Adherence to adhesive patch electrocardiographic monitoring among adults with disabilities.

BACKGROUND: Individuals with developmental and/or intellectual disabilities (I/DD) are at a greater risk for atrial fibrillation (AF), the most common type of cardiac arrhythmia. AF is associated with heart failure, stroke, poor mental health, and reduced quality of life. Management and treatment decisions are based on the ability to detect AF; however, noninvasive, remote cardiac monitoring may not be tolerated by individuals with I/DD. OBJECTIVE: To examine adherence to the placement of an ambulatory cardiac rhythm monitoring patch device by adult patients with I/DD. METHODS: Investigators extracted chart data from a consecutive series of adult patients (18 years+) who received the patch device as part of standard treatment at an adult health center between November 1, 2015 and October 31, 2019. RESULTS: A total of 95 patients were included in data analysis. Average age of subjects was 53.8 ± 13.9 years (range: 20.2-88.5); 66.7% were male. All subjects had intellectual disabilities as follows: mild, 37.9%; moderate, 29.5%; severe, 21.0%; and, profound, 11.6%. With a prescribed duration of 14 days, subjects wore the device a median (interquartile range [IQR]) of 12.2 days (4.1-14.0); total analysis time was a median of 9.5 days (3.4-13.5). A total of 29 subjects (30.5%) received cardiac diagnoses not previously identified (median = 1 new diagnosis; range: 1-5). CONCLUSIONS: This pilot study suggests the possible utility of an ambulatory monitoring patch device in an adult population with I/DD. Investigators recommend larger studies to confirm such preliminary findings to ultimately improve clinical management and patient quality of life.

Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants.

BACKGROUND: An unsafe sleep environment remains the leading contributor to unexpected infant death. PURPOSE: To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants. METHODS: A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018. RESULTS: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%. IMPLICATIONS FOR PRACTICE: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices. IMPLICATIONS FOR RESEARCH: Future studies on the impact of such an initiative at other hospitals are needed.

Challenges to Professional Success for Women Plastic Surgeons: An International Survey.

BACKGROUND: Female plastic surgeons face specific challenges in their careers that impact lifestyle and professional choices. OBJECTIVE: The authors sought to delineate these specific issues further through means of an anonymous survey and to suggest areas for improvement. METHODS: In August 2017, a link to an online email questionnaire via SurveyMonkey.com was sent to 398 women members of the International Society of Aesthetic Plastic Surgery, which included questions on demographics, surgical training, practice characteristics and preferences, leadership and professional activities, marriage and childcare, financial status, workplace sexism and sexual harassment and surgeon attitudes. RESULTS: A total of 138 female plastic surgeons responded to the survey for a response rate of 34.7%. Critical issues most cited by respondents included work-life balance and childcare responsibilities, sexual harassment and the lack of gender parity at meetings. CONCLUSIONS: Plastic surgery training programs, institutions and societies should acknowledge the additional challenges that female surgeons face. The greatest areas for improvement include the balance of work and family responsibilities, addressing the prevalence of sexual harassment and improved representation at scientific meetings. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Organ Distribution of 13N Following Intravenous Injection of [13N]Ammonia into Portacaval-Shunted Rats.

Ammonia is neurotoxic, and chronic hyperammonemia is thought to be a major contributing factor to hepatic encephalopathy in patients with liver disease. Portacaval shunting of rats is used as an animal model to study the detrimental metabolic effects of elevated ammonia levels on body tissues, particularly brain and testes that are deleteriously targeted by high blood ammonia. In normal adult rats, the initial uptake of label (expressed as relative concentration) in these organs was relatively low following a bolus intravenous injection of [13N]ammonia compared with lungs, kidneys, liver, and some other organs. The objective of the present study was to determine the distribution of label following intravenous administration of [13N]ammonia among 14 organs in portacaval-shunted rats at 12 weeks after shunt construction. At an early time point (12 s) following administration of [13N]ammonia the relative concentration of label was highest in lung with lower, but still appreciable relative concentrations in kidney and heart. Clearance of 13N from blood and kidney tended to be slower in portacaval-shunted rats versus normal rats during the 2-10 min interval after the injection. At later times post injection, brain and testes tended to have higher-than-normal 13N levels, whereas many other tissues had similar levels in both groups. Thus, reduced removal of ammonia from circulating blood by the liver diverts more ammonia to extrahepatic tissues, including brain and testes, and alters the nitrogen homeostasis in these tissues. These results emphasize the importance of treatment paradigms designed to reduce blood ammonia levels in patients with liver disease.

