Inside Pediatrics, Pulmonology

Pulmonology Telehealth Gets Good Reviews

When the pandemic hit in March 2020, most clinics at Children’s of Alabama pivoted to telehealth visits, including pulmonology. Although things have primarily returned to normal with in-person visits, telehealth still has a presence in the outpatient setting.

Given that, an interprofessional team of Pediatric Pulmonary Trainees at the University of Alabama at Birmingham led by Valerie Tarn, MS, RD, LD, training director of the Pediatric Pulmonary Center (PPC), launched a survey to assess how families and clinicians felt about televisits in the pulmonary clinic. “We wanted to evaluate our services and get feedback from our families since many have children with special healthcare needs that require multiple visits per year,” she said. “We wondered if we could do telehealth for every other visit in some populations.”

They surveyed families that had already had a televisit (most used their phones) and those that hadn’t, as well as clinicians who participated in the televisits, to see what, if any, barriers existed as well as collect demographic information.

Most families who had participated in telehealth said they would like to continue for some, but not all, visits. The greatest advantages were avoiding COVID-19 infection and not having to drive to the hospital. The latter is particularly important, Tarn said, since many families drive an hour or more to the clinic. As one parent commented, “This has been wonderful experience! I don’t have to worry about exposing her to COVID or the flu, which is very dangerous for my child. Hope to be able to continue this service in the future!”

About 90 percent of families that hadn’t had a pulmonary televisit reported having Internet access. When asked about potential disadvantages to such visits, they noted the inability to conduct a physical exam. As one parent wrote,  “Please allow the patient to have a choice as to whether or not the appointment is to be in-person or a telehealth appointment.”

Clinicians agreed that telehealth was probably here to stay, Tarn said, but they wanted a more consistent structure. That included prescreening families and finding ways to incorporate other members of the health care team into the visit. “A lot of our patients need to see other health professionals,” she said. “How do you get them to talk with the pharmacist or social worker or nutritionist?” In the spring, the doctors were typically emailing other clinicians or leaving a message in the patient’s secure medical record about the need for follow up.

In the cystic fibrosis clinic, however, nutritionists, social workers, and other allied health professionals rotatedthrough the visit, each taking turns with the iPad. “That worked fairly smoothly,” Tarn said, and could provide a model for other pulmonary clinics.

In the future, the clinicians noted, it would be helpful if patients had home equipment available, such as spirometers, peak flow meters, and weight scales.

But overall, Tarn said, families and healthcare professionals liked telehealth. Now that the surveys have been collected, the PPC trainees plan to present the research results to an interprofessional audience at a local or regional conference.

Inside Pediatrics, Neonatology

Addressing COVID-19 in the NICU

When you are responsible for the tiniest, sickest babies in the state and a global pandemic hits, there is no time to waste. That’s the approach Hannah Hightower, M.D., a neonatologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB), and her team took in early March 2020, when normal life seemed to cease overnight. The state started shutting down March 13, and by March 19 she and her team released their first set of guidelines for COVID-19-related maternal and infant care.

“I realized this would have a great effect on how the Neonatal Intensive Care Unit (NICU) and infant nurseries operated,” Hightower said. “The virus was a great unknown and very little published guidance was available. There was also a lot of fear among the staff. I felt an urgency to provide our NICU staff a framework of how to safely handle patients and families in the midst of the emerging virus.”

So she took what little information was available from other regions and countries and sought guidance from her pediatric infectious disease colleagues to develop Guidelines of Care for COVID-19-exposed mothers and infants.

Those first guidelines would form the foundation of numerous iterations over the following year as the virus spread and more data on its effects in pregnant women and their babies emerged. “As time went by, the protocols changed pretty frequently because of the speed of the emerging data,” she said.

Early policy changes limited visitors to the NICU to only the mother and one support person in order to reduce possible exposure of infants and staff in the NICU. They also followed national recommendations to briefly separate COVID-positive mothers from their babies after delivery in order to prevent transmission to the infant. That changed over the summer as evidence emerged that as long as the mother was not severely ill and used proper precautions, including wearing a mask and performing hand hygiene, the risk of transmission to her infant was low.

