Safe Ground Transport of Pediatric Patients: A Qualitative Assessment of Best Practice Guidelines Implementation.

OBJECTIVE: The National Highway Traffic Safety Administration issued guidelines on the safe transport of pediatric patients to lessen the chance of injury during ambulance transport. However, adherence to these standards have been slow to take hold. The objective of this quality improvement study is to evaluate barriers and facilitators of safe transport at the individual, organizational, and societal levels and identify improvement opportunities in the safe transport of pediatric patients. METHODS: This study was designed using an implementation science framework. Six focus groups were held with EMS clinicians to assess knowledge, behaviors, barriers, and facilitators of safe pediatric transport. Four interviews were conducted with EMS leadership to characterize organizational safe transport practices and policies. Detailed notes were taken during focus groups; interviews were recorded and transcribed. Qualitative data were analyzed using a thematic content analysis approach where team members reviewed transcripts using an established framework and identified major and minor themes related to safe pediatric transport. RESULTS: Three focus groups were conducted in a hospital setting and three were conducted at EMS base stations. Interview participants included two paramedic leaders, an ambulance service chief executive officer, and an ambulance service clinical coordinator. Recurring themes included the belief that children were inherently difficult to transport, the sentiment that training in pediatric transport is lacking, and the acknowledgement that familiarity with pediatric transport guidelines is low. Additionally, a major theme was that situational practicality can take precedence over adherence to best practice recommendations. Participants reported the presence of organizational and external barriers that made it more difficult for EMS personnel to follow safety guidelines. This included equipment unavailability, lack of clear policies, low pediatric patient volume, manufacturer design preferences, and prevailing EMS culture/norms. CONCLUSION: EMS clinicians need hands-on training and knowledge reinforcement in safe pediatric ground ambulance transport. EMS agencies should ensure that their crews have proper equipment, training, and protocols in place. Regulators and manufacturers can be catalysts for the implementation of these recommendations. Substantial change at the individual, organizational, and societal levels are needed to improve the safety of pediatric patients being transported via ground ambulance.

Which Sport Is More Dangerous: Ice Hockey or Field Hockey? A Review of the Head and Neck Injuries Associated With the Two Sports.

PURPOSE: Ice hockey and field hockey are contact sports with the potential for injury, especially to the head and neck regions. The purpose of this study is to estimate and compare hospital admission (injury severity) between ice hockey and field hockey of those who presented to the emergency department with head and neck injuries. METHODS: The investigators designed and implemented a 20-year retrospective cohort study using the National Electronic Injury Surveillance System database. We included data related to ice hockey and field hockey injuries from January 2000 to December 2019 in this study. The primary predictor variable was sport played (ice hockey vs field hockey). Secondary predictor variables and covariates were derived from patient and injury characteristics. The primary outcome variable was hospital admission. Logistic regression was used to determine independent risk factors for the outcome variable. RESULTS: Our final sample was composed of 5,472 patients: 4,472 patients suffered head and neck injuries from ice hockey while the remaining 1,000 patients suffered head and neck injuries from field hockey. Players less than 18 years old were associated with 2.07-fold odds of admission (P < .01). Injury to the head (odds ratio [OR] = 14.339; 95% confidence interval [CI], 2.0 to 105.1; P < .01) and neck (OR = 89.260; 95% CI, 11.2 to 712.6; P < .01) were independently associated with an increased odds of admission. Relative to contusions/abrasions, players who suffered a concussion (OR = 141.637; 95% CI, 11.5 to 1,741.5; P < .01), fracture (OR = 155.434; 95% CI, 17.0 to 1,419.2; P < .01), internal organ injury (OR = 186.450; 95% CI, 15.5 to 2,236.8; P < .01), or hematoma (OR = 23.046; 95% CI, 1.2 to 442.5; P < .05) were all independently associated with an increased odds of admission. Ice hockey was not an independent risk factor for admission relative to field hockey. CONCLUSIONS: The findings of this study suggest that ice hockey was more associated with injuries to the head and neck as well as with concussions and internal organ injury compared to field hockey. However, ice hockey was not associated with increased risk of hospitalization relative to field hockey.

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS: There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Porcine bladder extracellular matrix in paediatric pilonidal wound care: healing and patient experience evaluation.

