Since that time, management has evolved with the introduction of newer biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT), and epidemiology has changed with immunizations and improvement in intrapartum antibiotic prophylaxis.

A new algorithm, Step-by-Step, has been developed by a group of European pediatric emergency physicians and has been shown retrospectively to accurately identify groups of patients according to risk of noninvasive or invasive bacterial infection (IBI). This algorithm uses a sequential approach, evaluating the general appearance, age of the patient, urinalysis, and then other lab findings including CRP, PCT, and absolute neutrophil count (ANC). In this study, the authors sought to validate this algorithm prospectively in a larger multicenter population.

Study Design: Multicenter prospective study.

Setting: 11 European pediatric emergency departments in Spain, Italy, and Switzerland.

Synopsis: This study included infants ≤90 days of age presenting to the pediatric emergency department (PED) between September 2012 and August 2014 with fever without source (defined as temperature ≥38°C measured by thermometer at home or in the PED, with normal physical examination and no respiratory signs or symptoms or diarrheal process). Labs obtained for each patient included urinalysis, urine culture (obtained by bladder catheterization or suprapubic aspiration), white blood cell count, PCT, CRP, and blood culture. Further testing and management were determined by the treating physician and management protocols of each center.

Exclusion criteria included:

• Clear source of fever by history or physical examination.
• No fever in the PED and fever assessed only subjectively by parents prior to presentation without the use of a thermometer.
• Absence of one or more of the above lab tests.
• Refusal of parents to participate.

The study included 2,185 infants. Of these, 504 were diagnosed with bacterial infection, including 87 (3.9%) with IBI (defined as positive blood or cerebrospinal fluid culture) and 417 (19.1%) with non-IBI (409 of which were urinary tract infections). Following the first part of the Step-by-Step approach, which uses general appearance (well-appearing versus ill-appearing), age (older or younger than 21 days), and leukocyturia, identified 79.3% of patients with IBI and 98.5% of non-IBI. Adding the next steps in the approach, with PCT, CRP, and ANC, identified 991 low-risk patients (45.3% of the studied population). In this low-risk group, seven patients were subsequently identified as having IBI (0.7% of this group). Using the Step-by-Step approach led to a negative predictive value (NPV) of 99.3 for identifying IBI, with a negative likelihood ratio (LR) of 0.17.

In evaluation of the seven low-risk patients with IBI, three of these were noted to present to the PED within one hour of onset of fever, and three more patients had fever first detected on arrival in the PED. This short duration of fever, and the lack of time for a rise in biomarkers, is likely why these patients were missed in the initial assessment.

When the Rochester criteria were used for this group of 2,185 patients, 949 patients were identified as low risk, with 1.6% of the low-risk patients found to have IBI, leading to an NPV of 98.3 and negative LR of 0.41. The authors chose to compare their approach to the Rochester criteria because the other commonly used approaches (Boston, Philadelphia) recommend lumbar puncture in all febrile infants while Rochester does not, and more recent literature suggests an individualized approach rather than recommending the test systematically.

Limitations included:

• Prevalence of bacterial infection was similar to other European publications but higher than in many studies in the United States, primarily due to an increased rate of UTI. (In this study, the authors used a definition of leukocyturia and culture with ≥10,000 cfu/mL.)
• Band count, although part of the Rochester criteria, was not available in some of the centers and not included in analysis. Inclusion of this lab study could have changed the performance of the Rochester criteria.
• The Step-by-Step approach was not compared to other existing criteria.

Bottom Line: In this study, the Step-by-Step approach was very accurate in identifying febrile infants at low risk for invasive bacterial infection, performing better than the Rochester criteria, and may be helpful in evaluation of infants with fever in the emergency department. A cautious approach is warranted for patients with very short fever duration, as they may be missed by ancillary test results.

Citation: Gomez B, Mintegi S, Bressan S, et al. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138(2). pic:e20154381.

Carl Galloway, MD, is a hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D.

Clinical Question: What is the performance of the Step-by-Step approach to evaluate febrile infants, and how does it compare to other existing criteria?

Background: Multiple studies have been performed to find the best set of criteria to identify febrile infants at low risk for bacterial infection in order to manage them in a less invasive manner. Common criteria used in the United States include Rochester, Philadelphia, and Boston criteria, initially published in the early 1990s. Since that time, management has evolved with the introduction of newer biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT), and epidemiology has changed with immunizations and improvement in intrapartum antibiotic prophylaxis.

