James Xie

All Publications

• Artificial Intelligence in Perioperative Care: Opportunities and Challenges. Anesthesiology Han, L., Char, D. S., Aghaeepour, N. 2024; 141 (2): 379-387

  View details for DOI 10.1097/ALN.0000000000005013

  View details for PubMedID 38980160

• A Graphical Interface to Support Low-Flow Volatile Anesthesia: Implications for Patient Safety, Teaching, and Design of Anesthesia Information Management Systems. Journal of medical systems Xie, J., Jablonski, M., Smith, J., Navedo, A. 2024; 48 (1): 36

  View details for DOI 10.1007/s10916-024-02055-1

  View details for PubMedID 38532235

• Perioperative Regional Anesthesia Pain Outcomes in Children: A Retrospective Study of 3,160 Regional Anesthetics in Routine Practice. The Clinical journal of pain Xie, J., De Souza, E., Perez, F., Suárez-Nieto, M. V., Wang, E., Anderson, T. A. 2023

  Abstract

  Randomized controlled trials indicate regional anesthesia (RA) improves postoperative outcomes with reduced pain and opioid consumption. Therefore, we hypothesized children who received RA, regardless of technique, would have reduced pain/opioid use in routine practice.Using a retrospective cohort, we assessed the association of RA with perioperative outcomes in everyday practice at our academic pediatric hospital. Patients ≤18 years undergoing orthopedic, urologic, or general surgeries with and without RA from 5/2014 to 9/2021 were categorized as single-shot, catheter-based, or no-block. Outcomes included: intraoperative opioid exposure and dose, pre-incision anesthesia time, post anesthesia care unit (PACU) opioid exposure and dose, PACU antiemetic/antipruritic administration, PACU/inpatient pain scores, PACU/inpatient lengths of stay, and cumulative opioid exposure. Regression models estimated the adjusted association of RA with outcomes, controlling for multiple variables.11,292 procedures with 3,160 RAs were included. Compared to no-block group, single-shot and catheter-based blocks were associated with opioid-free intraoperative anesthesia and opioid-free PACU stays. Post-PACU (i.e. while inpatient), single-shot blocks were not associated with improved pain scores or reduced opioid use. Catheter-based blocks were associated with reduced PACU and inpatient opioid use until 24 hours post-op, no difference of opioid use from 24 to 36 hours, and higher probability of use from 36 to 72 hours. RA was not associated with reduced cumulative opioid consumption.Despite adjustment for confounders, the association of RA with pediatric pain/opioid use outcomes was mixed. Further investigation is necessary to maximize the benefits of RA.

  View details for DOI 10.1097/AJP.0000000000001172

  View details for PubMedID 37942728

• Effect of an electronic medical record nudge to improve quality improvement program tracking of neuraxial catheter replacements in obstetric patients. BMJ open quality Fedoruk, K., Xie, J., Wang, E., Fowler, C., Riley, E., Carvalho, B. 2023; 12 (4)

  Abstract

  Monitoring complications associated with medical procedures requires reliable and accurate record keeping. Nudge reminders executed by way of electronic medical record (EMR) alerts influence clinician behaviour. We hypothesised that the introduction of an EMR nudge would improve documentation of replaced neuraxial blocks by obstetric anaesthesiologists at our institution.We developed an EMR nudge that would alert the physician to a replaced neuraxial block if two or more neuraxial procedure notes in a single patient encounter were detected. The nudge encouraged physicians to document neuraxial block replacements in our institution's quality improvement database. We assessed the rate of physician adherence to replaced neuraxial block charting prior to the introduction of the nudge (January 2019-September 2019) and after the implementation (October 2019-December 2020).494 encounters during the chart review period, January 2019-December 2020, required a neuraxial block replacement, representing an actual neuraxial replacement rate of 6.3% prior to the introduction of the nudge in October 2019. This rate was largely unchanged (6.2%) after the introduction of the nudge (0.1% difference, 95% CI: -0.0119 to 0.0099). Prior to the introduction of the nudge, the proportion of correctly charted failed/replaced blocks in our quality improvement database was 80.0%, and after nudge introduction, the rate was 96.2% (p value <0.00001, OR=6.32, 95% CI: 3.15 to 12.66). A p-chart of the monthly adherence rate demonstrated sustained improvement over time.EMR nudge technology significantly improved adherence with quality metric monitoring of neuraxial catheter replacement in obstetric patients. The results imply that data collection for quality metric databases of neuraxial block failures and replacements that rely on clinician memory without a nudge are likely under-reporting neuraxial block failures and replacements. This study supports widespread implementation of nudges in EMRs to improve quality metric reporting.