OBJECTIVE: Pilonidal disease (PD) with inflammation and abscess formation occurs frequently in adolescents. The management of pilonidal disease, time to wound healing, and patient satisfaction, however remains variable despite advances in wound care methods. Porcine bladder extracellular matrix (PBEM) facilitates site-specific tissue deposition/re-growth for the management of a variety of wounds. The aim was to describe the use and outcomes of PBEM in PD at a single centre. METHOD: A retrospective chart review of adolescent patients who underwent treatment of pilonidal disease with PBEM between 2012 and 2016 at a single institution, was undertaken. Patient demographics and clinical characteristics were collected and compared with historical controls and literature regarding traditional wound therapies. RESULTS: We reviewed 52 pilonidal disease wounds on 41 patients. Of these 36 were treated with PBEM. The average age was 16 years old at the time of operation with 39% male. Furthermore, 85% were being treated for recurrent pilonidal disease. Follow-up was available by chart review for 89% of patients with documented complete wound healing in 78% of patients treated with PBEM at an average of two months. Subjective reports included majority positive experience with PBEM dressing, minimal pain and overall high levels of patient satisfaction. There were three patients in which pilonidal disease recurred within two years of initial treatment and underwent repeat treatment with PBEM. There was one patient who transitioned to wet-to-dry saline dressings because of difficulty keeping the PBEM dressing intact. CONCLUSION: Advances in wound care technology include materials such as PBEM to promote site-specific tissue deposition. Follow-up phone calls and a prospective study to compare alternative wound care with porcine PBEM in the management of pilonidal disease is underway to better quantify time to wound healing and patient satisfaction.

Effects of a surfactant-based gel on acute and chronic paediatric wounds: a panel discussion and case series.

On 20 November 2018, following the International Society for Paediatric Wound Care conference, a closed panel meeting took place in which the use of a surfactant-based gel (PluroGel (PMM), Medline Industries, Illinois, US) in paediatric wound care was discussed. The authors shared their experiences, thoughts, experimental data and clinical results. The panel identified the need for a product that can gently cleanse paediatric wounds and remove devitalised tissue without causing discomfort or skin reactions, as well as potentially promote healing. In adults, PMM has been shown to assist healing by hydrating the wound, controlling exudate and debriding non-viable tissue. Islands of neo-epithelium have also been reported to appear rapidly in different parts of the wound bed. No adverse effects on these proliferating cells have been observed. In vitro data suggest that PMM can remove biofilm, as well as potentially promote healing through cell salvage. The panel, therefore, set out to discuss their experiences of using PMM in the paediatric patients and to establish a consensus on the indications for its use and application in this population. This article will describe the main outcomes of that discussion and present case studies from paediatric patients with a variety of wound types, who were treated with PMM by members of the panel.

Photobiomodulation Therapy for Wound Care: A Potent, Noninvasive, Photoceutical Approach.

GENERAL PURPOSE: To provide background and examine evidence for the therapeutic application of light energy treatments for wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to:1. Explain the basics of lasers, light-emitting diodes, and light-tissue interactions as they apply to photobiomodulation therapy.2. Summarize the results of the authors' literature review of the evidence regarding the therapeutic applications of photobiomodulation treatments for wound healing. ABSTRACT: To provide background and examine evidence for the therapeutic applications of light energy treatments for wound healing.A search was performed in PubMed for peer-reviewed scientific articles published in the last 5 years using the search terms "photobiomodulation therapy" and "low-level laser therapy," and these terms combined with "wound," using a "human species" filter. This search yielded 218 articles on photobiomodulation therapy or low-level laser therapy and wounds. Of these, only articles on in vivo wound care using light treatments were specifically included in this review (n = 11).The wound healing effects of low-dose laser treatments were first described over 50 years ago. Various doses ranging from 0.1 to 10 J/cm and wavelengths ranging from 405 to 1,000 nm appear to provide therapeutic benefits for a broad range of chronic wounds. A range of light energy sources from LEDs to lasers have been used and have specific advantages and limitations. There is a lack of consensus on standardized treatment parameters such as wavelengths, dose, and therapeutic outcomes in the reviewed studies, preventing direct comparison and clinical protocol recommendation. An expert opinion based on ongoing research studies and reported literature is offered.Noninvasive, economical, and multipurpose light devices are an attractive tool for wound management. However, there is an urgent need in the wound care community to develop optimal clinical protocols for use based on well-designed, rigorous clinical research studies.