A new algorithm, Step-by-Step, has been developed by a group of European pediatric emergency physicians and has been shown retrospectively to accurately identify groups of patients according to risk of noninvasive or invasive bacterial infection (IBI). This algorithm uses a sequential approach, evaluating the general appearance, age of the patient, urinalysis, and then other lab findings including CRP, PCT, and absolute neutrophil count (ANC). In this study, the authors sought to validate this algorithm prospectively in a larger multicenter population.

Study Design: Multicenter prospective study.

Setting: 11 European pediatric emergency departments in Spain, Italy, and Switzerland.

Synopsis: This study included infants ≤90 days of age presenting to the pediatric emergency department (PED) between September 2012 and August 2014 with fever without source (defined as temperature ≥38°C measured by thermometer at home or in the PED, with normal physical examination and no respiratory signs or symptoms or diarrheal process). Labs obtained for each patient included urinalysis, urine culture (obtained by bladder catheterization or suprapubic aspiration), white blood cell count, PCT, CRP, and blood culture. Further testing and management were determined by the treating physician and management protocols of each center.

Exclusion criteria included:

• Clear source of fever by history or physical examination.
• No fever in the PED and fever assessed only subjectively by parents prior to presentation without the use of a thermometer.
• Absence of one or more of the above lab tests.
• Refusal of parents to participate.

The study included 2,185 infants. Of these, 504 were diagnosed with bacterial infection, including 87 (3.9%) with IBI (defined as positive blood or cerebrospinal fluid culture) and 417 (19.1%) with non-IBI (409 of which were urinary tract infections). Following the first part of the Step-by-Step approach, which uses general appearance (well-appearing versus ill-appearing), age (older or younger than 21 days), and leukocyturia, identified 79.3% of patients with IBI and 98.5% of non-IBI. Adding the next steps in the approach, with PCT, CRP, and ANC, identified 991 low-risk patients (45.3% of the studied population). In this low-risk group, seven patients were subsequently identified as having IBI (0.7% of this group). Using the Step-by-Step approach led to a negative predictive value (NPV) of 99.3 for identifying IBI, with a negative likelihood ratio (LR) of 0.17.

In evaluation of the seven low-risk patients with IBI, three of these were noted to present to the PED within one hour of onset of fever, and three more patients had fever first detected on arrival in the PED. This short duration of fever, and the lack of time for a rise in biomarkers, is likely why these patients were missed in the initial assessment.

When the Rochester criteria were used for this group of 2,185 patients, 949 patients were identified as low risk, with 1.6% of the low-risk patients found to have IBI, leading to an NPV of 98.3 and negative LR of 0.41. The authors chose to compare their approach to the Rochester criteria because the other commonly used approaches (Boston, Philadelphia) recommend lumbar puncture in all febrile infants while Rochester does not, and more recent literature suggests an individualized approach rather than recommending the test systematically.

Limitations included:

• Prevalence of bacterial infection was similar to other European publications but higher than in many studies in the United States, primarily due to an increased rate of UTI. (In this study, the authors used a definition of leukocyturia and culture with ≥10,000 cfu/mL.)
• Band count, although part of the Rochester criteria, was not available in some of the centers and not included in analysis. Inclusion of this lab study could have changed the performance of the Rochester criteria.
• The Step-by-Step approach was not compared to other existing criteria.

Bottom Line: In this study, the Step-by-Step approach was very accurate in identifying febrile infants at low risk for invasive bacterial infection, performing better than the Rochester criteria, and may be helpful in evaluation of infants with fever in the emergency department. A cautious approach is warranted for patients with very short fever duration, as they may be missed by ancillary test results.

Citation: Gomez B, Mintegi S, Bressan S, et al. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138(2). pic:e20154381.

Carl Galloway, MD, is a hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D.

Clinical Question: What is the performance of the Step-by-Step approach to evaluate febrile infants, and how does it compare to other existing criteria?

Background: Multiple studies have been performed to find the best set of criteria to identify febrile infants at low risk for bacterial infection in order to manage them in a less invasive manner. Common criteria used in the United States include Rochester, Philadelphia, and Boston criteria, initially published in the early 1990s. Since that time, management has evolved with the introduction of newer biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT), and epidemiology has changed with immunizations and improvement in intrapartum antibiotic prophylaxis.