The more the NICU team learned, the more they reached out to share their knowledge, Hightower said. “I coordinated with nursing leadership and other neonatologists around the state to share our experiences with each other,” she said. “It was a big collaborative effort.” She also spent a lot of time on Zoom and national conference calls with other pediatric and neonatal physicians, as well as the hospital’s own infectious disease specialists. In addition, there was also ongoing education for the staff about how to protect themselves and others.

A big part of their effort was educating the families about safety protocols and helping them get COVID tested when necessary, and then explaining the need to quarantine or isolate. After a year of living with the pandemic, Hightower now says, “We are more comfortable handling infants and families dealing with COVID-19. Even though vaccines are becoming available, it will remain important to continue masking throughout the year. For now, limiting visitors is also going to continue,” she said, and they still encourage families to limit their interactions outside the hospital.

Inside Pediatrics, Nephrology

Managing COVID-19 in the Dialysis Unit

When COVID-19 hit in early March, hospitals, including Children’s of Alabama, pivoted to telehealth appointments and canceled non-urgent procedures. But that’s not an option for children who need dialysis, particularly since Children’s is the only hospital in Alabama providing pediatric dialysis.

“We were running at full staff and operating as usual,” said Suzanne White, dialysis director at Children’s renal care center. That meant seeing hemodialysis patients three times a week, home dialysis patients once a month, and implementing protocols to reduce the risk of infection to patients and staff. It also meant that even if a patient tested positive for COVID-19, they still had to come to the hospital for dialysis. “You can’t reschedule dialysis if you have COVID,” said Sahar Fathallah-Shaykh, M.D., a pediatric nephrologist at Children’s and the University of Alabama at Birmingham (UAB). The task was made more challenging as with kidney transplants on hold, the dialysis center was seeing twice as many patients.

Among the changes the unit implemented:

  • Moving hemodialysis patients to peritoneal (home) dialysis whenever possible to limit visits to the hospital. This posed its own challenges, including training family members and coordinating with surgeons. “We did more peritoneal dialysis surgeries in those early months than we had done in years,” Fathallah-Shaykh said.
  • Limiting visitors in the unit. “We could accommodate eight patients at one time but we couldn’t have people gathering,” White said.” That meant families calling from the parking lot when they arrived, mask wearing, initial screening when they entered the hospital, and more advanced screening before they entered the dialysis unit. We drilled down to avoid screening fatigue,” she said.
  • Extensive education with families about COVID-19 and risk mitigation. “We had to make sure they realized the impact of this illness,” Fathallah-Shaykh said.
  • Treating COVID-positive patients in an isolation room when the unit was empty and implementing a special deep cleaning process.

“We were diligent because we knew what the illness could cause,” White said. The team was particularly concerned about the staff. Dialysis nurses require extensive training, and there are few available if one becomes sick. “If several got sick, it would be a disaster,” Fathallah-Shaykh said. In the end, just four staff and four patients tested positive, all community acquired. And, Fathallah-Shaykh stressed, “We never relaxed our standards. We added COVID to our high standard of care; we didn’t adjust our standard of care for COVID.”

Inside Pediatrics, Nephrology

Becoming the Leaders in Treating Congenital Nephrotic Syndrome

It is one of the most challenging congenital kidney conditions pediatric nephrologists see. Called  congenital nephrotic syndrome (CNS), it is an extremely rare genetic disease that affects the glomerular filtration system of the kidneys, leading to tremendous loss of protein through the urine. The result is extensive edema, skin breakdown and impaired respiration.

And that’s just the beginning, said Daniel Feig, M.D., Ph.D., the Margaret M. Porter Endowed Chair in Pediatric Nephology at Children’s of Alabama and the University of Alabama at Birmingham (UAB).“These kids are very susceptible to infections because so many immune chemicals are lost in the urine,” he said. They are also prone to blood clots because of low water volume and poor circulation, which can severely damage other organs, leading to bowel infarction and stroke. “They also become very malnourished because they can’t take in enough protein to keep up with the losses through the urine,” he said.

Symptoms usually appear by 2 months of age. “But because this is a structural problem in the kidney filters, there is no medicine that stops it,” he said. Early management involves trying to replace lost protein, “but that’s usually not enough.” Second-line management includes medications to slow kidney function, “but now we’re walking a tightrope of impaired kidney function to reduce protein losses.”

Eventually, the kidneys need to be removed so the child can receive enough nourishment. That means dialysis until they can receive a transplant.