Lessons Learned in Promoting Evidence-Based Public Health: Perspectives from Managers in State Public Health Departments.

Evidence-based public health (EBPH) practice, also called evidence-informed public health, can improve population health and reduce disease burden in populations. Organizational structures and processes can facilitate capacity-building for EBPH in public health agencies. This study involved 51 structured interviews with leaders and program managers in 12 state health department chronic disease prevention units to identify factors that facilitate the implementation of EBPH. Verbatim transcripts of the de-identified interviews were consensus coded in NVIVO qualitative software. Content analyses of coded texts were used to identify themes and illustrative quotes. Facilitator themes included leadership support within the chronic disease prevention unit and division, unit processes to enhance information sharing across program areas and recruitment and retention of qualified personnel, training and technical assistance to build skills, and the ability to provide support to external partners. Chronic disease prevention leaders' role modeling of EBPH processes and expectations for staff to justify proposed plans and approaches were key aspects of leadership support. Leaders protected staff time in order to identify and digest evidence to address the common barrier of lack of time for EBPH. Funding uncertainties or budget cuts, lack of political will for EBPH, and staff turnover remained challenges. In conclusion, leadership support is a key facilitator of EBPH capacity building and practice. Section and division leaders in public health agencies with authority and skills can institute management practices to help staff learn and apply EBPH processes and spread EBPH with partners.

Scaling Up Evidence-Based Public Health Training.

Evidence-based public health (EBPH) is the process of integrating science-based interventions with community preferences. Training in EBPH improves the knowledge and skills of public health practitioners. To reach a wider audience, we conducted scale-up efforts including a train-the-trainer version of the EBPH course to build states' capacity to train additional staff. In this essay, we describe formats for course delivery and local adaptations to content, and we review success factors and barriers for state-based replication of the EBPH training course. Findings were based on our experiences and interviews. EBPH training was delivered in varied blended formats as well as in person and in distance courses, each with advantages and disadvantages. Adaptations were made to meet the needs of learners. Success factors included having committed and competent coordinators and trainers, organizational incentives, leadership support, funding, internal and external collaborators, the infrastructure to support training, and models to learn from. Barriers reported included insufficient staff or trainer capacity; time constraints for organizers, trainers, and participants; and lack of sustained funding. We hope our experience and findings will be a guide for states that are committed to building and sustaining capacity through continued EBPH training. Our lessons may also apply more generally to other workforce development training efforts.

Skeletal muscle regeneration by extracellular matrix biological scaffold: a case report.

A case report of a 17-year-old female with a complex, non-healing, two-month-old wound, wherein exposed fibula was evident. On assessment, the wound measured 35cm in length, 3cm in width, and was 1cm deep, along the lateral aspect of the left lower leg. A rim of granulation tissue was visible along the wound edge. The exposed bone measured 20cm in length, and was 3cm wide. Porcine-derived, extracellular matrix (ECM) biological scaffold was placed on the wound bed to facilitate regeneration of the patient's skeletal muscle. The patient healed without incident postoperatively and was able to regain her ambulatory ability. This technique has, in the authors' experience, proved successful and without complication in complex non-healing wound cases, particularly in patients who have lost a large volume of skeletal muscle. The authors believe that patients and surgeons would benefit from early consideration of ECM biological scaffolds in similar types of large, open, and complex wounds.

Novel use of porcine extracellular matrix in recurrent stricture following repair of tracheoesophageal fistula.

Anastomotic stricture is a common complication following repair of esophageal atresia (EA). Many factors are thought to contribute to stricture formation and a variety of management techniques have been developed. In this case report, we describe the treatment of a recurrent anastomotic stricture following repair of long-gap esophageal atresia. Porcine bladder extracellular matrix (ECM) was mounted on a stent and delivered endoscopically to the site of recurrent stricture. An appropriate positioning was confirmed using direct endoscopic visualization and intra-operative fluoroscopy. The patient recovered well with persistent radiographic and functional improvements in previous stricture.

Intensive care unit admission predicts hospital readmission in pediatric trauma.