A new algorithm, Step-by-Step, has been developed by a group of European pediatric emergency physicians and has been shown retrospectively to accurately identify groups of patients according to risk of noninvasive or invasive bacterial infection (IBI). This algorithm uses a sequential approach, evaluating the general appearance, age of the patient, urinalysis, and then other lab findings including CRP, PCT, and absolute neutrophil count (ANC). In this study, the authors sought to validate this algorithm prospectively in a larger multicenter population.

Study Design: Multicenter prospective study.

Setting: 11 European pediatric emergency departments in Spain, Italy, and Switzerland.

Synopsis: This study included infants ≤90 days of age presenting to the pediatric emergency department (PED) between September 2012 and August 2014 with fever without source (defined as temperature ≥38°C measured by thermometer at home or in the PED, with normal physical examination and no respiratory signs or symptoms or diarrheal process). Labs obtained for each patient included urinalysis, urine culture (obtained by bladder catheterization or suprapubic aspiration), white blood cell count, PCT, CRP, and blood culture. Further testing and management were determined by the treating physician and management protocols of each center.

Exclusion criteria included:

• Clear source of fever by history or physical examination.
• No fever in the PED and fever assessed only subjectively by parents prior to presentation without the use of a thermometer.
• Absence of one or more of the above lab tests.
• Refusal of parents to participate.

The study included 2,185 infants. Of these, 504 were diagnosed with bacterial infection, including 87 (3.9%) with IBI (defined as positive blood or cerebrospinal fluid culture) and 417 (19.1%) with non-IBI (409 of which were urinary tract infections). Following the first part of the Step-by-Step approach, which uses general appearance (well-appearing versus ill-appearing), age (older or younger than 21 days), and leukocyturia, identified 79.3% of patients with IBI and 98.5% of non-IBI. Adding the next steps in the approach, with PCT, CRP, and ANC, identified 991 low-risk patients (45.3% of the studied population). In this low-risk group, seven patients were subsequently identified as having IBI (0.7% of this group). Using the Step-by-Step approach led to a negative predictive value (NPV) of 99.3 for identifying IBI, with a negative likelihood ratio (LR) of 0.17.

In evaluation of the seven low-risk patients with IBI, three of these were noted to present to the PED within one hour of onset of fever, and three more patients had fever first detected on arrival in the PED. This short duration of fever, and the lack of time for a rise in biomarkers, is likely why these patients were missed in the initial assessment.

When the Rochester criteria were used for this group of 2,185 patients, 949 patients were identified as low risk, with 1.6% of the low-risk patients found to have IBI, leading to an NPV of 98.3 and negative LR of 0.41. The authors chose to compare their approach to the Rochester criteria because the other commonly used approaches (Boston, Philadelphia) recommend lumbar puncture in all febrile infants while Rochester does not, and more recent literature suggests an individualized approach rather than recommending the test systematically.

Limitations included:

• Prevalence of bacterial infection was similar to other European publications but higher than in many studies in the United States, primarily due to an increased rate of UTI. (In this study, the authors used a definition of leukocyturia and culture with ≥10,000 cfu/mL.)
• Band count, although part of the Rochester criteria, was not available in some of the centers and not included in analysis. Inclusion of this lab study could have changed the performance of the Rochester criteria.
• The Step-by-Step approach was not compared to other existing criteria.

Bottom Line: In this study, the Step-by-Step approach was very accurate in identifying febrile infants at low risk for invasive bacterial infection, performing better than the Rochester criteria, and may be helpful in evaluation of infants with fever in the emergency department. A cautious approach is warranted for patients with very short fever duration, as they may be missed by ancillary test results.

Citation: Gomez B, Mintegi S, Bressan S, et al. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138(2). pic:e20154381.

Carl Galloway, MD, is a hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Sepsis begins outside the hospital for 80% of patients, according to a recent CDC evaluation, reported in Vital Signs. CDC researchers who reviewed medical records of 246 adults and 79 children at 4 New York hospitals in Albany and Rochester found that 7 in 10 patients with sepsis had recently used health care services or had chronic diseases requiring frequent medical care.

Related: The Role of Procalcitonin in the Management of Infectious Diseases

Sepsis is most common in adults aged ≥ 65 years, infants < 1 year, people with weakened immune systems, or people with chronic conditions, such as diabetes. Nearly all the adults (97%) had at least 1 comorbidity, and 70% of children who developed sepsis had a health condition that may have put them at risk.