“They’re a challenge,” he said. “But over the years, we’ve had very good success in moving down the pathway and getting them transplanted and they do well.” Because the condition is so rare, most pediatric nephrologists only see one or two patients their entire career. But word of Children’s program has spread, and today the team is treating patients from throughout the south.

“As a program we are happy to take care of these kids and share our expertise with other programs,” Feig said. One challenge has been reimbursement since health insurance may not cover out-of-state care. “We’re negotiating with other states and our own internal services to accept what we can get and then just take care of the kids, he said, adding, “A big shout out to the flexibility of the institution to allow us to do this.”

The goal is to build a center of excellence for children with CNS that demonstrates not only superior outcomes, he said, but cost savings.  

Becoming a referral center also allows greater clinical research into the disease, Feig said. Clinical trials for new therapies are difficult to conduct because there are so few children with the disease. But Children’s is slowly building a repository of biometric information and tissue for future research. “We don’t have a faculty researcher right now who is focused on CNS, but as we continue to recruit faculty that’s an untapped opportunity.” All the challenges of caring for these kids, he said, is worth it once they get a transplant. “They grow and develop and play just like all other small children. It’s a boon to these families who go through this terrible neonatal course and then get their kids back.”

Inside Pediatrics, Neonatology

Helping the Tiniest Babies Grow

Ariel A. Salas, M.D., a neonatologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB), was completing his master’s in public health when he first became interested in growth and nutrition in premature infants. “It’s a growing field,” he said. For years, neonatology was primarily focused on lung disease because most survival was linked to the degree of respiratory disease, he said, but with significant improvement in respiratory care and outcomes, “we’re now trying to optimize outcomes among the surviving infants.”

Premature infants, particularly those born at the limits of viability, typically don’t grow well during their hospital stay and have a higher risk of developing long-term nutritional complications related to extreme prematurity. Yet nutritional issues were traditionally an afterthought.

Now, thanks to a five-year, $777,384 Mentored Patient-Oriented Research Career Development Award (K23), Salas hopes to change that. The award provides him with the mentorship, training, and research experience to become an independent clinician scientist and leader in neonatal nutrition research. As he wrote in his grant application: “My long-term career goal is to reduce the burden of postnatal growth failure through novel translational studies and large scale, multi-center clinical trials of promising dietary interventions that optimize growth, reduce dysbiosis of the gut microbiome, and ultimately improve neurodevelopment.”

The grant will support a study to determine if giving preemies protein-enriched human milk during their first two weeks can promote lean body mass accretion, stimulate maturation of the gastrointestinal tract, and modify the gut microbiome.

One thing that makes this study unique is its focus on lean mass growth versus growth overall, Salas said. “Preemies are born so small they can grow really fast, but that could be because they’re getting too much fat in the diet,” he said, which could lead to later problems, including obesity. “There are a lot of unknowns in the implications of changing fat mass in preemies.” Still, he said, it will take two decades before the full implications of improved lean mass in premature infants is known.

“The advantage of protein is that it’s so important for structural growth.” Indeed, preliminary evidence from another study he participated in found that increased protein did improve the amount of lean mass growth in premature babies, he said. Those babies received the enhanced milk when they were older and their condition more stable; this study will start babies on the milk in the first two weeks.

The study uses a human-based protein fortifier added either to the mother’s breast milk or milk from the milk bank. It also uses a novel approach of measuring biomarkers in urine to see if they can predict the amount of lean mass seen in the body scans.

It’s not clear how lean mass affects development, Salas said, since the field is so new. “It’s only been in the past 10 years that we started measuring lean mass with non-invasive methods in extremely premature infants,” he said. Data over the past decade suggests, however, that overall lean mass is the safest approach to growth, leading to greater length and other outcomes.

The next step in this research, he said, is to see how the additional protein is digested and absorbed in the intestines and how it affects the gut microbiome. “Possibly some of those microbes can facilitate the digestion and absorption of the nutrients and if we can improve both, we may be able to improve growth overall.”

“This is a fascinating area,” said Salas, “and it probably has more serious implications in preterm infants because they have so much potential for growth.”