BACKGROUND: Hospital readmission in adult trauma is associated with significant morbidity, mortality, and resource utilization. In this study, we examine pediatric intensive care unit (PICU) admission as a risk factor for hospital readmission in pediatric trauma. MATERIALS AND METHODS: This was a retrospective cohort study of patients aged 1 through 19 y in the Pediatric Health Information System database discharged with a trauma diagnosis. Patient and clinical variables included demographics, payer status, length of stay, chronic comorbid conditions, presence of mechanical ventilation, all-patient refined diagnosis-related group and calculated severity of illness, and discharge disposition. The main outcome variable was hospital readmission within 30 d of discharge. Odds ratios (ORs) were calculated in both univariate and multivariate analyses with corresponding 95% confidence intervals (CIs). RESULTS: During the 5-year study period, 90,467 patients were admitted with a trauma diagnosis, of which 16,279 (18.0%) were admitted to the PICU. Hospital readmissions occurred in 3.1% of patients. On univariate analysis, patients admitted to the PICU on the first day of hospital admission (direct PICU admission), and those first admitted to the PICU after the day of hospital admission (delayed PICU admission), had 2-3 times the risk of hospital readmission compared with those never admitted to the PICU (4.8% versus 7.2% versus 2.7%, respectively, P < 0.001). On multivariate analysis, controlling for demographic and clinical variables, the adjusted ORs for hospital readmission in patients with direct and delayed PICU admission were 1.34 (95% CI 1.20-1.50) and 1.88 (95% CI 1.50-2.35) versus no PICU admission, respectively. CONCLUSIONS: PICU admission, either direct or delayed, during hospitalization for trauma care is an independent risk factor for hospital readmission within 30 d of discharge. Further risk stratification may help focus resources on high-risk patients to improve clinical outcomes and reduce readmissions.

Novel use of porcine urinary bladder matrix for pediatric pilonidal wound care: preliminary experience.

BACKGROUND: Extracellular matrix is used in various applications. We present our preliminary experience using a new device that consists of a porcine extracellular matrix with an epithelial basement membrane (MatriStem(®), ACell, Inc. Columbia, MD, USA) for adolescent pilonidal disease. METHODS: A retrospective review of four patients with pilonidal disease was undertaken. Three occurred in the gluteal cleft, and the fourth in the umbilicus. In the first patient, the wound deficit was filled with lyophilized MicroMatrix powder and a sheet of Multilayer Wound Matrix was placed to cover the wound. In the second patient, two sinus tracts were debrided, packed with MicroMatrix, and a sheet of fenestrated Burn Matrix was applied. In the third patient, MicroMatrix and Surgical Matrix PSMX (six-layer) was applied as a roll filling the dead space. In the last patient, an umbilical sinus 3 cm deep was packed with MicroMatrix powder followed by a rolled sheet of 2-ply Surgical Matrix RS. Patients were evaluated weekly post-operatively, and more MicroMatrix and sheet material was added if a wound deficit was still present. Measurements were taken in two dimensions, diameter and depth, to characterize wounds. RESULTS: Resolution of wound deficit was graphed versus time. Pain was assessed by scoring 0-10. Rapid wound closure was achieved. Two of the patients had failed wound healing with saline dressing changes prior to MatriStem application. These two patients in particular were highly satisfied with the comfort of the MatriStem approach relative to their time with saline dressings. Most had no pain after 1 week when bolster sutures were removed. CONCLUSION: In the treatment of open pilonidal wounds in adolescents, porcine urinary bladder matrix wound care devices offer closure times and cost similar to well-established methods while offering a substantial advantage in terms of patient comfort and convenience. This preliminary experience supports a prospective study.

Repair of esophageal atresia with proximal fistula using endoscopic magnetic compression anastomosis (magnamosis) after staged lengthening.

We describe the treatment of a patient with long-gap esophageal atresia with an upper pouch fistula, mircogastria and minimal distal esophageal remnant. After 4.5 months of feeding via gastrostomy, a proximal fistula was identified by bronchoscopy and a thoracoscopic modified Foker procedure was performed reducing the gap from approximately 7-5 cm over 2 weeks of traction. A second stage to ligate the fistula and suture approximate the proximal and distal esophagus resulted in a gap of 1.5 cm. IRB and FDA approval was then obtained for endoscopic placement of 10-French catheter mounted magnets in the proximal and distal pouches promoting a magnetic compression anastomosis (magnamosis). Magnetic coupling occurred at 4 days and after magnet removal at 13 days an esophagram demonstrated a 10 French channel without leak. Serial endoscopic balloon dilation has allowed drainage of swallowed secretions as the baby learns bottling behavior at home.