  View details for DOI 10.1136/bmjoq-2022-002240

  View details for PubMedID 37903567

• Unintentional Pediatric Ingestion of Cannabis-Addressing a Growing Public Health Risk. JAMA pediatrics Tobin, T., Xie, J., George, K. 2023

  View details for DOI 10.1001/jamapediatrics.2023.2652

  View details for PubMedID 37603345

• Benefits and challenges of combined pediatrics-anesthesiology residency programs: A qualitative study. Paediatric anaesthesia Nguyen, C., Xie, J., Brandford, E., Wang, T., Rassbach, C. E. 2023

  Abstract

  BACKGROUND: The combined pediatrics-anesthesiology residency program was created in 2011 for trainees interested in careers within both specialties. Prior studies have cited challenges of combined training, but none have systematically identified benefits.AIMS: Our objective was to describe the perceived educational and professional benefits and challenges of combined pediatrics-anesthesiology residency programs.METHODS: In this qualitative study using a phenomenological approach, all graduates of combined pediatrics-anesthesiology residency programs from 2016 to 2021, program directors, associate program directors, and faculty mentors were invited to participate in surveys and interviews. Study members conducted interviews using a semi-structured interview guide. Each transcript was coded inductively by two authors and themes were developed using thematic analysis through the lens of self-determination theory.RESULTS: 43 of 62 graduates and faculty responded to our survey (69% response rate), and 14 graduates and five faculty were interviewed. Survey and interview data represented seven programs, including five currently accredited combined programs. Themes emerged regarding benefits of training: it 1) fosters residents' clinical expertise in managing critically ill and medically complex children; 2) provides residents with exceptional knowledge and skills in communicating between medical and perioperative services; and 3) affords unique academic and career opportunities. Other themes emerged regarding the challenges of long duration of training and transitions between pediatrics and anesthesiology rotations.CONCLUSIONS: This is the first study to describe the perceived educational and professional benefits of combined pediatrics-anesthesiology residency programs. Combined training affords exceptional clinical competence and autonomy in the management of pediatric patients and the ability to skillfully navigate hospital systems, and leads to robust academic and career opportunities. However, the duration of training and challenging transitions may threaten residents' sense of relatedness to colleagues and peers, and their self-perceived competence and autonomy. These results can inform mentoring and recruitment of residents to combined pediatrics-anesthesiology programs and career opportunities for graduates.

  View details for DOI 10.1111/pan.14727

  View details for PubMedID 37435637

• Adolescent Privacy and the Electronic Health Record - Creating a Guardrail System to Ensure Appropriate Activation of Adolescent Portal Accounts. Applied clinical informatics Xie, J., Hogan, A., McPherson, T., Pageler, N., Lee, T. C., Carlson, J. 2023

  Abstract

  CASE PRESENTATION: The parent of an adolescent patient noticed an upcoming appointment in the patient's portal account that should have remained confidential to the parent. As it turned out, this parent was directly accessing their child's adolescent patient portal account instead of using a proxy account. After investigation of this case, it was found that the adolescent account had been activated with the parent's demographic information. This case illustrates the challenges of using adult-centric electronic health record (EHR) systems and how our institution addressed the problem of incorrect portal account activations.BACKGROUND: Confidentiality is fundamental to providing healthcare to adolescents. To comply with the 21st Century Cures Act's information blocking rules, confidential information must be released to adolescent patients when appropriate while also remaining confidential from their guardians. While complying with this national standard, systems of care must also account for interstate variability in which services allow for confidential adolescent consent. Unfortunately, there are high rates of guardian access to adolescent portal accounts. Therefore, measures must be taken to minimize the risk of inadvertent confidentiality breaches via adolescent patient portals. Solutions and Lessons Learned: Our institution implemented a guardrail system that checks the adolescent patient's contact information against the contact information of their parent/guardian/guarantor. This guardrail reduced the rate of account activation errors after implementation. However, the guardrail can be bypassed when demographic fields are missing. Thus, ongoing efforts to create pediatric-appropriate demographic fields in the EHR and workflows for registration of proxy accounts in the patient portal are needed.

  View details for DOI 10.1055/a-2015-0964

  View details for PubMedID 36652961

• Paging the Clinical Informatics Community: Respond STAT to Dobbs v Jackson's Women's Health Organization. Applied clinical informatics Arvisais-Anhalt, S., Ravi, A., Weia, B., Aarts, J., Ahmad, H. B., Araj, E., Bauml, J. A., Benham-Hutchins, M., Boyd, A. D., Brecht-Doscher, A., Butler-Henderson, K., Butte, A., Cardillo, A. B., Chilukuri, N., Cho, M. K., Cohen, J. K., Craven, C. K., Crusco, S. J., Dadabhoy, F., Dash, D., DeBolt, C., Elkin, P. L., Fayanju, O. A., Fochtmann, L., Graham, J. V., Hanna, J., Hersh, W., Hoffard, M. R., Hron, J., Huang, S. S., Jackson, B. R., Kaplan, B., Kelly, W., Ko, K., Koppel, R., Kurapati, N., Labbad, G., Lee, J., Lehmann, C. U., Leitner, S., Liao, Z. C., Medford, R. J., Melnick, E. R., Muniyappa, A. N., Murray, S., Neinstein, A., Nichols-Johnson, V., Novak, L., Ogan, W. S., Ozeran, L., Pageler, N., Pandita, D., Perumbeti, A., Petersen, C., Pierce, L., Puttagunta, R., Ramaswamy, P., Rogers, K. M., Rosenbloom, T., Ryan, A., Saleh, S., Sarabu, C., Schreiber, R., Shaw, K. A., Sim, I., Sirintrapun, S. J., Solomonides, A., Spector, J. D., Starren, J. B., Stoffel, M., Subbian, V., Swanson, K., Tomes, A., Trang, K., Unertl, K. M., Weon, J. L., Whooley, M., Wiley, K., Williamson, D. F., Winkelstein, P., Wong, J., Xie, J., Yarahuan, J. K., Yung, N., Zera, C., Ratanawongsa, N., Sadasivaiah, S. 2022