Timely pain management in the emergency department.

BACKGROUND: Delivering timely pain relief remains a challenge for most emergency departments. OBJECTIVE: To evaluate the effectiveness of a policy aimed at delivering analgesics within 30 min to patients presenting to an emergency department with severe pain. METHODS: Subjects were aged ≥19 years, had a principal diagnosis of renal colic, hip fracture, or sickle cell disease, reported a pain score ≥8 on a scale of 0 to 10 at triage, and continued to report a score in this range until receiving analgesia. The study compared proportions of patients receiving analgesics within the 30-min target, median time to analgesic administration, and median time to relief of severe pain (decline in pain level to score <8) during 6 months before vs. 6 months after implementation of the new pain management policy. RESULTS: Paradoxically, the median total waiting time to analgesic administration increased from 64 min (n = 75) to 80 min (n = 70) after policy implementation (p = 0.01), and the proportion of patients receiving analgesics within 30 min declined from 17% (13/75) to 7% (5/70) (p = 0.08). Median time to relief of severe pain did not differ significantly between periods (130.5 vs. 153 min; p = 0.31). CONCLUSIONS: After implementation of the new pain management policy, the proportion of patients with severe pain receiving analgesics within 30 min actually declined. Although a 30-min target may be unrealistic, it seems reasonable to conclude that something is wrong when patients with notoriously painful conditions must typically wait 1-2 h to obtain relief. Given the millions of individuals who receive care in emergency departments nationwide each year, the suffering caused by delays occurs on a large scale, so creative approaches are clearly needed to overcome the obstacles.

Impact of AOA status and perceived lifestyle on career choices of medical school graduates.

BACKGROUND: Based upon student ratings of such factors as predictable work hours and personal time, medical specialties have been identified as lifestyle friendly, intermediate, or unfriendly. Lifestyle friendly programs may be more desirable, more competitive, and for students elected to the Alpha Omega Alpha (AOA) Honor Medical Society, more attainable. OBJECTIVE: The objective of this study was to evaluate whether AOA students increasingly entered lifestyle friendly residency programs and whether trends in program selection differed between AOA and non-AOA graduates. DESIGN: This retrospective cohort study examined PGY-2 data from the Association of American Medical Colleges and the 12 allopathic schools in the Associated Medical Schools of New York. PARTICIPANTS: Data on 1987-2006 graduates from participating schools were evaluated. MAIN MEASURES: Residency program selection over the 20-year period served as the main outcome measure. KEY RESULTS: AOA graduates increasingly entered lifestyle-friendly residencies--from 12.9% in 1987 to 32.6% in 2006 (p < 0.01). There was also a significant decrease in AOA graduates entering lifestyle unfriendly residencies, from 31.6% in 1987 to 12.6% in 2006 (p < 0.01). Selection of lifestyle intermediate residencies among AOA graduates remained fairly stable at an average of 53%. Similar trends were found among non-AOA students. However, within these categories, AOA graduates increasingly selected radiology, dermatology, plastic surgery and orthopedics while non-AOA graduates increasingly selected anesthesiology and neurology. CONCLUSIONS: While lifestyle factors appear to influence residency program selection, AOA graduates differentially were more likely to either choose or attain certain competitive, lifestyle-friendly specialties. Health care reform should be targeted to improve lifestyle and decrease income disparities for specialties needed to meet health manpower needs.

Dosing of unfractionated heparin in obese patients with venous thromboembolism.

BACKGROUND: Aggressive weight-based dosing guidelines help achieve prompt therapeutic anticoagulation in patients with venous thromboembolism (VTE). While obese patients with VTE face an increased risk of recurrence, physicians typically resist prescribing doses two to three times the usual dose because of concern about bleeding complications. OBJECTIVE: To examine the use of unfractionated heparin in obese patients with VTE at an academic teaching hospital in order to document the extent and pattern of underprescribing in this high-risk patient population. DESIGN: Three-year, cross-sectional consecutive case series. PATIENTS: Adult inpatients with VTE and a body mass index ≥30 kg/m(2) who were treated with unfractionated heparin. MEASUREMENTS: Time to achievement of therapeutic anticoagulation (activated partial thromboplastin time >60 s) and gap between recommended and prescribed heparin doses. RESULTS: Time to attainment of therapeutic anticoagulation exceeded 24 h in 29% of study patients (n = 84) and exceeded 48 h in 14% of patients. In 75 patients (89%), the prescribed bolus dose fell below the recommended dose of 80 units/kg, and in 64 patients (76%) the initial continuous infusion fell more than 100 units/h below--in some cases more than 1000 units/h below--the recommended dose of 18 units/kg/h. There was a significant correlation between time to therapeutic anticoagulation and initial infusion dose (Spearman r = -0.27; p < 0.02). Each decrease of 1 unit/kg/h translated to a delay ranging from about 0.75 h to 1.5 h over the range of prescribed doses (6 to 22 units/kg/h). CONCLUSIONS: A substantial proportion of obese patients treated with unfractionated heparin experienced a delay >24 h in achieving adequate anticoagulation, and the vast majority received an inadequate heparin bolus or initial continuous infusion (or both) according to current dosing guidelines.