A Case of Metastatic Melanoma Post Orthotopic Liver Transplantation.

With the rising prevalence of organ transplantation, clinicians must be aware of the many potential complications that may arise. One such complication is post-transplantation melanoma. Herein, we present a case of advanced metastatic melanoma following orthotopic liver transplantation (OLT).  This is a 54-year-old cirrhotic male who underwent OLT that was complicated by metastatic melanoma. Despite adherence to yearly screening guidelines and timely radiation and immunotherapy, the disease course was rapidly progressive and fatal. This case aims to highlight the risk of post-transplantation melanoma and the potential need for screening modifications to identify melanoma earlier in its development.  The association between organ transplantation and melanoma is well-reported, but the underlying risks and mechanisms remain incompletely understood. One potential risk factor is post-transplant immunosuppressive therapy, which may result in fatally aggressive melanoma. Understanding the potential mortality risks in transplant patients, modifications to peri-transplant screening guidelines, and immunosuppressive therapy may be lifesaving.

Splenic conservation: variation between pediatric and adult trauma centers.

OBJECTIVES: Nonoperative management of hemodynamically stable children and adolescents with splenic injury regardless of grade has become standard; however, numerous studies have shown a wide variation in management. We compared the treatment and outcomes of adolescent splenic injuries in our region, which includes a pediatric level I trauma center (PTC) and an adult level I trauma center (ATC). METHODS: A retrospective review of the trauma registry was performed on patients 14 to 17 y old with blunt splenic injury admitted to either the local PTC or ATC from January 1999 through December 2010. Demographics, interventions, and hospital course were recorded and compared using Fisher exact, Student t-test, and multivariate analysis. RESULTS: Eighty-six adolescent patients presenting to the PTC and 65 patients presenting to the ATC met the criteria over the 12-y period. Although the ATC received more significantly injured and slightly older patients, logistic multivariate analysis demonstrated that the location of presentation was the only independent factor associated with splenectomy (P = 0.0015). A higher injury severity score was associated with a longer length of stay (LOS), but the nonoperative approach was not associated with a longer LOS (P = 0.96). CONCLUSIONS: Our study demonstrates that the location of presentation was independently associated with splenectomy while controlling for a higher injury severity score at the ATC. With the higher percentage of nonoperative management, treatment at the PTC was not associated with an increased LOS (total or intensive care unit).

Are facilities following best practices of pediatric abdominal CT scans?

BACKGROUND: Established guidelines for pediatric abdominal CT scans include reduced radiation dosage to minimize cancer risk and the use of intravenous (IV) contrast to obtain the highest-quality diagnostic images. We wish to determine if these practices are being used at nonpediatric facilities that transfer children to a pediatric facility. METHODS: Children transferred to a tertiary pediatric facility over a 16-mo period with abdominal CT scans performed for evaluation of possible appendicitis were retrospectively reviewed for demographics, diagnosis, radiation dosage, CT contrast use, and scan quality. If CT scans were repeated, the radiation dosage between facilities was compared using Student t-test. RESULTS: Ninety-one consecutive children transferred from 29 different facilities had retrievable CT scan images and clinical information. Half of CT scans from transferring institutions used IV contrast. Due to poor quality or inconclusive CT scans, 19 patients required a change in management. Children received significantly less radiation at our institution compared to the referring adult facility for the same body area scanned on the same child (9.7 mSv versus 19.9 mSv, P = 0.0079). CONCLUSION: Pediatric facilities may be using less radiation per CT scan due to a heightened awareness of radiation risks and specific pediatric CT scanning protocols. The benefits of IV contrast for the diagnostic yield of pediatric CT scans should be considered to obtain the best possible image and to prevent additional imaging. Every facility performing pediatric CT scans should minimize radiation exposure, and pediatric facilities should provide feedback and education to other facilities scanning children.

Computed tomography scanning in pediatric trauma: opportunities for performance improvement and radiation safety.