Inside Pediatrics, Neonatology

Marking a Milestone: RNICU Goes More Than One Year Without Central Line Associated Bloodstream Infections

Three hundred and ninety days.That’s how long the Regional Neonatal Intensive Care Unit (RNICU) at the University of Alabama at Birmingham (UAB) has gone without a central line associated bloodstream infection (CLABSI). And that, in the world of tiny, sick babies, is huge.

Healthcare-acquired infections (HAI) are a major problem in all hospitals, said Lindy Winter, M.D., Medical Director, but particularly for premature babies. “They are more vulnerable to infections because their immune systems are immature,” she said, “and they can’t fight off bacteria in the same way that adults are able to.”

Ideally, the rate of CLABSIs in a NICU should be zero, she said. Buta few years ago UAB’s rate was higher than national benchmarks, a rate determined through a formula based on the number of days patients have an IV line and how often infections occur. It’s also a major quality indicator for hospitals, reported to the Centers for Disease Control and Prevention and required for US News & World Report’s Best Hospitals ranking.

Thus, in 2013, UAB NICU leadership launched a major initiative to bring down the rate of CLABSIs. It was not an easy task, Winter said. “It required a huge culture change,” she said, “because NICU clinicians around the country believed such infections were inevitable, a natural outcome because these infants were immunocompromised anyway and nothing could be done to prevent it.”

She and her team set out to prove them wrong. They started with operational changes in how the central line was inserted and accessed, working closely with materials management to try different products to improve sterility. They changed how the skin and devices were prepped, and moved from having a single nurse insert, access, and manage the line, including changing dressings, to a buddy system in which at least one nurse is PICC (peripherally inserted central catheter) certified.

They studied their data to see which babies were more likely to get an infection. They discovered it was those who had umbilical lines that had been inserted at birth and remained longer than five days. “We did a lot of education with providers about switching from the umbilical to a PICC line to move closer to that five-day goal,” Winter said.

They also added central lines to the list of 10 things clinicians discuss during their daily patient rounds. This, Winter said, reminds staff to think about central lines and if they were needed as part of their daily routine.

Their efforts paid off. By 2016, the NICU started seeing a steady reduction in CLABSIs. And then, starting in the summer of 2019, there were none for more than a year.  “We held our breath all year,” said Winter. When they reached the 365-day mark they celebrated, ordering in food from the staff’s favorite restaurants.

The streak eventually broke when a critically ill baby developed an infection. After the emergency was over, the team instituted a “swarm,” a rapid cycle debrief to figure out what happened. “He was very sick and we had to access the line frequently for medications,” said Winter. “We think that was the issue.”

 Since that one infection, there have been no others tied to central lines.

“It was such a team effort,” said Winter. It’s not just the doctors and nurses, but the respiratory therapists, housekeeping staff, even materials management, all working together to reach the goal of zero.

Editor’s Note: The UAB Department of Pediatrics Neonatology Division and its 23 board-certified neonatologists works in collaboration with the Regional Neonatal Intensive Care Unit (RNICU) at UAB and the Neonatology Intensive Care Unit (NICU) at Children’s of Alabama. The RNICU provides care for infants with varying diagnoses, including extreme prematurity and cardiac defects, in an environment equipped with the latest patient care technology. The RNICU is housed in UAB’s new Women and Infants Center. The NICU at Children’s of Alabama is a Level IV unit with 48 private rooms available for neonates and infants and provides care for patients similar to the RNICU in addition to surgical procedures, ECMO and specialized dialysis (Aquadex) for the neonatal population.

Hematology and Oncology, Inside Pediatrics

Robust LLH Program Continues Expanding, Raising Profile

With an overarching goal of improving cure rates while decreasing treatment toxicity and side effects, the Leukemia, Lymphoma and Histiocytosis (LLH) program at Children’s of Alabama has nearly doubled in size over the past decade as faculty members continue raising its national and international profile and spearheading innovative clinical trials and research.

            The LLH program includes five physicians and four nurse practitioners within the division of pediatric hematology and oncology, which includes more than 25 faculty. LLH clinicians consult on about half of the new cancer diagnoses seen each year at Children’s, said Director Matthew Kutny, M.D., also an associate professor of pediatric hematology and oncology at the University of Alabama at Birmingham (UAB).