Although multiple infections and organisms were implicated, Staphylococcus aureus, Escherichia coli, and some types of Streptococcus were identified most often. Among adults with sepsis, 35% had a lung infection, 25% had a urinary tract infection, 11% had a gastrointestinal infection, and 11% had a skin infection.

Related: Mass Transit for Viruses

Most of the patients had recent interactions with the health care system before admission with sepsis, which likely reflects their vulnerability to infection, the researchers say, “it also suggests that health care facilities and providers could play a central role in sepsis prevention.” The CDC report advises the following for health care providers:

• Follow infection control requirements;
• Ensure that patients receive recommended vaccines (such as flu and pneumococcal);
• Educate patients and families, stressing the need to seek care if they see signs of severe infection or sepsis;
• “Think sepsis”—know the signs and symptoms and treat them early;
• Act fast—order tests to identify infection, start antibiotics and other care immediately; document dose, duration, and purpose; and
• Check patient progress frequently; reassess antibiotic therapy at 24 to 48 hours or sooner to change therapy if needed

Sepsis begins outside the hospital for 80% of patients, according to a recent CDC evaluation, reported in Vital Signs. CDC researchers who reviewed medical records of 246 adults and 79 children at 4 New York hospitals in Albany and Rochester found that 7 in 10 patients with sepsis had recently used health care services or had chronic diseases requiring frequent medical care.

Related: The Role of Procalcitonin in the Management of Infectious Diseases

Sepsis is most common in adults aged ≥ 65 years, infants < 1 year, people with weakened immune systems, or people with chronic conditions, such as diabetes. Nearly all the adults (97%) had at least 1 comorbidity, and 70% of children who developed sepsis had a health condition that may have put them at risk.

Although multiple infections and organisms were implicated, Staphylococcus aureus, Escherichia coli, and some types of Streptococcus were identified most often. Among adults with sepsis, 35% had a lung infection, 25% had a urinary tract infection, 11% had a gastrointestinal infection, and 11% had a skin infection.

Related: Mass Transit for Viruses

Most of the patients had recent interactions with the health care system before admission with sepsis, which likely reflects their vulnerability to infection, the researchers say, “it also suggests that health care facilities and providers could play a central role in sepsis prevention.” The CDC report advises the following for health care providers:

• Follow infection control requirements;
• Ensure that patients receive recommended vaccines (such as flu and pneumococcal);
• Educate patients and families, stressing the need to seek care if they see signs of severe infection or sepsis;
• “Think sepsis”—know the signs and symptoms and treat them early;
• Act fast—order tests to identify infection, start antibiotics and other care immediately; document dose, duration, and purpose; and
• Check patient progress frequently; reassess antibiotic therapy at 24 to 48 hours or sooner to change therapy if needed

Sepsis begins outside the hospital for 80% of patients, according to a recent CDC evaluation, reported in Vital Signs. CDC researchers who reviewed medical records of 246 adults and 79 children at 4 New York hospitals in Albany and Rochester found that 7 in 10 patients with sepsis had recently used health care services or had chronic diseases requiring frequent medical care.

Related: The Role of Procalcitonin in the Management of Infectious Diseases

Sepsis is most common in adults aged ≥ 65 years, infants < 1 year, people with weakened immune systems, or people with chronic conditions, such as diabetes. Nearly all the adults (97%) had at least 1 comorbidity, and 70% of children who developed sepsis had a health condition that may have put them at risk.

Although multiple infections and organisms were implicated, Staphylococcus aureus, Escherichia coli, and some types of Streptococcus were identified most often. Among adults with sepsis, 35% had a lung infection, 25% had a urinary tract infection, 11% had a gastrointestinal infection, and 11% had a skin infection.

Related: Mass Transit for Viruses

Most of the patients had recent interactions with the health care system before admission with sepsis, which likely reflects their vulnerability to infection, the researchers say, “it also suggests that health care facilities and providers could play a central role in sepsis prevention.” The CDC report advises the following for health care providers:

• Follow infection control requirements;
• Ensure that patients receive recommended vaccines (such as flu and pneumococcal);
• Educate patients and families, stressing the need to seek care if they see signs of severe infection or sepsis;
• “Think sepsis”—know the signs and symptoms and treat them early;
• Act fast—order tests to identify infection, start antibiotics and other care immediately; document dose, duration, and purpose; and
• Check patient progress frequently; reassess antibiotic therapy at 24 to 48 hours or sooner to change therapy if needed

According to a VA national screening program, about 1 in 4 female veterans has experienced a sexual assault of some type. Sexual trauma can lead to major depressive disorder (MDD) (some research suggests that 1 in 3 rape victims will have at least 1 period of MDD during their lives) and posttraumatic stress disorder (PTSD) with repeated thoughts of the assault, memories, nightmares, and increased arousal (eg, difficulty sleeping and concentrating).