  Abstract

  n/a.

  View details for DOI 10.1055/a-2000-7590

  View details for PubMedID 36535703

• National Survey of Combined Pediatrics-Anesthesiology Residents and Graduates: Factors Contributing to Changing Career Aspirations Over Time. Anesthesia and analgesia Liu, J., Jackson, S. S., Xie, J., Rowland, M. J., Michelson, C. D. 2022

  Abstract

  BACKGROUND: The Dual Pathway for Certification in Pediatrics and Anesthesiology was created in 2011 to develop leaders in caring for children with complex medical and surgical conditions. While existing dual-trained practitioners report continued practice in both pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM), recent surveys of dual pathway trainees have shown that only one-quarter still currently plan to pursue training in PCCM, a change from their initial plans to complete training in both PA and PCCM. The aim of this study was to further characterize the motivations driving shifts in career trajectory during training as well as factors affecting the combined training experience.METHODS: We conducted an online mixed-methods survey of all individuals who had matriculated at 1 of the 7 Accreditation Council for Graduate Medical Education-accredited combined pediatrics-anesthesiology residencies from 2011 to 2018. The survey consisted of a 30-item questionnaire addressing training experience, anticipated career trajectory, and respondent demographics. Descriptive statistics were used for closed-format questions. Responses to open-ended questions were systematically analyzed through inductive iterative review by 2 of the authors to elicit a set of overarching themes.RESULTS: We achieved a response rate of 85% (n = 53/62) with respondents from 7 of 7 combined residency programs. When asked about career goals, the majority of respondents planned to pursue both PA and PCCM (60%, n = 32) at the start of residency. However, at the time of survey completion, the percentage of respondents who were still planning to (or had already completed) train in both PA and PCCM had decreased to 23% (n = 12). Factors such as lifestyle and length of training contributed more to career choices during/after training compared to before residency. Thematic analysis of open-ended questions regarding transition between specialties, impact of dual training, and general comments revealed 3 major themes: (1) challenges of transitioning between specialties, (2) dual training is mutually beneficial, and (3) the need for an established fellowship training pathway.CONCLUSIONS: While there is continued interest in dual training in PA/PCCM for residents who enter the combined pediatrics-anesthesiology residency, factors such as duration of training and lifestyle become more important during residency and alter their career trajectories, often away from PCCM. Optimization of dual-subspecialty fellowship training will be critical to sustaining interest in dual-subspecialty training in PA/PCCM.

  View details for DOI 10.1213/ANE.0000000000006308

  View details for PubMedID 36729970

• Keeping an Open Mind About Open Notes: Sharing Anesthesia Records With Patients. Anesthesia and analgesia Ramaswamy, P., Xie, J., Marsiglio, A. M., Burgart, A. M., Schmiesing, C. A., Cohen, N. H., Robinowitz, D. L., Wang, E. 2022; 135 (4): 697-703

  Abstract

  ADDENDUM: Please note that in the interim since this paper was accepted for publication, new governmental regulations, pertinent to the topic, have been approved for implementation. The reader is thus directed to this online addendum for additional relevant information: http://links.lww.com/AA/E44.

  View details for DOI 10.1213/ANE.0000000000005800

  View details for PubMedID 36108183

• Iatrogenic Pediatric Pneumothorax: Comment. Anesthesiology Xie, J., Ramamurthi, R. J. 2022

  View details for DOI 10.1097/ALN.0000000000004270

  View details for PubMedID 35666979

• Association of Race and Ethnicity with Pediatric Postoperative Pain Outcomes. Journal of racial and ethnic health disparities Rosenbloom, J. M., De Souza, E., Perez, F. D., Xie, J., Suarez-Nieto, M. V., Wang, E., Anderson, T. A. 2022

  Abstract

  INTRODUCTION: Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes.METHODS: Medical records of children 0 to≤18years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference).PRIMARY OUTCOME: post-anesthesia care unit mean pain score.SECONDARY OUTCOMES: inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates.RESULTS: Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score.CONCLUSIONS: Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.

