Child maltreatment surveillance following the ICD-10-CM transition, 2016-2018.

BACKGROUND: Child maltreatment is poorly documented in clinical data. The International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM) represents the first time that confirmed and suspected child maltreatment can be distinguished in medical coding. The utility of this distinction in practice remains unknown. This study aims to evaluate the application of these codes by patient demographic characteristics and injury type. METHODS: We conducted secondary data analysis of emergency department (ED) discharge records of children under 18 years with an ICD-10-CM code for confirmed (T74) or suspected (T76) child maltreatment. Child age, sex, race/ethnicity, insurance status and co-occurring injuries (S00-T88) were compared by maltreatment type (confirmed or suspected). RESULTS: From 2016 to 2018, child maltreatment was documented in 1650 unique ED visits, or 21.7 per 10 000 child ED visits. Suspected maltreatment was documented most frequently (58%). Half of all maltreatment-related visits involved sexual abuse, most often in females and individuals of non-Hispanic white race. Physical abuse was coded in 36% of visits; injuries to the head were predominant. Non-Hispanic black children were more frequently documented with confirmed physical abuse than suspected (38.7% vs 23.7%, p<0.01). The rate of co-occurring injuries documented with confirmed and suspected maltreatment differed by 30% (9.2 vs 12.5 per 10 000 ED visits, respectively). CONCLUSIONS: The ability to discriminate confirmed and suspected maltreatment may help mitigate clinical barriers to maltreatment surveillance associated with delayed diagnosis and subsequent intervention. Racial disparities in suspected and confirmed cases were identified which may indicate biased diagnostic behaviours in the ED.

Analysis of Complications in Outpatient ICD Surgery On or Off Warfarin Anticoagulation.

BACKGROUND: Implantable cardioverter defibrillator (ICD) implantation is being performed differently at many hospitals, with some keeping patients overnight after procedure while others discharge patients home same day. In addition, many centers are now performing ICD surgery while on warfarin anticoagulation. There are, however, limited data on outpatient ICD surgery on anticoagulated (AC) patients. OBJECTIVE: We wished to evaluate the safety of performing outpatient ICD surgery with and without warfarin anticoagulation. METHODS: We evaluated 866 patients who underwent outpatient ICD surgery between April 2010 and September 2014. Patients who were on novel oral anticoagulants, or did not have an international normalized ratio drawn within 24 hours of the procedure were excluded and the remainder were divided into two groups based on whether they were on (n = 230) or off (n = 518) warfarin anticoagulation. We evaluated both procedural and 30-day complications in both groups. RESULTS: The complication rate at 30 days in the warfarin AC group was 4.3%, while in the nonanticoagulated (NAC) group was 2.9% and not significantly different (P = 0.31). However, the pocket hematoma rate in the warfarin anticoagulated group was 3.5%, as compared to the NAC group that was 0.4% (P = 0.001). CONCLUSION: Complications from ICD surgery are low in the ambulatory setting on or off warfarin anticoagulation and appear to be comparable. However, warfarin use during ICD surgery is associated with an increased risk of pocket hematoma.

Providing the Tools to Facilitate Quality Care for Children with Sickle Cell Disease.

Meeting best-practice guidelines can significantly enhance quality of life and longevity for those with sickle cell disease (SCD). However, many clinical settings lack the necessary resources for optimal care. We present an integrated suite of tools and collaborative actions designed to enhance SCD care.

Unravelling the complex interplay of factors behind exercise limitations and physical inactivity in COPD.

Exercise limitation and physical inactivity are known treatable traits for people with COPD. Maximising exercise capacity and keeping people physically active improves health status and survival rates among people with COPD. However, managing these two treatable traits can be extremely challenging for clinicians due to the complex intersectionality of factors influencing an individual's capacity, opportunity and motivation to engage in physical activity. This review presents the complex factors influencing exercise capacity ("can do"), levels of physical activity ("do do") and sedentary behaviours amongst people with COPD and provides practical recommendations on how clinicians can address some of these factors in practice. Most importantly, it highlights the importance of referring to pulmonary rehabilitation as a way to improve exercise capacity among people with COPD.

A prospective study comparing the sensed R wave in bipolar and extended bipolar configurations: the PropR study.