Related: Update on Sexual Assault in the Military

The Warrior Renew treatment program can make a big difference to survivors of assault—particularly veterans, according to findings from recent studies. Warrior Renew, developed by Lori Katz, PhD, was designed specifically to address the “unique aspects” of military sexual trauma for both men and women. The program offers an integrated curriculum that helps participants develop coping skills for improving sleep; reducing anxiety, triggers, anger/resentment, and grief; resolving self-blame; and improving communication. By targeting trauma-related perceptions and feelings that may replicate themselves in relationships, the program also helps participants build a more positive self-perception and optimistic vision for the future, Katz says.

The program format consists of 90-minute “core” classes  4 days a week, adjunctive therapy classes (self-care, art therapy, yoga, relaxation), and recreational outings. Unlike other treatments for trauma, Warrior Renew does not have an exposure component. Instead, it’s grounded in the principles of holographic reprocessing (HR), an evidence-based treatment that helps participants identify emotional themes (such as feeling endangered) and interpersonal patterns. Participants also are taught skills for affect management and self-soothing, such as a technique of “cleansing breath, observation, positive self-talk, and explanation” (COPE) to calm the excitatory system.

Dr. Katz’s outcome studies have shown promising results, and most participants show “reliable” and sustained clinical change in anxiety, depression and posttraumatic negative cognitions, as well as significant increases in self-esteem, optimism, and satisfaction with life.

Related: Sexual Trauma in the Military

Katz also led a study to examine the change in “attachment style” in program graduates—that is, to find out whether they could learn to form healthier relationships. In this study, 62 veterans graduated the program over more than 2 years. Of those, 95% had been diagnosed with PTSD, 57% reported being in recovery from substance abuse, and 45% had considered suicide. Nearly all reported chronic medical conditions. The participants took the Relationship Scales Questionnaire and Brief Symptom Inventory pre- and posttreatment.

The graduates reported significant decreases in “fearful” and “dismissive” insecure attachment as perceived in relationships, with significant increases in “secure” attachment. Improved scores were significantly correlated with reported levels of symptoms of anxiety and depression.

A fourth study, still in review, evaluated the treatment protocol delivered in an outpatient therapy group for survivors of military sexual trauma at a VA medical center. Participants met twice a week to discuss topics such as coping with feelings, sleep and nightmares, and remembering trauma. Again, findings revealed significant reductions in symptoms of anxiety, depression, posttraumatic negative thinking, and PTSD.

Related: Recovering From Military Sexual Trauma

According to Dr. Katz, relating to others with less fear and avoidance while feeling more secure may translate into more engagement in activities and social interactions, supporting an “upward spiral” in healing.

According to a VA national screening program, about 1 in 4 female veterans has experienced a sexual assault of some type. Sexual trauma can lead to major depressive disorder (MDD) (some research suggests that 1 in 3 rape victims will have at least 1 period of MDD during their lives) and posttraumatic stress disorder (PTSD) with repeated thoughts of the assault, memories, nightmares, and increased arousal (eg, difficulty sleeping and concentrating).

Related: Update on Sexual Assault in the Military

The Warrior Renew treatment program can make a big difference to survivors of assault—particularly veterans, according to findings from recent studies. Warrior Renew, developed by Lori Katz, PhD, was designed specifically to address the “unique aspects” of military sexual trauma for both men and women. The program offers an integrated curriculum that helps participants develop coping skills for improving sleep; reducing anxiety, triggers, anger/resentment, and grief; resolving self-blame; and improving communication. By targeting trauma-related perceptions and feelings that may replicate themselves in relationships, the program also helps participants build a more positive self-perception and optimistic vision for the future, Katz says.