  View details for DOI 10.1007/s40615-022-01327-1

  View details for PubMedID 35622316

• Anesthesia Machine Oxygen Analyzer Error Margins Xie, J., Ramamurthi, R. J. LIPPINCOTT WILLIAMS & WILKINS. 2022: 53

  View details for Web of Science ID 000770094900027

• Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard. Applied clinical informatics Safranek, C. W., Feitzinger, L., Joyner, A. K., Woo, N., Smith, V., Souza, E. D., Vasilakis, C., Anderson, T. A., Fehr, J., Shin, A. Y., Scheinker, D., Wang, E., Xie, J. 2022; 13 (2): 370-379

  Abstract

  BACKGROUND: Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers.OBJECTIVES: This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data.METHODS: We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation.RESULTS: The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data.CONCLUSION: A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.

  View details for DOI 10.1055/s-0042-1744387

  View details for PubMedID 35322398

• Content Evaluation of Residency Websites for All 159 Anesthesiology ACGME Programs in the USA. The journal of education in perioperative medicine : JEPM Cohen, S. A., Cohen, L. E., Perez, F. D., Macario, A., Xie, J. 2022; 24 (1): E683

  Abstract

  Background: The shift to virtual interviews during the COVID-19 pandemic has elevated the vital role of Accreditation Council for Graduate Medical Education residency program websites in conveying information to applicants. The purpose of our study was to assess the recruitment, education, and diversity and inclusion content on websites for anesthesiology residency programs. Second, we aimed to test the hypothesis that the content scores of websites are higher in programs with more National Institutes of Health funding, in programs that are university-based versus community-based, and in larger programs, as measured by number of residents.Methods: Two independent reviewers evaluated the websites of the 159 anesthesiology residency programs accredited by the Accreditation Council for Graduate Medical Education for the presence (yes/no) of 12 recruitment, 6 education, and 8 diversity and inclusion criteria. Multiple linear regression was used to determine which program factors were most associated with total website content score.Results: Anesthesiology residency program websites contained a mean of 12.9 (SD = 3.4; range, 3-21) of the 26 study-defined criteria. The most common recruitment, education, and diversity and inclusion criteria were, respectively, program description, rotation information, and community demographics. Controlling for program factors, a university-based affiliation (P = .016) was associated with higher website content scores.Conclusions: There is large variation in the recruitment, education, and diversity and inclusion content on anesthesiology residency program websites nationally. Since program websites averaged only half of criteria, this may provide an impetus for programs to modify their websites, which may inform applicant decisions about which programs align with their training and career goals.

  View details for DOI 10.46374/volxxiv_issue1_xie

  View details for PubMedID 35707018

• Ensuring Adolescent Patient Portal Confidentiality in the Age of the Cures Act Final Rule. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Xie, J., McPherson, T., Powell, A., Fong, P., Hogan, A., Ip, W., Morse, K., Carlson, J. L., Lee, T., Pageler, N. 2021

  Abstract

  PURPOSE: Managing confidential adolescent health information in patient portals presents unique challenges. Adolescent patients and guardians electronically access medical records and communicate with providers via portals. In confidential matters like sexual health, ensuring confidentiality is crucial. A key aspect of confidential portals is ensuring that the account is registered to and utilized by the intended user. Inappropriately registered or guardian-accessed adolescent portal accounts may lead to confidentiality breaches.METHODS: We used a quality improvement framework to develop screening methodologies to flag guardian-accessible accounts. Accounts of patients aged 12-17 were flagged via manual review of account emails and natural language processing of portal messages. We implemented a reconciliation program to correct affected accounts' registered email. Clinics were notified about sign-up errors and educated on sign-up workflow. An electronic alert was created to check the adolescent's email prior to account activation.RESULTS: After initial screening, 2,307 of 3,701 (62%) adolescent accounts were flagged as registered with a guardian's email. Those accounts were notified to resolve their logins. After five notifications over 8 weeks, 266 of 2,307 accounts (12%) were corrected; the remaining 2,041 (88%) were deactivated.CONCLUSIONS: The finding that 62% of adolescent portal accounts were used/accessed by guardians has significant confidentiality implications. In the context of the Cures Act Final Rule and increased information sharing, our institution's experience with ensuring appropriate access to adolescent portal accounts is necessary, timely, and relevant. This study highlights ways to improve patient portal confidentiality and prompts institutions caring for adolescents to review their systems and processes.