BACKGROUND: Progress in implantable cardiac defibrillator (ICD) technology has allowed for switching the sensing polarity for the detection of ventricular fibrillation (VF). However, whether one sensing polarity confers additional advantage over the other is not known. OBJECTIVES: To determine whether one sensing polarity is superior to the other for the detection of VF. METHODS: Patients were enrolled into a prospective randomized study of sensing of VF and R waves in normal rhythm. Sensing of VF was determined by number of under sensed beats (USB), and time to detection of VF (TDVF). Each patient underwent ICD implantation followed by testing of the ICD. At each induction, patients were randomized to sensing in extended bipolar (EBP) or true bipolar (TBP) configuration. Additionally, R waves were compared at implant and at 1-month follow-up. RESULTS: A total of 50 patients were enrolled into the study. When evaluating the primary endpoint, no difference was found between USB in EBP or TBP configuration; 1.1 ± 1.2 beats versus 1.3 ± 1.3 beats; P = NS. Also, no difference was found between TDVF in EBP or TBP configurations; 5.9 ± 0.6 seconds versus 5.9 ± 0.6 seconds; P = NS. With regard to the secondary endpoints, there was no difference between R waves in EBP or TBP configurations at the time of implant 10.9 ± 4.8 mV versus 10.9 ± 4.8 mV P = NS; or at 1-month follow-up 12.4 ± 4.7 mV versus 12.0 ± 5.4 mV P = NS. CONCLUSIONS: There is no difference in the detection of VF between EBP or TBP configurations in patients undergoing ICD implantation.

Reducing Family Violence Through Child Welfare Intervention: A Propensity Score-Matched Study of Fathers for Change.

Intimate partner violence (IPV) is prevalent, costly, and detrimental to children's health and development. It often co-occurs with child abuse and neglect. Most children referred to child protective services (CPS) have witnessed IPV and are at increased risk for subsequent exposure, as well as repeat maltreatment. For CPS referred children, there is often a missed opportunity to interrupt family violence and prevent future occurrences. Fathers for Change (F4C) is a family level intervention designed to reduce IPV by improving emotion regulation and reflective functioning in fathers. To date, no study has examined whether F4C is associated with reduced recidivism in families referred to CPS. Using propensity score matching (PSM) to simulate an experimental design, the current study tests the hypothesis that families with fathers who completed F4C will have significantly lower rates of new CPS reports over a 12-month period compared to a PSM sample of families of fathers not referred to F4C. Data were extracted from a state CPS electronic case records system on all accepted child maltreatment reports received between January 1, 2015, and April 30, 2020. PSM was successful in balancing potential confounders (e.g., race, number of prior maltreatment reports, risk level, date of report), resulting in a comparison group approximate to one that could be achieved via a randomized control trial. Logistic regression analyses of 1:1 PSM pairs revealed that control fathers were 2.4 times more likely to have a repeat maltreatment report during the 12-month follow-up period than F4C fathers. These findings suggest that F4C may provide an effective approach for reducing risk of repeat maltreatment among CPS referred children with identified IPV exposure.

Patient-perceived outcomes of the AdVance sling up to 40 months post procedure.

AIMS: The objective of this study was to determine patient-perceived outcomes of the AdVance sling over 40 months and to determine if results were durable over time. METHODS: This study represents a retrospective chart review of a single-surgeon's experience with the AdVance sling paired with a follow-up 5 question telephone survey performed in April 2010. The telephone survey consisted of 2 validated questions pertaining to patient satisfaction (the PGI-I and the PGI-S) along with 3 additional questions pertaining to number of pads per day (PPD) used, additional therapies tried, and whether or not the patient would recommend the procedure to a friend. Ordinal and non-normally distributed variables were analyzed via rank order correlation (Spearman's rho) and the association between the number of pads per day used at the time of telephone survey and progressing time since sling procedure was plotted with linear regression analysis. RESULTS: The surgeon performed a total of 44 AdVance sling procedures from 2006 to April 2011. 42 charts were available for review and 36 (85.7%) patients were reached via telephone. Average patient age was 63.64 years and average time in months since sling procedure was 18.76. Average number of PPD used was 2.11 preoperatively, 0.38 at the one month post-operative visit, and 1.67 at time of the telephone survey. Additionally, advancing time since sling operation correlated with higher numbers of PPD. 34/36 patients would recommend the procedure to a friend. CONCLUSION: Despite patient satisfaction with the sling procedure, our data show that patients were using an increasing number of PPD as time from sling procedure advanced. This is important information for patients and physicians to consider when choosing this procedure.

Perceptions of Racism in Children and Youth (PRaCY): properties of a self-report instrument for research on children's health and development.