BACKGROUND: Recently, pediatric CT scanning protocols have reduced radiation exposure in children. Because evaluation with CT scan after trauma contributes to significant radiation exposure, we reviewed the CT scans in children at both initial presentation at a non-pediatric facility and subsequent transfer to a level I pediatric trauma center (PTC) to determine the number of scans, body area scanned, radiation dosage, and proportion of scans at each facility. METHODS: The trauma database was retrospectively reviewed for children aged 0 to 17 y initially evaluated for trauma at another facility and then transferred to our PTC for pediatric specialty care between January 2000 and December 2010. RESULTS: A total of 1562 patients with 1335 CT scans were reviewed over an 11-y period. The majority of CT scans occur at the referring facility compared to the PTC in a ratio of 7:3. CT of the head was the most frequent scan obtained (52%), and 17.9% of CT scans were repeated at the PTC. Less than 1% of CT scans performed at the non-pediatric centers contained radiation dosage information, precluding analysis of radiation exposure. CONCLUSIONS: The majority of CT scans for trauma occur at non-pediatric facilities, which demonstrates the need for referring facilities to perform optimal CT scans with the least amount of radiation exposure to the child. We believe this provides an opportunity for PTC performance improvement by facilitating the transfer of images and educating referring facilities about indications for CT scans, dosage amounts, and radiation reduction protocols.

Sociodemographic Factors Associated with Do-Not-Resuscitate Order Utilization in the Surgical Intensive Care Unit: An Observational Study.

The use of a do-not-resuscitate (DNR) order is a powerful tool in outlining end-of-life care. This study explores sociodemographic factors associated with selection of a DNR order and assigning a healthcare proxy in the Surgical Intensive Care Unit (SICU). A retrospective chart review of 312 patients who expired in the SICU over a 7-year period was conducted. We analyzed the association of sociodemographic factors to selection of a DNR order and assignment of a healthcare proxy. Year of admission, age, religion, and proxy were independently associated with selection of DNR. In particular, the relative chance of a DNR selection in 2019 compared to 2012 was 3.538 (95% CL = 2.001-6.255, P < .01). There are significant sociodemographic factors that influence DNR utilization, highlighting the need to consider the social and religious backgrounds when engaging patients and their families in end-of-life care. Future studies will need to be conducted on whether these sociodemographic factors influence surviving patients as this study's findings can only be applied to those who have expired.

Expanding access to difficult urinary catheter insertion services through a novel nurse practitioner-led team.

BACKGROUND: Within the United States health care system, one of the most common procedures performed daily is urinary catheterization. Oftentimes, the urinary catheter is placed by nursing personnel without any difficulty. Although the procedure is usually simple and routine, there are instances in which placement can be problematic. LOCAL PROBLEM: Urology is one of the smallest surgical subspecialties, with intermittent availability given active commitments in the operating room and clinic. This opened an opportunity for nurse practitioners (NPs) at an urban quaternary care hospital to further enhance their skill set in the care of these patients. METHODS: Fifteen Rapid Response Team NPs were selected based on specific criteria. Their roles expanded to include consults for difficult urinary catheter insertions. INTERVENTION: A 2-step training program was implemented for NPs to develop proficiency in inserting urinary catheters in patients with new or known urologic conditions. RESULTS: Of the 391 catheter consults made to the NP group, 73 (18.7%) of them required urology follow-up. CONCLUSION: This program can benefit patients by potentially reducing catheter-related complications and associated length of stay.

An analysis of American physician professional statements about gun violence against children.

BACKGROUND: We examine the content of physician professional association statements and assess the extent to which these statements kept gun violence-especially against children-on policymakers' agendas. METHODS: After constructing a list of U.S. physician professional associations, we located position statements by consulting association websites, conducting a PubMed search, and reviewing the citations of identified statements. Once unique statements were identified (N = 32), two reviewers independently coded content such as major events, pediatric focus, firearm type, and policy recommendations. RESULTS: Recent statements appear to be timed following mass casualty events such as the Sandy Hook and Parkland school shootings. Associations have increasingly adopted public health framing over time. Nine statements focused on the pediatric population, while an additional 13 made reference to the pediatric population. The most common recommendations include increased gun violence research or research funding (84%), freedom of physician counseling (75%), mandatory background checks (72%), and safe storage (72%). CONCLUSION: Based on this analysis, recent statement volume appears to be tied to current events rather than keeping daily gun violence against children continuously on the agenda. Mentions of "gun control" have receded over time and have been replaced by public health framing that places advocacy for firearm injury prevention in the physician's domain. LEVEL OF EVIDENCE: III/IV.