  View details for DOI 10.1016/j.jadohealth.2021.09.009

  View details for PubMedID 34666956

• Assessment of Prevalence of Adolescent Patient Portal Account Access by Guardians. JAMA network open Ip, W., Yang, S., Parker, J., Powell, A., Xie, J., Morse, K., Aikens, R. C., Lee, J., Gill, M., Vundavalli, S., Huang, Y., Huang, J., Chen, J. H., Hoffman, J., Kuelbs, C., Pageler, N. 2021; 4 (9): e2124733

  Abstract

  Importance: Patient portals can be configured to allow confidential communication for adolescents' sensitive health care information. Guardian access of adolescent patient portal accounts could compromise adolescents' confidentiality.Objective: To estimate the prevalence of guardian access to adolescent patient portals at 3 academic children's hospitals.Design, Setting, and Participants: A cross-sectional study to estimate the prevalence of guardian access to adolescent patient portal accounts was conducted at 3 academic children's hospitals. Adolescent patients (aged 13-18 years) with access to their patient portal account with at least 1 outbound message from their portal during the study period were included. A rule-based natural language processing algorithm was used to analyze all portal messages from June 1, 2014, to February 28, 2020, and identify any message sent by guardians. The sensitivity and specificity of the algorithm at each institution was estimated through manual review of a stratified subsample of patient accounts. The overall proportion of accounts with guardian access was estimated after correcting for the sensitivity and specificity of the natural language processing algorithm.Exposures: Use of patient portal.Main Outcome and Measures: Percentage of adolescent portal accounts indicating guardian access.Results: A total of 3429 eligible adolescent accounts containing 25 642 messages across 3 institutions were analyzed. A total of 1797 adolescents (52%) were female and mean (SD) age was 15.6 (1.6) years. The percentage of adolescent portal accounts with apparent guardian access ranged from 52% to 57% across the 3 institutions. After correcting for the sensitivity and specificity of the algorithm based on manual review of 200 accounts per institution, an estimated 64% (95% CI, 59%-69%) to 76% (95% CI, 73%-88%) of accounts with outbound messages were accessed by guardians across the 3 institutions.Conclusions and Relevance: In this study, more than half of adolescent accounts with outbound messages were estimated to have been accessed by guardians at least once. These findings have implications for health systems intending to rely on separate adolescent accounts to protect adolescent confidentiality.

  View details for DOI 10.1001/jamanetworkopen.2021.24733

  View details for PubMedID 34529064

• Association between regional anesthesia and analgesic outcomes: a single-center retrospective study of 2,761 pediatric regional anesthetics Xie, J. J., De Souza, B., Perez, F. D., Suarez-Nieto, M. V., Wang, E., Anderson, T. A. LIPPINCOTT WILLIAMS & WILKINS. 2021: 934-936

  View details for Web of Science ID 000752526600403

• Pediatric Subspecialty Adoption of Telemedicine Amidst the COVID-19 Pandemic: An Early Descriptive Analysis. Frontiers in pediatrics Xie, J., Prahalad, P., Lee, T. C., Stevens, L. A., Meister, K. D. 2021; 9: 648631

  Abstract

  Telemedicine has rapidly expanded in many aspects of pediatric care as a result of the COVID-19 pandemic. However, little is known about what factors may make pediatric subspeciality care more apt to long-term adoption of telemedicine. To better delineate the potential patient, provider, and subspecialty factors which may influence subspecialty adoption of telemedicine, we reviewed our institutional experience. The top 36 pediatric subspecialties at Stanford Children's Health were classified into high telemedicine adopters, low telemedicine adopters, and telemedicine reverters. Distance from the patient's home, primary language, insurance type, institutional factors such as wait times, and subspecialty-specific clinical differences correlated with differing patterns of telemedicine adoption. With greater awareness of these factors, institutions and providers can better guide patients in determining which care may be best suited for telemedicine and develop sustainable long-term telemedicine programming.

  View details for DOI 10.3389/fped.2021.648631

  View details for PubMedID 33928058

• Comparison of regional analgesia techniques for pleurodesis pain in pediatric patients PEDIATRIC ANESTHESIA Xie, J., Mooney, D. P., Cravero, J. 2020

  Abstract

  Mechanical pleurodesis can prevent recurrence of spontaneous pneumothorax but is associated with significant postoperative pain. Adequate pain control is not only beneficial for patient comfort but also critical for mobilization and pulmonary recovery. Thoracic epidural catheters and paravertebral blocks have been used to alleviate pain after thoracoscopic surgery. However, no studies have evaluated the safety and efficacy of paravertebral block vs epidural analgesia vs no block in children undergoing pleurodesis.In this retrospective case series review, data were extracted from a single institution's integrated patient outcome database on children who underwent thoracoscopic pleurodesis from 2013 to 2018. Demographics, operative indication, procedure performed, and perioperative pain management were assessed by chart review. Patients whose operation was converted to thoracotomy, who had an underlying diagnosis of chronic pain, or who underwent pleurodesis for other indications were excluded. The primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes included psot anesthesia care unit length of stay, hospital length of stay, functional outcomes during recovery, and any adverse events.66 patients met inclusion criteria: 23 received thoracic epidurals, 34 received paravertebral blocks, and 9 received no epidural/paravertebral block. Patient characteristics did not significantly differ among groups. Although mean pain scores were statistically significantly lower in the epidural group on post-op day 1, all three groups' pain scores were in the 1 to 3 out of 10 range during the entire postoperative period. Thus, this statistical significance had little clinical significance as all groups had good pain control. The epidural group had significantly lower opioid consumption on post-op days 0 - 2 compared to paravertebral block. No adverse events related to epidural or paravertebral block were noted.We present the an analysis of epidural vs paravertebral block (with comparison to no regional analgesia) following pleurodesis in children. Pain is well managed, regardless of the method; however, additional systemic opioid consumption was decreased in the epidural analgesia cohort. Prospective trials and comparisons with other analgesic techniques for pediatric thoracic surgeries are needed.Thoracic epidural analgesia offers a reduction in opioid use in the first two post-op days after pleurodesis but did not produce a clinically significant reduction in pain scores in comparison with paravertebral block or no block.