The influence of career stage, practice type and location, and physician's sex on surgical practices among board-certified plastic surgeons performing breast augmentation.

BACKGROUND: Breast augmentation is the most commonly performed cosmetic surgical procedure in the United States, but surgeon preferences in terms of technique and postoperative care regimen vary widely. OBJECTIVES: The authors investigated the influence of career stage, practice type and location, and physician's sex on surgical technique preferences among board-certified plastic surgeons performing breast augmentation. METHODS: In October 2009, an online survey was e-mailed to all active members of the American Society of Plastic Surgeons practicing within the United States. Response frequencies were calculated and correlated with surgeon demographics. RESULTS: From the pool of 4737 respondents, 898 responses were received (18.9%). Surgeons performing breast augmentation were more frequently male, between 46 and 65 years old, and had practiced for at least 20 years in solo private practice in a suburban setting. Surgical volume most frequently consisted of 10% to 25% cosmetic surgery, with 10 to 50 breast augmentations performed per year. Surgeons in practice for five years or less were more likely to use smooth, round silicone gel-filled implants, to select implants smaller than 300 cc, to use the dual-plane pocket, and to recommend yearly follow-up. Surgeons in practice for more than 20 years were more likely to select saline implants, utilize the subglandular plane, perform closed capsulotomy, and place drains. Surgeons at academic centers performed fewer breast augmentation surgeries and placed smaller implants than those in private practice, while surgeons in suburban locations performed more breast augmentations than those in urban or rural locations. Surgeons in the West performed the greatest number of augmentations, although the largest-sized implants were placed in the Southwest. Compared with men, women surgeons appeared significantly less likely to use saline implants, were less likely to perform more than 100 breast augmentations per year, and were significantly more likely to place implants less than 300 cc. CONCLUSIONS: Surgical preferences were associated with years in practice and included differences in technique and postoperative care. Practice location was associated with differences in procedural volume, implant size, incision location, and recommended follow-up time, while practice type was related to surgical volume, implant size, implant location, and percentage of cosmetic surgery performed.

Is Earlier Better? The Relationship between Age When Starting Early Intervention and Outcomes for Children with Autism Spectrum Disorder: A Selective Review.

Although the conventional wisdom is that "earlier is better" when it comes to intervention for children with ASD, it is not clear what evidence exists to support this notion. This review examined a group of studies that addressed outcomes for young children with ASD who started early intervention at a range of ages. The review was selective by including only papers that examined the age of initiation of treatment as well as baseline cognitive, language, or adaptive level and, in addition, employed a method to control for the covariance between early ability level and age of beginning intervention. Fourteen studies were identified and then compared on methods and outcomes. The support for "earlier is better" was mixed, but it was clear that complex relationships among predictor variables need to be explored in order to understand the role of age of starting early intervention for later outcomes.

Technology and social media use by adult patients with intellectual and/or developmental disabilities.

BACKGROUND: Technology and social media offer individuals with intellectual and/or developmental disabilities (I/DD) unique and innovative ways to facilitate active participation in their own healthcare process. What remains unclear is the extent to which devices are currently used by this growing patient population. OBJECTIVE: To explore the prevalence of technology and social media use, as well as the possible barriers, among adult patients with I/DD. METHODS: A cross-sectional study utilizing an anonymous, accessible survey was used to obtain data from all adult patients (18 + years of age) with I/DD presenting for primary care services at a healthcare facility in New York between September and December of 2016. RESULTS: A total of 370 individuals completed the survey (529 approached, 69.9% response rate). Less than half (44.6%) of respondents used devices such as a tablet, smartphone or desktop; most (86.8%) did not use social media. Only 21.6% of respondents indicated that they use some type of assistive technology. While some respondents (46.0%) were identified by their caregivers as having a disability that would prevent them from learning/using technology, other respondents reported having no challenges (18.0%), needing training and/or ongoing support (7.4%), or being uncertain as to whether they would experience any challenges (15.5%). CONCLUSIONS: Many adult patients with I/DD do not use technology and social media that could promote self-determination and participation in their healthcare. Continued efforts must be made to promote technology use among adults with I/DD and to ensure that appropriate training is available for both the individual and his/her caregivers to achieve adoption and utilization.