            LLH faculty members published 34 research articles in peer-reviewed journals over the last two years and presented more than 30 times at national oncology meetings. Additionally, several members sit on national steering committees or review boards that develop pediatric cancer treatment guidelines, Kutny said. The LLH program also participates in several key clinical trial consortiums, such as the National Cancer Institute’s Children’s Oncology Group, including selected membership in a network studying the newest oncology treatments in children.

            “Our faculty has expanded, but we’ve also gained greatly in our expertise,” Kutny explained. “When children come here with a particular diagnosis, they’re not just treated by a general hematologist or oncologist, but rather, through our disease-specific teams.”

            “We have providers who really understand that disease and are involved at a national level in developing the best treatments for that disease,” he added.

            Kutny’s own research efforts include leading several national trials in myeloid leukemias as well as focusing on central nervous system disease in acute myeloid leukemia. Other notable faculty research efforts include:

  • Aman Wadhwa, M.D., M.S.P.H.: Working with Smita Bhatia, M.D., M.P.H., Wadhwa is examining how body composition affects childhood cancer outcomes in lymphomas, with an eye toward predicting and modifying toxicities.
  • Wayne Liang, M.D., M.S.: With a dual appointment in bioinformatics, Liang is harnessing the power of big data via electronic health records to better match patients to appropriate clinical trials, among other efforts.
  • Julie Wolfson, M.D., M.S.H.S.: Involved in many local and national projects, Wolfson is concentrating on outcomes disparities in adolescents and young adults with cancer, an at-risk group not often incorporated into clinical trials.
  • Ana Xavier, M.D.: Leading several national trials in difficult-to-treat lymphomas, Xavier is also focusing on reducing the burden of chemotherapy and radiation exposure in lymphoma patients.
Hematology and Oncology, Inside Pediatrics

ICOS Research Advances to Benefit Survivors, Improve Outcomes

By numbers alone, the Institute for Cancer Outcomes and Survivorship at the University of Alabama School of Medicine has posted an impressive list of accomplishments: Just six years after its founding, ICOS has received funding or commitments for $40 million, up $30 million since 2019. Additionally, faculty members have published approximately 500 journal papers, 167 of those in just the last year.

But the mission of ICOS far transcends those numbers. In their quest to study cancer outcomes long-term and identify issues survivors face, institute members – who include epidemiologists, physician-scientists, behavioral scientists, molecular biologists and nurse-scientists – have aggressively pursued research questions aiming to help survivors prevent and manage long-term complications from cancer and its treatment.

“Institute members are asking some terrific, clinically pertinent questions and going after them like a dog after a bone,” said ICOS Director Smita Bhatia, M.D., M.P.H., who’s also the Gay and Bew White Endowed Chair in Pediatric Oncology at the University of Alabama at Birmingham (UAB). “Really changing practice to improve clinical outcomes – that’s our goal.”

Over the past two years, notable ICOS studies have produced clinically useful results as well as spawned new and related research. Bhatia offered updates on several key efforts:

  • Examining the molecular basis of long-term complications in pediatric cancer survivors: Boosted by a sizable 7-year grant from the National Institutes of Health, ICOS researchers have “unearthed some very interesting genes associated with chemotherapy that cause heart failure,” Bhatia reported. “They’ve also developed a risk prediction model that allows us to say, ‘If you have this genetic makeup, we can predict whether you’ll develop heart failure or not.’”
  • Testing strategies to improve adherence to oral chemotherapy among adolescents with acute lymphoblastic leukemia (ALL): Physicians texted patients each night to remind them to take their chemotherapy, with a duplicate text sent to parents. Parents were instructed to watch their children take the medication. Families also watched educational videos on the topic. “Among adolescents at baseline who were non-adherers, they benefited most with this intervention,” Bhatia said. “Those findings were published and we’re now taking this to the next level in a 2,000-patient trial.”
  • Understanding how to treat older cancer patients without undue toxicity: Geriatric assessment surveys were given to older adults with colorectal cancer, multiple myeloma and other malignancies that are pinpointing how a patient’s total fat and muscle tissue may be linked to treatment toxicity levels. “This is like a gold mine in terms of giving us so many good findings we can apply in clinic,” Bhatia said.
Cardiology, Inside Pediatrics

Using Stem Cells to Strengthen the Hearts of HLHS Patients

While advanced surgical techniques, ICU care and outpatient management have dramatically improved survival rates for children born with hypoplastic left heart syndrome (HLHS), additional treatment options are still very much needed. That’s why pediatric cardiologists at Children’s of Alabama are eager to join forces with the Mayo Clinic to test stem cell therapy on HLHS patients from Alabama and the surrounding region.