Experiences of racial discrimination have been demonstrated to be related to racial and ethnic disparities in mental and physical health and healthcare. There has been little study, however, of the relationship between racism and health in children, and few psychometrically valid and reliable instruments to measure Perceptions of Racism in Children and Youth (PRaCY) exist. This paper reports on the development and testing of such an instrument, the PRaCY. Development of the instrument began with open-ended qualitative interviews, from which a proto-questionnaire was created. The questionnaire gathered information on the prevalence, attribution, emotional responses, and coping responses to 23 situations identified by participants in the qualitative phase. The proto-questionnaire was administered to 277 children between the ages of 8 and 18 years (38% Latino/a, 31% African-American, 19% multiracial/multicultural, 7% West Indian/Caribbean, and 5% Other). Item analysis resulted in two developmentally appropriate 10-item instruments (one for ages 7-13, another for ages 14-18). Internal consistency reliability was strong (alpha = 0.78 for both versions of the instrument). Confirmatory factor analysis demonstrated good fit for both versions (younger-Comparative Fit Index (CFI): 0.967, Root Mean Square Error of Approximation (RMSEA): 0.047; older-CFI: 0.934, RMSEA: 0.056). Differential item functioning analyses demonstrated no group-specific biases in item response. PRaCY scores were appropriately associated with higher depressive symptom scores and elevated anxiety scores in the younger sample. Results indicate that the PRaCY is a valid and reliable instrument that measures perceptions of racism and discrimination in children and youth aged 8-18 from diverse racial/ethnic backgrounds.

Changes in Blood Profile from Steady State in Patients with Sickle Cell Anemia Admitted for Vaso-occlusive Crisis and Acute Chest Syndrome.

Close to half of all patients with sickle cell disease (SCD) will have at least one episode of acute chest syndrome (ACS) during their lifetime. Multiple cells and molecules involved with the inflammatory cascade play a role in the development of ACS. We found that patients with SCD who developed ACS as a complication of a vaso-occlusive crisis (VOC) had a significant increase in leukocytes and decrease in platelets from their steady state when compared with a separate admission for VOC without ACS development. No significant change from steady state hemoglobin or reticulocyte count was noted between the two admissions. These results indicate that trending laboratory markers may be useful to predict patients at risk for ACS development.

Identification of Child Maltreatment-Related Emergency Department Visits in Connecticut, 2011 to 2014.

Child maltreatment identified by medical professionals is poorly represented in records of child protection. International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes may better represent the burden of maltreatment treated in clinical settings. Using emergency department (ED) discharge data from 2011 to 2014, we enumerated presentations of maltreatment treated in Connecticut EDs for children under 10 years. Of 790 080 discharges, child maltreatment was explicitly documented in 265 (0.03%) unique ED visits, consistent with prior studies. Sexual maltreatment was most prevalent. A total of 3634 visits included an ICD-9-CM code suggestive of maltreatment. Children with these codes were significantly younger, more likely to be of white race, and use private insurance. Use of ICD codes in child maltreatment surveillance may elucidate characteristics of maltreatment not captured by child welfare data. Combining ICD codes for explicit and suggestive maltreatment will aid in understanding the extent of this problem.

The Experience of Latina Mothers of Children and Youth With Special Health Care Needs: A Qualitative Study.

Children and youth with special health care needs (CYSHCN) comprise a growing proportion of the pediatric population; the patient- and family-centered medical home provides a comprehensive model for caring for these patients. Given the limited literature available as well as extreme patient vulnerability, we sought to understand the experience of Latino parents in caring for their CYSHCN within our patient-centered medical home in an urban neighborhood in North Philadelphia. A convenience sample of 14 mothers or grandmothers of CYSHCN participated in semistructured interviews, which were analyzed using a thematic, constant comparative approach to identify common themes. Themes identified included "Waiting," "Communication/Trust," "All-Consuming Requirements of Care/Sacrifice," and "Fate/Faith/Blessings." These themes corresponded with identified goals of the patient-centered medical home. Our findings suggest that the principles of the patient-centered medical home can be applied in unique ways to caring for this unique patient population.

Discrimination and Mental Health in a Representative Sample of African-American and Afro-Caribbean Youth.

