Development and Validation of Pediatric Opioid Analgesia Self-Instruction System (PedOASIS): An Opioid Knowledge Tool for Pediatric Clinicians.

BACKGROUND: Acute pain is common in children and young adults with cancer and sickle cell disease. Current training curricula fail to adequately impart skills for pain management. We sought to develop and validate an education and assessment tool to address the safe effective use of opioids for pain management by pediatrics trainees. METHODS: The first version of the tool contained 10 case-based, multiple-choice questions. It was pilot tested within a medium-sized pediatric residency program using preintervention and postintervention surveys to assess residents' knowledge and comfort related to prescribing opioids. Content validation was performed through an expert panel of physicians. Internal reliability was tested by administering the tool to learners and practitioners with varying levels of training. RESULTS: Comfort with choosing and converting between opioids increased significantly in pilot testing (P=0.005). Mean objective knowledge scores increased from 51% to 85.9% (P<0.001). The revised tool showed internal reliability within each group (Cronbach alpha 0.71 to 0.78) and significant differences in mean scores between groups (F ratio=9.45, P=0.0002). CONCLUSIONS: This tool demonstrates validity and internal reliability. Its use was associated with short-term educational gains and it garnered overall favorable feedback from users. Further testing is needed to assess the duration of these gains.

Identifying Risk Factors for Elbow Injury in Children Presenting to the Emergency Department With Distal Forearm Fractures.

BACKGROUND: Pediatric distal forearm fractures are one of the most common injuries seen in the emergency department. Orthopedic teaching instructs providers to radiograph the joint above and the joint below the fracture site for concurrent injury. Despite this teaching, there is little evidence to suggest that elbow injuries are common in children with distal forearm fractures. Similarly, there are few data that help the clinician predict which children are at higher risk for co-injury. METHODS: We conducted a cross-sectional analysis of the 2011 National Emergency Department Sample data set. Children aged 2 to 17 years with an International Classification of Disease, Ninth Revision, code for a distal forearm fracture were included in the study. The primary outcome of interest was an "elbow" injury, defined as an International Classification of Disease, Ninth Revision, code for proximal radius, proximal ulna, or distal humeral fracture or dislocation. Multivariable logistic regression was performed using patient demographics, injury severity score, mechanism of injury, and underlying medical conditions. RESULTS: A total of 54,262 children with a distal forearm fracture were identified. Of these children, only 0.8% (n = 463) had an elbow injury. Supracondylar fractures of the humerus were the most common elbow injury seen (48.2% of elbow injuries seen). Children were more likely to have a co-injury if they were younger (9.8 years vs 8.3 years, P < 0.01), female (36% vs 44%, P < 0.01), injured via fall (68% vs 76%, P < 0.01), had a higher injury severity score (4.1 vs 4.5, P < 0.01), or were admitted for their injuries (1.5% vs 15.7%, P < 0.01). In the adjusted model, only age and disposition were predictors of co-injury. Isolated buckle fracture of the radius and metaphyseal fracture of the radius with dorsal angulation were protective against elbow injury (odds ratio = 0.39 and 0.60, respectively). CONCLUSIONS: Children with distal forearm fractures very rarely have concurrent elbow injuries. These injuries are more likely in younger female children.

PARTIAL HOSPITALIZATION: AN INTERVENTION FOR YOUTH WITH POORLY CONTROLLED DIABETES MELLITUS.

Objective: To examine the efficacy of an integrated medical/psychiatric partial hospitalization program (PHP) to improve glycemic control in youth with both diabetes mellitus and mental health disorders. Methods: This retrospective chart review is of patients admitted to a PHP between 2005-2015 with concerns about diabetes mellitus care. Clinical characteristics, laboratory data, diabetic ketoacidosis hospitalizations, and outpatient clinic visit frequency were collected from the year prior to the year after PHP admission. Results: A total of 43 individuals met inclusion criteria: 22 (51%) were female, 40 (93%) had type 1 diabetes, the mean age was 15.2 ± 2.3 years, and the mean diabetes mellitus duration was 4.6 ± 3.6 years. Of those individuals, 35 of these patients had hemoglobin A1c (HbA1c) data available at baseline, 6 months, and 1 year after PHP. The average HbA1c before PHP admission was 11.3 ± 2.3% (100.5 ± 25 mmol/mol), and decreased to 9.2 ± 1.3% (76.7 ± 14.8 mmol/mol) within 6 months of PHP admission (P<.001). The average HbA1c 1 year after PHP was 10.7 ± 1.7 % (93.3 ± 19.1 mmol/mol). Overall, 24 patients (68%) had lower HbA1c, and 75% of those with improvement maintained an HbA1c reduction of ≥1% (≥10 mmol/mol) at 1 year compared to before PHP. Conclusion: Most patients demonstrated improved glycemic control within 6 months of PHP admission, and many of those maintained a ≥1% (≥10 mmol/mol) reduction in HbA1c at 1 year following PHP admission. This program may represent a promising intervention that could serve as a model for intensive outpatient management of youth with poorly controlled diabetes mellitus. Abbreviations: ADA = American Diabetes Association; DKA = diabetic ketoacidosis; EMR = electronic medical record; HbA1c = hemoglobin A1c; ICD-9 = International Classification of Diseases, 9th revision; PHP = partial hospitalization program.

Understanding predictors of continued long-term pediatric cancer care across the region: A report from the Consortium for New England Childhood Cancer Survivors.