A year after joining the Mayo Clinic’s HLHS Consortium – about a dozen prominent children’s institutions spread across the United States and Canada – Children’s is taking part in clinical research to determine if stem cells from a patient’s own umbilical cord blood can strengthen the right side of the heart.

Born with an array of underdeveloped structures on the left side of their hearts, HLHS patients typically undergo three surgeries over their first four years of life. Children’s treats between 12 and 20 such patients every year.

“This was a uniformly fatal diagnosis before these operations were used,” said Waldemar Carlo, M.D., an associate professor of pediatrics in the Division of Pediatric Cardiology at Children’s and the University of Alabama at Birmingham (UAB). “Outcomes are ever-improving for this diagnosis, and we’ve gotten the first-year mortality down to under 10%. But we know that the decreasing function of the right ventricle over time limits how long these patients can live.”

The Phase 2 clinical trial, in which Children’s is completing enrollment, is based on successful Phase 1 results and will further determine the safety and efficacy using cell-based regenerative therapy to help manage HLHS. Parents expecting babies known to have HLHS are approached before childbirth and offered the opportunity to bank their baby’s umbilical cord blood. Stem cells derived from that blood are then injected directly into the infant’s right ventricular muscle during second-stage (Glenn) surgery.

To compare outcomes over time, the trial will also include a placebo arm of patients who do not receive stem cells during second-stage surgery. Several HLHS patients at Children’s will be included in each arm.

“The thought with this therapy is that stem cells would initiate a response in the right ventricle to strengthen the heart muscle over time – hopefully preserving its function longer than would otherwise happen,” Carlo said.

“We were chosen because we have very good clinical results in the care of children with HLHS at Children’s of Alabama,” Carlo added. “That is a prerequisite before participating in clinical research using novel therapies. It’s certainly an honor to participate with these other excellent centers.”

Cardiology, Inside Pediatrics

Comparing Delayed Sternal Closure Results Reinforces Success at Children’s of Alabama

Leaving the chest open for a day or two after complex neonatal heart surgery has been standard procedure at Children’s of Alabama for about a dozen years. The practice is believed to be a “safety mechanism” that lessens compression on the heart and lungs as swollen babies begin to recover from their operations, according to Robert Dabal, M.D., chief of pediatric cardiothoracic surgery at Children’s and an associate professor of surgery at the University of Alabama at Birmingham (UAB).

But does the approach, known as delayed sternal closure, actually produce better outcomes than closing a newborn’s chest at the conclusion of surgery? The Pediatric Cardiac Critical Care Consortium (PC4) recently invited Children’s and University of Michigan’s C.S. Mott Children’s Hospital to debate the question by comparing each hospital’s outcomes. Unlike standard practice at Children’s, C.S. Mott cardiothoracic surgeons “tend to close a lot of complex neonates,” Dabal explained.

Children’s has been a member of PC4 – which aims to improve the quality of care to patients in North America and beyond with critical pediatric and congenital cardiovascular disease – since the group’s inception about 12 years ago. The head-to-head comparison of outcomes between Children’s and C.S. Mott showed survival rates to be higher at Children’s, though the gap was not statistically significant, Dabal said.

“We found that delayed sternal closure doesn’t really negatively impact patients in any way, either in length of stay or rate of complications, but it does make them a little easier to manage in the immediate postoperative period,” he said.

Mortality rates at Children’s for complex neonatal heart surgeries are consistently far lower than the U.S. average, he noted. For example, for the Norwood procedure – a three-step heart surgery for hypoplastic left heart syndrome – Children’s mortality rate has been about 5.5% over the last five years, compared with a national average of about 15%.

Possible complications from leaving the chest open after surgery include slightly higher odds of infection, “though we haven’t really seen that here,” Dabal said. The practice also requires greater sedation to prevent patients from “moving around a lot” in the days after surgery and a slight delay in removing ventilators.

But the PC4 debate results essentially reinforce Children’s approach, and Dabal expects delayed sternal closure to continue here as the standard of care. “I don’t think we’ll be making major changes, though we’re always interested in continuing to improve our results,” he said.