  View details for DOI 10.1111/pan.13996

  View details for Web of Science ID 000566287600001

  View details for PubMedID 32780896

• Association between regional anesthesia and analgesic outcomes: a single-center retrospective study of 2038 pediatric regional anesthetics Xie, J. J., De Souza, B., Wang, E., Anderson, T. A. LIPPINCOTT WILLIAMS & WILKINS. 2020: 862–63

  View details for Web of Science ID 000619264500417

• Direct activation of G-protein-gated inward rectifying K+ channels promotes nonrapid eye movement sleep. Sleep Zou, B., Cao, W. S., Guan, Z., Xiao, K., Pascual, C., Xie, J., Zhang, J., Xie, J., Kayser, F., Lindsley, C. W., Weaver, C. D., Fang, J., Xie, X. S. 2019; 42 (3)

  Abstract

  A major challenge in treating insomnia is to find effective medicines with fewer side effects. Activation of G-protein-gated inward rectifying K+ channels (GIRKs) by GABAB agonists baclofen or γ-hydroxybutyric acid (GHB) promotes nonrapid eye movement (NREM) sleep and consolidates sleep. However, baclofen has poor brain penetration, GHB possesses abuse liability, and in rodents both drugs cause spike-wave discharges (SWDs), an absence seizure activity. We tested the hypothesis that direct GIRK activation promotes sleep without inducing SWD using ML297, a potent and selective GIRK activator.Whole-cell patch-clamp recordings from hypocretin/orexin or hippocampal neurons in mouse brain slices were made to study neuronal excitability and synaptic activity; spontaneous activity, locomotion, contextual and tone-conditioned memory, and novel object recognition were assessed. Electroencephalogram/electromyogram (EEG/EMG) recordings were used to study GIRK modulation of sleep.ML297, like baclofen, caused membrane hyperpolarization, decreased input resistance, and blockade of spontaneous action potentials. Unlike baclofen, ML297 (5-10 µM) did not cause significant depression of postsynaptic excitatory and inhibitory currents (EPSCs-IPSCs), indicating preferential postsynaptic inhibition. ML297 (30 mg/kg, i.p.) inhibited wake activity and locomotion, and preferentially increased NREM sleep without altering EEG delta power, REM sleep, inducing SWDs, or impairing conditioned memory and novel object recognition.This study finds that direct activation of neuronal GIRK channels modulates postsynaptic membrane excitability and prolongs NREM sleep without changing sleep intensity, inducing SWDs, or impairing memory in rodents. These results suggest that direct GIRK activation with a selective compound may present an innovative approach for the treatment of chronic insomnia.

  View details for DOI 10.1093/sleep/zsy244

  View details for PubMedID 30535004

  View details for PubMedCentralID PMC6424090

• Analgesic Microneedle Patch for Neuropathic Pain Therapy ACS NANO Xie, X., Pascual, C., Lieu, C., Oh, S., Wang, J., Zou, B., Xie, J., Li, Z., Xie, J., Yeomans, D. C., Wu, M. X., Xie, X. S. 2017; 11 (1): 395-406

  Abstract

  Neuropathic pain caused by nerve injury is debilitating and difficult to treat. Current systemic pharmacological therapeutics for neuropathic pain produce limited pain relief and have undesirable side effects, while current local anesthetics tend to nonspecifically block both sensory and motor functions. Calcitonin gene related peptide (CGRP), a neuropeptide released from sensory nerve endings, appears to play a significant role in chronic neuropathic pain. In this study, an analgesic microneedle (AMN) patch was developed using dissolvable microneedles to transdermally deliver selective CGRP antagonist peptide in a painless manner for the treatment of localized neuropathic pain. Local analgesic effects were evaluated in rats by testing behavioral pain sensitivity in response to thermal and mechanical stimuli using neuropathic pain models such as spared-nerve injury and diabetic neuropathy pain, as well as neurogenic inflammatory pain model induced by ultraviolet B (UVB) radiation. Unlike several conventional therapies, the AMN patches produced effective analgesia on neuropathic pain without disturbing the normal nociception and motor function of the rat, resulting from the high specificity of the delivered peptide against CGRP receptors. The AMN patches did not cause skin irritation or systemic side effects. These results demonstrate that dissolvable microneedle patches delivering CGRP antagonist peptide provide an effective, safe, and simple approach to mitigate neuropathic pain with significant advantages over current treatments.