BACKGROUND: Racism and discrimination are psychosocial stressors that affect the health of minority populations. While discrimination has been associated with poor mental health, little is known about the relationship between discrimination and mental health outcomes in youth nationally. Furthermore, mental and behavioral health consequences of discrimination may differ in different minority groups. OBJECTIVE: The goal of this study is to determine (1) how common perceptions of discrimination are in a nationally representative sample of African-American (AA) and Afro-Caribbean (AC) teens, (2) the relationship between discrimination and mental health conditions, and (3) whether discrimination has different associations with mental health in AA and AC youth. DESIGN: Cross-sectional comparison study SETTING: National Survey of American Life-Adolescent Supplement, a nationwide sample of African-American and Afro-Caribbean youth drawn from a nationally representative household survey of AA and AC population PARTICIPANTS: One thousand, one hundred and seventy AA and AC youth between 13 and 17 years EXPOSURE: Experiences with discrimination (Everyday Discrimination Scale) MAIN OUTCOMES: Lifetime and past 12-month major depression and anxiety RESULTS: Ninety percent of AA and 87% of AC youth experienced discrimination. Discrimination was significantly associated with lifetime and 12-month major depression and lifetime and 12-month anxiety. There were no differences in the associations between discrimination and mental health between AA and AC youth except for lifetime anxiety: as discrimination increased, the likelihood of lifetime anxiety disorder increased at a higher rate among AC youth compared to AA. CONCLUSIONS: Discrimination is a common psychosocial stressor in African-American and Afro-Caribbean youth. It is associated with poor mental health outcomes. There was no difference in the occurrence of discrimination between African-American and Afro-Caribbean youth or in its mental health consequences.

A New EHR Training Curriculum and Assessment for Pediatric Residents.

Background Conventional classroom Electronic Health Record (EHR) training is often insufficient for new EHR users. Studies suggest that enhanced training with a hands-on approach and closely supported clinical use is beneficial. Objectives Our goals were to develop an enhanced EHR learning curriculum for Post Graduate Year 1 (PGY1) residents and measure changes in EHR skill proficiency, efficiency, and self-efficacy. Methods A novel three-phase, multimodal enhanced EHR curriculum was designed for a cohort of PGY1 residents. After basic training, residents began phase 1 of enhanced training, including demonstrations, live practice, and order set review. Phase 2 involved skills-oriented assignments, role playing, and medication entry. Phase 3 included shadowing, scribing histories, and supervised order entry. Residents' EHR skills and attitudes were measured and compared before and after the enhanced curriculum via proficiency test and a survey of efficiency and self-efficacy. Results Nineteen of 26 PGY1 residents participated in the study (73%). There was significant improvement in mean proficiency scores and two of the five individual proficiency scores. There were significant improvements in most efficiency survey responses from pre- to postintervention. For the self-efficacy presurvey, many PGY1s reported to be "very" or "somewhat confident" performing each of the five tasks, and perceptions did not improve or worsened on most postsurvey responses. The greatest resource was the time required to design and deliver the enhanced training. Conclusion An enhanced training curriculum along with a proficiency assessment was developed and described here. An enhanced training curriculum significantly improved PGY1 EHR efficiency and some measures of proficiency but not self-efficacy. This intervention may support improved EHR-related clinic workflows, which ultimately could enable residents and preceptors to prioritize patient care and time for clinical education.

Vitamin D supplementation, the metabolic syndrome and oxidative stress in obese children.

BACKGROUND: Previous studies suggest that vitamin D may play a role in cardiovascular and metabolic health. Oxidative stress has also been implicated in the development of cardiovascular disease. Evidence suggests that vitamin D deficiency may contribute to the occurrence of oxidative stress. This study aimed to determine whether treatment and correction of vitamin D deficiency in obese children led to changes in their metabolic profile, independent of changes in adiposity. In addition, we aimed to determine whether vitamin D deficiency and oxidative stress are causally related in obese children. METHODS: In the retrospective arm, chart review identified 32 obese children who experienced normalization of vitamin D deficiency or insufficiency with vitamin D supplementation. We then correlated laboratory and anthropometric data with vitamin D levels. In the prospective arm of the study, urinary 8-isoprostane and hydrogen peroxide were measured before and after correction of vitamin D deficiency/insufficiency and correlated to vitamin D levels in seven patients. RESULTS: In our predominantly Hispanic population of obese children in an urban setting, we demonstrated a cause-effect relationship between vitamin D deficiency and oxidative stress. In contrast, we found no association between vitamin D status, adiposity, and markers of insulin sensitivity, nor any effect of vitamin D treatment on the same parameters. CONCLUSIONS: These discordant findings suggest a differential effect of vitamin D on cardiovascular risk factors such as oxidative stress and insulin resistance. To confirm these findings, further prospective studies with larger sample size and longer follow-up are warranted.

Hyperparathyroidism but a negative sestamibi scan: a clinical dilemma.

BACKGROUND: The outcomes of patients with biochemically confirmed hyperparathyroidism but a negative Tc-99 Sestamibi scan are unclear. We examined the outcomes and quality of life of patients having surgery and those who had medical therapy. METHODS: Patients having a diagnosis of hyperparathyroidism with confirmed elevated calcium and parathormone levels, yet negative sestamibi scans were identified. The RAND SF-36 Health Survey was administered via mail to these patients. The patient's charts were then reviewed to verify treatments and to determine outcomes. RESULTS: Ninety-five patients fitting the criteria were identified. Twenty patients completed all aspects of the study. Ten of the respondents had undergone parathyroidectomy, and 10 had not. The surgical patients scored more favorably in all 8 of the measured parameters than patients treated medically. The differences in 3 domains, physical functioning, pain, and social functioning, were statistically significant. CONCLUSIONS: Our findings suggest that surgical therapy confers a better quality of life and is superior to medical therapy in the treatment of primary hyperparathyroidism, even in patients having a negative sestamibi scan.