The program format consists of 90-minute “core” classes  4 days a week, adjunctive therapy classes (self-care, art therapy, yoga, relaxation), and recreational outings. Unlike other treatments for trauma, Warrior Renew does not have an exposure component. Instead, it’s grounded in the principles of holographic reprocessing (HR), an evidence-based treatment that helps participants identify emotional themes (such as feeling endangered) and interpersonal patterns. Participants also are taught skills for affect management and self-soothing, such as a technique of “cleansing breath, observation, positive self-talk, and explanation” (COPE) to calm the excitatory system.

Dr. Katz’s outcome studies have shown promising results, and most participants show “reliable” and sustained clinical change in anxiety, depression and posttraumatic negative cognitions, as well as significant increases in self-esteem, optimism, and satisfaction with life.

Related: Sexual Trauma in the Military

Katz also led a study to examine the change in “attachment style” in program graduates—that is, to find out whether they could learn to form healthier relationships. In this study, 62 veterans graduated the program over more than 2 years. Of those, 95% had been diagnosed with PTSD, 57% reported being in recovery from substance abuse, and 45% had considered suicide. Nearly all reported chronic medical conditions. The participants took the Relationship Scales Questionnaire and Brief Symptom Inventory pre- and posttreatment.

The graduates reported significant decreases in “fearful” and “dismissive” insecure attachment as perceived in relationships, with significant increases in “secure” attachment. Improved scores were significantly correlated with reported levels of symptoms of anxiety and depression.

A fourth study, still in review, evaluated the treatment protocol delivered in an outpatient therapy group for survivors of military sexual trauma at a VA medical center. Participants met twice a week to discuss topics such as coping with feelings, sleep and nightmares, and remembering trauma. Again, findings revealed significant reductions in symptoms of anxiety, depression, posttraumatic negative thinking, and PTSD.

Related: Recovering From Military Sexual Trauma

According to Dr. Katz, relating to others with less fear and avoidance while feeling more secure may translate into more engagement in activities and social interactions, supporting an “upward spiral” in healing.

According to a VA national screening program, about 1 in 4 female veterans has experienced a sexual assault of some type. Sexual trauma can lead to major depressive disorder (MDD) (some research suggests that 1 in 3 rape victims will have at least 1 period of MDD during their lives) and posttraumatic stress disorder (PTSD) with repeated thoughts of the assault, memories, nightmares, and increased arousal (eg, difficulty sleeping and concentrating).

Related: Update on Sexual Assault in the Military

The Warrior Renew treatment program can make a big difference to survivors of assault—particularly veterans, according to findings from recent studies. Warrior Renew, developed by Lori Katz, PhD, was designed specifically to address the “unique aspects” of military sexual trauma for both men and women. The program offers an integrated curriculum that helps participants develop coping skills for improving sleep; reducing anxiety, triggers, anger/resentment, and grief; resolving self-blame; and improving communication. By targeting trauma-related perceptions and feelings that may replicate themselves in relationships, the program also helps participants build a more positive self-perception and optimistic vision for the future, Katz says.

The program format consists of 90-minute “core” classes  4 days a week, adjunctive therapy classes (self-care, art therapy, yoga, relaxation), and recreational outings. Unlike other treatments for trauma, Warrior Renew does not have an exposure component. Instead, it’s grounded in the principles of holographic reprocessing (HR), an evidence-based treatment that helps participants identify emotional themes (such as feeling endangered) and interpersonal patterns. Participants also are taught skills for affect management and self-soothing, such as a technique of “cleansing breath, observation, positive self-talk, and explanation” (COPE) to calm the excitatory system.

Dr. Katz’s outcome studies have shown promising results, and most participants show “reliable” and sustained clinical change in anxiety, depression and posttraumatic negative cognitions, as well as significant increases in self-esteem, optimism, and satisfaction with life.

Related: Sexual Trauma in the Military

Katz also led a study to examine the change in “attachment style” in program graduates—that is, to find out whether they could learn to form healthier relationships. In this study, 62 veterans graduated the program over more than 2 years. Of those, 95% had been diagnosed with PTSD, 57% reported being in recovery from substance abuse, and 45% had considered suicide. Nearly all reported chronic medical conditions. The participants took the Relationship Scales Questionnaire and Brief Symptom Inventory pre- and posttreatment.

The graduates reported significant decreases in “fearful” and “dismissive” insecure attachment as perceived in relationships, with significant increases in “secure” attachment. Improved scores were significantly correlated with reported levels of symptoms of anxiety and depression.