  View details for DOI 10.1021/acsnano.6b06104

  View details for Web of Science ID 000392886500040

  View details for PubMedID 28001346

• Up to Speed: A Role for Trainees in Advancing Health Information Technology. Pediatrics Xie, J. 2015; 136 (3): 412-4

  View details for DOI 10.1542/peds.2015-1827

  View details for PubMedID 26240215

• Galvanizing medical students in the administration of influenza vaccines: the Stanford Flu Crew. Advances in medical education and practice Rizal, R. E., Mediratta, R. P., Xie, J., Kambhampati, S., Hills-Evans, K., Montacute, T., Zhang, M., Zaw, C., He, J., Sanchez, M., Pischel, L. 2015; 6: 471-477

  Abstract

  Many national organizations call for medical students to receive more public health education in medical school. Nonetheless, limited evidence exists about successful servicelearning programs that administer preventive health services in nonclinical settings. The Flu Crew program, started in 2001 at the Stanford University School of Medicine, provides preclinical medical students with opportunities to administer influenza immunizations in the local community. Medical students consider Flu Crew to be an important part of their medical education that cannot be learned in the classroom. Through delivering vaccines to where people live, eat, work, and pray, Flu Crew teaches medical students about patient care, preventive medicine, and population health needs. Additionally, Flu Crew allows students to work with several partners in the community in order to understand how various stakeholders improve the delivery of population health services. Flu Crew teaches students how to address common vaccination myths and provides insights into implementing public health interventions. This article describes the Stanford Flu Crew curriculum, outlines the planning needed to organize immunization events, shares findings from medical students' attitudes about population health, highlights the program's outcomes, and summarizes the lessons learned. This article suggests that Flu Crew is an example of one viable service-learning modality that supports influenza vaccinations in nonclinical settings while simultaneously benefiting future clinicians.

  View details for DOI 10.2147/AMEP.S70294

  View details for PubMedID 26170731

  View details for PubMedCentralID PMC4492543

• Characteristics and Direct Costs of Academic Pediatric Subspecialty Outpatient No-Show Events JOURNAL FOR HEALTHCARE QUALITY Perez, F. D., Xie, J., Sin, A., Tsai, R., Sanders, L., Cox, K., Haberland, C. A., Park, K. T. 2014; 36 (4): 32-42

  Abstract

  BACKGROUND: Clinic no shows (NS) create a lost opportunity for provider-patient interaction and impose a financial burden to the healthcare system and on society. We aimed to: (1) to determine the clinical and demographic factors associated with increased NS rates at a children's hospital's subsubspecialty clinics and (2) to estimate the direct institutional financial costs associated with NS events. METHODS: A comprehensive database was generated from all clinic encounters for 15 subspecialty outpatient clinics (five surgical and 10 medical) between September 12, 2005 and December 30, 2010. Multivariate logistic regressions were performed to identify the variables associated with NS events. Direct costs of NS events were estimated using annual revenue for each clinic. RESULTS: A total of 284,275 encounters and 17,024 NS events were available for analysis. Public insurance coverage (Medicaid and Title V), compared to private insurance or self-pay status, was associated with an increased likelihood NS (OR 2.19, 95% CI 2.10-2.28, p < 0.0005 for Medicaid; OR 1.56, 95% CI 1.50-1.62, p < 0.0005 for Title V). Compared to patients 21-30 years of age, patients <12 years (OR 2.08, 95% CI 1.77-2.45, p < 0.0005) had increased likelihood of NS. Scheduled visits with medical subspecialists were more likely than surgical subspecialty visits to result in a NS (OR 1.69, 95% CI 1.63-1.75, p < 0.0005). The predicted annualized lost revenue associated with NS visits was estimated at $730,000 from the 15 clinics analyzed, approximately $210 per NS event. CONCLUSION: Pediatric subspecialty NS events are common, costly, and potentially preventable.

  View details for Web of Science ID 000348450800003

  View details for PubMedID 23551280

• Hypocretin/Orexin Neurons Contribute to Hippocampus-Dependent Social Memory and Synaptic Plasticity in Mice JOURNAL OF NEUROSCIENCE Yang, L., Zou, B., Xiong, X., Pascual, C., Xie, J., Malik, A., Xie, J., Sakurai, T., Xie, X. (. 2013; 33 (12): 5275-?