The efficacy of a US-based medicine recycling program delivering antiretroviral drugs worldwide.

Since 1996, AID FOR AIDS International (AFAI) has collected unused antiretroviral drugs (ART) and ;;recycled'' these medications to over 600 people living with human immunodeficiency virus/AIDS abroad under its AIDS Treatment Access Program. The investigators evaluated AIDS Treatment Access Program's efficacy using immunologic and virologic outcomes. Of the 404 eligible clients who had baseline and follow-up CD4 counts, mean baseline versus most recent measure was 230 + 222 cells/mm( 3) versus 372 + 256 cells/mm(3) (P < .01). Of the 216 eligible clients who had baseline (>400 copies/mL) and follow-up viral loads, 62% (134/ 216) had undetectable viral loads (<400 copies/mL) at their most recent measure. Median enrollment time in the recycling program was 3.1 years (range: 6 months to 9.5 years). AFAI's medication recycling program is efficacious in reaching and improving the clinical outcomes of people living with HIV/AIDS (PLWHA). Such programs should be considered a viable option among scale-up programs until governments provide universal access of ART to PLWHA.

Children's drinking water: parental preferences and implications for fluoride exposure.

PURPOSE: The purposes of this study were to: describe children's drinking water sources; determine if any demographic factors are associated with water choice; describe parents' reasons for selecting bottled water; and determine parents' ability to provide enough information about their drinking water for providers to assess children's fluoride exposure. METHODS: Subjects were parents of children 6 months to 15-years-old. A questionnaire was verbally administered in English or Spanish. Chi-square analyses were used to evaluate associations among study variables. RESULTS: Of 194 parents, 134 (69%) gave their children bottled water either exclusively or with tap water. Bottled water use was not significantly associated with the primary source of tap water, parent's education level, or household income. Reasons for giving children bottled water included: fear of contaminants in tap water; taste and/or smell of tap water; and convenience of bottled water. For parents using bottled water, over 65% did not know the brand's fluoride content. CONCLUSIONS: Barriers to an accurate fluoride assessment include frequent bottled water use and parental uncertainty about its fluoride content. By initiating communication with parents and educating them about fluoride sources, health care and dental providers may be able to better evaluate the adequacy of children's fluoride exposure and decide whether fluoride supplementation is necessary.

Intensity of Vasopressor Therapy for Septic Shock and the Risk of In-Hospital Death.

CONTEXT: Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions. OBJECTIVES: To determine if intensity of vasopressor therapy accurately predicts in-hospital death. METHODS: This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship. RESULTS: A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival. CONCLUSION: When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.

Parental perceptions and use of complementary and alternative medicine practices for children with autistic spectrum disorders in private practice.

The prevalence of autistic spectrum disorder (ASD) in the United States is approximately 1 in 150 children. Many health care providers are unaware of parental beliefs and treatments, both medical and complementary, that parents use for their child with ASD. Understanding these beliefs and practices concerning diagnosis, cause, and utilization of medical and complementary care may help physicians provide better comprehensive care. Parents of children with ASD from 2 private practices-one in New York and one in New Jersey-were mailed a 6-page, self-administered survey. In addition to demographics and ASD type, the survey asked parents who diagnosed their child and if there was a perceived delay in that diagnosis; whether they believed there was any causal reason for their child's autism; what chronic symptoms, if any, their child experiences; and, if they had used any complementary and/or alternative therapies and at whose recommendation. Respondents included 77 of the 150 parents (51%) contacted. Most children were diagnosed by a neurologist and/or developmental pediatrician (54% and 47%, respectively). Average perceived delay in diagnosis was 18 months. Parents most frequently cited immunizations (54%), genetic predisposition (53%), and environmental exposure (38%) as a cause of their child's autism. Approximately half of children were reported as having at least one gastrointestinal, neurological, and/or allergic symptom; more than a third had immunological symptoms. Almost all parents (95%) indicated some use of complementary and alternative medicine (CAM) therapies, with most of the self-reported referrals generated from a physician or nurse (44%). Systemic complaints, parental beliefs, and use of CAM practices warrant open discussion by all health care professionals who provide care to this population.

Parental beliefs about autism: implications for the treating physician.