A fourth study, still in review, evaluated the treatment protocol delivered in an outpatient therapy group for survivors of military sexual trauma at a VA medical center. Participants met twice a week to discuss topics such as coping with feelings, sleep and nightmares, and remembering trauma. Again, findings revealed significant reductions in symptoms of anxiety, depression, posttraumatic negative thinking, and PTSD.

Related: Recovering From Military Sexual Trauma

According to Dr. Katz, relating to others with less fear and avoidance while feeling more secure may translate into more engagement in activities and social interactions, supporting an “upward spiral” in healing.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Very hot and very cold temperatures during pregnancy may increase the risk of preterm birth, say NIH researchers who analyzed records from 223,375 live births at 12 clinical centers.

They linked patients’ electronic records to hourly temperature records for the region surrounding each center. Because “hot” and “cold” can vary depending on the person and place, they defined cold and hot temperatures as below the 10th percentile and above the 90th percentile of average temperatures, respectively.

Related: Home-Visiting Program to Support Young Native American Families 

Women who experienced extreme cold for the first 7 weeks of their pregnancies had a 20% higher risk of delivering before 34 weeks, a 9% higher risk of delivering between 34 and 36 weeks, and 3% higher risk of delivering in weeks 37 and 38.

But the researchers found more consistent associations with early delivery after exposure to extreme heat than extreme cold. Overall, exposure to extreme heat for the duration of pregnancy was associated with increases in risk for delivery at 34 weeks and 36 to 38 weeks by 6% to 21%. The researchers suggest that during cold spells, people are more likely to seek shelter and get warm—and may be more likely to just endure hot weather.

Related: Coordinating Better Care for Opioid-Addicted Women and Their Children

The researchers theorize that the stress of temperature extremes could hinder the development of the placenta or alter blood flow to the uterus, both of which could lead to early labor.

Very hot and very cold temperatures during pregnancy may increase the risk of preterm birth, say NIH researchers who analyzed records from 223,375 live births at 12 clinical centers.

They linked patients’ electronic records to hourly temperature records for the region surrounding each center. Because “hot” and “cold” can vary depending on the person and place, they defined cold and hot temperatures as below the 10th percentile and above the 90th percentile of average temperatures, respectively.

Related: Home-Visiting Program to Support Young Native American Families 

Women who experienced extreme cold for the first 7 weeks of their pregnancies had a 20% higher risk of delivering before 34 weeks, a 9% higher risk of delivering between 34 and 36 weeks, and 3% higher risk of delivering in weeks 37 and 38.

But the researchers found more consistent associations with early delivery after exposure to extreme heat than extreme cold. Overall, exposure to extreme heat for the duration of pregnancy was associated with increases in risk for delivery at 34 weeks and 36 to 38 weeks by 6% to 21%. The researchers suggest that during cold spells, people are more likely to seek shelter and get warm—and may be more likely to just endure hot weather.

Related: Coordinating Better Care for Opioid-Addicted Women and Their Children

The researchers theorize that the stress of temperature extremes could hinder the development of the placenta or alter blood flow to the uterus, both of which could lead to early labor.

Very hot and very cold temperatures during pregnancy may increase the risk of preterm birth, say NIH researchers who analyzed records from 223,375 live births at 12 clinical centers.

They linked patients’ electronic records to hourly temperature records for the region surrounding each center. Because “hot” and “cold” can vary depending on the person and place, they defined cold and hot temperatures as below the 10th percentile and above the 90th percentile of average temperatures, respectively.

Related: Home-Visiting Program to Support Young Native American Families 

Women who experienced extreme cold for the first 7 weeks of their pregnancies had a 20% higher risk of delivering before 34 weeks, a 9% higher risk of delivering between 34 and 36 weeks, and 3% higher risk of delivering in weeks 37 and 38.

But the researchers found more consistent associations with early delivery after exposure to extreme heat than extreme cold. Overall, exposure to extreme heat for the duration of pregnancy was associated with increases in risk for delivery at 34 weeks and 36 to 38 weeks by 6% to 21%. The researchers suggest that during cold spells, people are more likely to seek shelter and get warm—and may be more likely to just endure hot weather.

Related: Coordinating Better Care for Opioid-Addicted Women and Their Children

The researchers theorize that the stress of temperature extremes could hinder the development of the placenta or alter blood flow to the uterus, both of which could lead to early labor.