Managing anemia in low-income toddlers: barriers, challenges and context in primary care.

Iron-deficiency remains a concern among low-income toddlers in the U.S. This formative study describes how primary care providers serving high-risk 1- to 3-year-old children in an urban ambulatory care setting approach anemia. Data collection included a retrospective review of randomly selected medical records (n=264) and semi-structured interviews with clinicians (n=41). Thirty-eight percent of the children presented with anemia (Hgb < 11.0 g/dl) at least once between 12 and 36 months of age. Just under half of these children were treated for anemia. Follow-up laboratories for iron-treated children were completed within 35 days in 16% of cases (median: 3 months). Interviews identified four key themes (iron-deficiency, communication, poverty, system) running through the two major categories of prevention and treatment. Treatment cut-points were variable. While providers felt clinically comfortable with anemia, they felt burdened and challenged by follow-up. Communication and system barriers weighed most heavily on perceived treatment outcomes.

Results From a Patient Experience Study in Pediatric Gastrointestinal Endoscopy.

OBJECTIVE: Gastrointestinal endoscopy in children has become a standard diagnostic and therapeutic modality. The aim of our study was to characterize the most memorable elements of the patient experience from the parent's and patient's perspective and determine ways to improve the overall quality of their experience. METHODS: Using a structured questionnaire, we conducted 47 phone interviews with families who had recently undergone gastrointestinal endoscopic procedures. RESULTS: Our study showed clear communication and mutual agreement on care decisions contributed to positive experiences. Inadequate communication of information regarding alternatives to the procedure and risk of complications during the informed consent discussion contributed to negative patient experiences. Standardization of postprocedure follow-up and timely communication of pathology findings also had potential for improvement. CONCLUSION: Our study revealed 2 areas for quality improvement interventions: The need to ensure that alternatives and complications are thoroughly discussed and the need for standardization of postprocedure follow-up.

Keeping the Heat on for Children's Health: A Successful Medical-Legal Partnership Initiative to Prevent Utility Shutoffs in Vulnerable Children.

OBJECTIVE: Energy insecurity may result in adverse consequences for children's health, particularly for children with special health needs or chronic health conditions. We aimed to determine whether a multimodal intervention addressing energy insecurity within the framework of a medical-legal partnership (MLP) resulted in an increase in the provision of certifications of medical need for utility coverage in an inner city academic primary care practice. METHODS: Working within a medical-legal partnership, we standardized criteria for providers approving medical need utility certification requests. We compared prior-year utility certification requests and approvals (pre-intervention) with the intervention year for families who reported energy insecurity on a waiting-room screening questionnaire. RESULTS: Between the first and second years of the study, certification of medical need approvals increased by 65%, preventing utility shut-offs for 396 more families with vulnerable children. CONCLUSIONS: Energy insecurity can be screened for and addressed in a busy urban practice, potentially improving the wellbeing of vulnerable children.

The effect of curtailed hospitalization on the management and outcome of lumbar discectomy patients in a private practice setting.

With the accelerated development of managed care systems in the 1990s, physician practices experienced curtailed authorization for length of stay (LOS) for in-patient care. Using lumbar discectomy (CPT 63030) as a surgical model, we reviewed records of patients from 1994 and 1996 as these two years were within the period of accelerated managed care penetration in our state. The Chi Square and Fisher Exact tests were used to explore statistical significance and differences in population characteristics, management and outcome in the two years. Factors including age, sex, associated medical conditions, other presenting symptoms and signs, cause of disc herniation, and duration of symptoms were not significantly different. We demonstrated that the shortened LOS did not adversely influence the medical or functional outcome from lumbar discectomy but that there appeared to be a shift of the burden of care to the postoperative outpatient setting. Functional outcome was not significantly different between the two years when assessed by either Prolo Outcome or return-to-work rate. These findings were corroborated with a more recent review of patients operated upon in 2000. As spinal surgery grows in complexity, managed care companies should initiate programs that routinely assist physician offices in accelerating postoperative rehabilitation. In addition, as emphasis grows for evaluation and management services, surgical outcome studies should document the intensity of postoperative management to document better the overall nonoperative care that surrounds any spinal surgery.