This study investigated parental beliefs about the etiology, diagnosis, and treatment of autism spectrum disorders. Sixty-two families of affected children completed a questionnaire asking when the parent first noticed developmental or behavioral problems, when they were told the diagnosis, how confident they were about the ability of their child's physician to recognize autism, whether they believed anything specific might have caused their child's autism, and what medications and complementary or alternative therapies they had tried. Two-thirds of parents suspected a specific cause, and three-quarters questioned their physician's ability. Parents who perceived a greater delay in diagnosis or who had tried more different therapies both tended to have less confidence in their physician (p = 0.20 and p = 0.07, respectively). Physicians should inquire about parental beliefs concerning etiology, learn what treatments the children are receiving, perform screening at the 18 month visit, and make referrals for further evaluation as soon as a child begins to exhibit signs suggestive of autism.

Educational posters to reduce antibiotic use.

INTRODUCTION: Antibiotic overuse promotes resistant strains of bacteria and puts patients at risk for adverse reactions. Given the use of educational posters in government-sponsored public health campaigns, this study examined the effectiveness of a waiting room poster in reducing excessive antibiotic use in clinical practice. METHODS: Investigators conducted a 1-month trial of an educational poster with historical controls using three private pediatric group practices in Westchester County, New York. Children between the ages of 6 months and 10 years at the time of a visit to diagnose and treat symptoms of respiratory illness were enrolled as subjects. Antibiotic prescriptions for children with respiratory illnesses seen during the poster month were compared with prescriptions written during three 1-month historical control periods. The proportion of visits that resulted in a prescription for an antibiotic served as the outcome measure. RESULTS: Overall, 326 of the 720 patients (45.2%) enrolled in the study were treated with an antibiotic. Multiple logistic regression analysis revealed no statistically significant difference in the proportion of visits resulting in an antibiotic prescription among the 4 study months (P = .79), indicating that the educational poster had no effect on antibiotic use. DISCUSSION: Public education in the form of a waiting room poster was not sufficient to decrease antibiotic prescriptions. This finding has implications for current large-scale programs and for health care providers as they continue to attempt to educate patients on the appropriate use of antibiotics.

Autism Spectrum Disorder Screening Instruments for Very Young Children: A Systematic Review.

Research on ASD in infancy has provided a rationale for developing screening instruments for children from the first year of life to age of 18 months. A comprehensive literature search identified candidate screening tools. Using methodological probe questions adapted from the Quality Assessment of Diagnostic Accuracy Studies (QUADAS), two Level 1 and three Level 2 screening instruments were reviewed in detail. Research evidence conclusions were that instrument development was in beginning phases, is not yet strong, and requires further development. Clinical recommendations were to continue vigilant developmental and autism surveillance from the first year on but to use the screening instruments per se only for high-risk children rather than for population screening, with considerations regarding feasibility for individual settings, informing caregivers about strengths and weaknesses of the tool, and monitoring new research.

Is fluorescence under an alternate light source sufficient to accurately diagnose subclinical bruising?

This single-blinded, randomized validation study was conducted to evaluate whether fluorescence under alternate light sources (ALS) is sufficient to diagnose subclinical bruising (bruising not visible under white light). Standardized trauma was induced on randomly selected ventral forearms. On days 1, 7, and 14 investigators independently examined case forearms under white light for perceived bruising and under ALS for fluorescence and compared body maps. 56 case and 62 control forearms (n = 118) were examined. Sensitivity of ALS on days 1, 7, and 14 was 76.8%, 69.6%, and 60.7%, respectively, compared to 69.6%, 60.0%, and 32.1% for white light. The specificity of ALS on days 1, 7, and 14 was 51.6%, 59.7%, and 53.2%, respectively, compared to 71.0%, 81.4%, and 86.9% for white light. ALS has increased sensitivity yet low specificity compared to white light in accurately detecting bruises. Fluorescence under ALS is not sufficient to accurately or responsibly diagnose subclinical bruising.

The impact of a hospital-based educational video on maternal perceptions and planned practices of infant safe sleep.

PURPOSE: To evaluate whether an educational video would impact infant sleep practices among new mothers. DESIGN AND METHODS: Survey responses of new mothers who did (n = 43) versus did not (n = 49) watch the educational video were compared to identify differences in observed and planned infant sleep practices. RESULTS: Mothers who watched the video were more likely to observe safe sleep practices while in the hospital (67.4% vs. 46.9%, p < .05). They were also less likely to plan for (unsafe) side positioning (23.9% vs. 7.1%, p < .05). PRACTICE IMPLICATIONS: Given the potentially fatal consequence of unsafe sleep, a brief video provided by nursing staff can be a prudent component of new parent education.