  Abstract

  Hypocretin/orexin (Hcrt)-producing neurons in the lateral hypothalamus project throughout the brain, including to the hippocampus, where Hcrt receptors are widely expressed. Hcrt neurons activate these targets to orchestrate global arousal state, wake-sleep architecture, energy homeostasis, stress adaptation, and reward behaviors. Recently, Hcrt has been implicated in cognitive functions and social interaction. In the present study, we tested the hypothesis that Hcrt neurons are critical to social interaction, particularly social memory, using neurobehavioral assessment and electrophysiological approaches. The validated "two-enclosure homecage test" devices and procedure were used to test sociability, preference for social novelty (social novelty), and recognition memory. A conventional direct contact social test was conducted to corroborate the findings. We found that adult orexin/ataxin-3-transgenic (AT) mice, in which Hcrt neurons degenerate by 3 months of age, displayed normal sociability and social novelty with respect to their wild-type littermates. However, AT mice displayed deficits in long-term social memory. Nasal administration of exogenous Hcrt-1 restored social memory to an extent in AT mice. Hippocampal slices taken from AT mice exhibited decreases in degree of paired-pulse facilitation and magnitude of long-term potentiation, despite displaying normal basal synaptic neurotransmission in the CA1 area compared to wild-type hippocampal slices. AT hippocampi had lower levels of phosphorylated cAMP response element-binding protein (pCREB), an activity-dependent transcription factor important for synaptic plasticity and long-term memory storage. Our studies demonstrate that Hcrt neurons play an important role in the consolidation of social recognition memory, at least in part through enhancements of hippocampal synaptic plasticity and cAMP response element-binding protein phosphorylation.

  View details for DOI 10.1523/JNEUROSCI.3200-12.2013

  View details for Web of Science ID 000316553800020

  View details for PubMedID 23516292

  View details for PubMedCentralID PMC3640412

• Rodent motor and neuropsychological behaviour measured in home cages using the integrated modular platform SmartCage (TM) CLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY Khroyan, T. V., Zhang, J., Yang, L., Zou, B., Xie, J., Pascual, C., Malik, A., Xie, J., Zaveri, N. T., Vazquez, J., Polgar, W., Toll, L., Fang, J., Xie, X. 2012; 39 (7): 614-622

  Abstract

  1. To facilitate investigation of diverse rodent behaviours in rodents' home cages, we have developed an integrated modular platform, the SmartCage(™) system (AfaSci, Inc. Burlingame, CA, USA), which enables automated neurobehavioural phenotypic analysis and in vivo drug screening in a relatively higher-throughput and more objective manner. 2, The individual platform consists of an infrared array, a vibration floor sensor and a variety of modular devices. One computer can simultaneously operate up to 16 platforms via USB cables. 3. The SmartCage(™) detects drug-induced increases and decreases in activity levels, as well as changes in movement patterns. Wake and sleep states of mice can be detected using the vibration floor sensor. The arousal state classification achieved up to 98% accuracy compared with results obtained by electroencephalography and electromyography. More complex behaviours, including motor coordination, anxiety-related behaviours and social approach behaviour, can be assessed using appropriate modular devices and the results obtained are comparable with results obtained using conventional methods. 4. In conclusion, the SmartCage(™) system provides an automated and accurate tool to quantify various rodent behaviours in a 'stress-free' environment. This system, combined with the validated testing protocols, offers powerful a tool kit for transgenic phenotyping and in vivo drug screening.

  View details for DOI 10.1111/j.1440-1681.2012.05719.x

  View details for Web of Science ID 000305758200005

  View details for PubMedID 22540540

• Electrophysiological outcomes after spinal cord injury NEUROSURGICAL FOCUS Xie, J., Boakye, M. 2008; 25 (5)

  Abstract

  Electrophysiological measures can provide information that complements clinical assessments such as the American Spinal Injury Association sensory and motor scores in the evaluation of outcomes after spinal cord injury (SCI). The authors review and summarize the literature regarding tests that are most relevant to the study of SCI recovery--in particular, motor evoked potentials and somatosensory evoked potentials (SSEPs). In addition, they discuss the role of other tests, including F-wave nerve conductance tests and electromyography, sympathetic skin response, and the Hoffman reflex (H-reflex) test as well as the promise of dermatomal SSEPs and the electrical perceptual threshold test, newer quantitative tests of sensory function. It has been shown that motor evoked potential amplitudes improve with SCI recovery but latencies do not. Somatosensory evoked potentials are predictive of ambulatory capacity and hand function. Hoffman reflexes are present during spinal shock despite the loss of tendon reflexes, but their amplitudes increase with time after injury. Further, H-reflex modulation is reflective of changes in spinal excitability. While these tests have produced data that is congruent with clinical evaluations, they have yet to surpass clinical evaluations in predicting outcomes. Continuing research using these methodologies should yield a better understanding of the mechanisms behind SCI recovery and thus provide potentially greater predictive and evaluative power.

  View details for DOI 10.3171/FOC.2008.25.11.E11

  View details for Web of Science ID 000260566600011

  View details for PubMedID 18980471