BACKGROUND: Many survivors of childhood cancer do not receive recommended longitudinal oncology care. Factors present at the time of childhood cancer diagnosis may identify patients who are vulnerable to poor adherence to follow-up. METHODS: This cohort of survivors of acute lymphoblastic leukemia (ALL) diagnosed from 1996 to 1999 at seven Consortium for New England Childhood Cancer Survivors institutions was evaluated for attendance at oncology clinics at 5 and 10 years from diagnosis. Demographic, socioeconomic, disease, and treatment characteristics were analyzed as risk factors for nonadherence to follow-up. RESULTS: Of 317 patients, 90% were alive 5 years from diagnosis and 88% of those remained in active follow-up. At 10 years from diagnosis, 88% were alive, 73% of whom continued in active follow-up. Insurance status at diagnosis was significantly associated with adherence at both 5 and 10 years. At 10 years, initial enrollment on therapeutic study was associated with increased attendance and central nervous system (CNS) leukemia with decreased attendance. In multivariable modeling of follow-up at 5 years, patients who were adults were less likely to participate and those with private insurance at diagnosis more likely to participate. At 10 years, insurance status at diagnosis remained a predictor of adherence to follow-up. CONCLUSIONS: In this regional cohort, many patients who are survivors of ALL continue to participate in oncology care at 5 and 10 years from diagnosis. Factors known at diagnosis including insurance status, CNS leukemia, older age, and enrollment on therapeutic study were associated with differential attendance to follow-up visits.

Severe bronchopulmonary dysplasia: outcomes before and after the implementation of an inpatient multidisciplinary team.

OBJECTIVE: Severe bronchopulmonary dysplasia (sBPD) can lead to long term morbidity. We created a sBPD multidisciplinary team in 2011 to optimize care and improve outcomes. STUDY DESIGN: Retrospective chart review of three groups between 2008 and 2016: patients with sBPD born before 2011, patients with sBPD born after 2011, and patients with moderate BPD born after 2011. RESULTS: Infants with sBPD after 2011 had a shorter NICU length of stay compared with children born before 2011 (mean 140 days vs 170 days p < 0.007), weighed more at discharge (z-score -0.8 vs -1.35 p = 0.01), had less failure to thrive post discharge (32% vs 51% p = 0.05) and had more well visits in the first six months of life (mean 6.7 vs 5.3 p = 0.04). No difference was observed in the rate of readmissions in the first two years of life. CONCLUSION: Our multidisciplinary team has improved the inpatient management of patients with sBPD.

Addressing clinical trials: can the multidisciplinary Tumor Board improve participation? A study from an academic women's cancer program.

OBJECTIVE: The Tumor Board (TB) allows for an interdisciplinary approach to cancer treatment designed to encourage evidence-based treatment. However, its role in facilitating clinical trial participation has not been reported. We aimed to determine whether a prospective TB is an effective strategy for trial recruitment and to identify steps within the TB process that facilitate discussion of trial eligibility and optimize accrual. METHODS: We conducted a retrospective cross-sectional analysis of women presented to Gynecologic Oncology TB between March and December 2008. Patient demographics, TB recommendations, and post-TB patient discussions were abstracted. These were compared to data derived from the Department of Oncology Research to determine research team awareness of eligible patients and confirm trial enrollment(s). Data analysis was completed with Chi-square test; risk ratios and confidence intervals were calculated as summary measures. RESULTS: We reviewed 1213 case presentations involving 916 women. Overall, 358 TB recommendations (30%) identified eligible patients, of which enrollment consisted of 87 (24%) trials (6% therapeutic trials and 18% non-therapeutic trials). Compared to other types of TB recommendations, those involving trials were discussed less frequently at post-TB patient visits (79% vs. 44%). Documentation of trial discussion at the post-TB visit was more likely to result in trial participation, versus solely relying on the research staff to communicate enrollment eligibility with the treating team (RR 2.5, p=0.006). CONCLUSIONS: Patients identified by the TB were 2.5-times as likely to enroll in a clinical trial, but trials were mentioned only 44% of the time. Interventions that facilitate trial discussions during post-TB meetings are needed to improve trial participation.

Use of Pediatric Primary Care Telephone Advice by Families Whose Usual Language Spoken at Home Is Not English.

Language barriers and access to telephone advice have been shown to affect patient care. Less is known about access to telephone advice for families whose usual language is not English. The objective was to characterize the use of pediatric primary care telephone advice by families based on usual language spoken at home. A total of 277 surveys were completed by families presenting for sick visits at an academic pediatric primary care practice. No meaningful differences in the use of telephone advice when a child was sick were found by language category. Overall, 80.5% reported calling the clinic first when the clinic was open, but 77.6% went to the emergency department when the clinic closed. In conclusion, use of telephone advice was similar among families regardless of usual language. Most families reported going to the emergency department when the clinic was closed. More research is needed to identify barriers to the use of telephone advice, particularly after hours.

Oral Health and Dental Clinic Attendance in Pediatric Refugees.

Purpose: Dental pathology is common among refugees. The purpose of this study was to identify pediatric refugees at increased risk of caries, poor clinic attendance, and need for urgent or surgical intervention under general anesthesia. Methods: A retrospective chart review of newly arrived pediatric refugees to the United States was performed. Data collected included demographics, caries risk, treatment urgency, missed appointments, and surgical intervention under general anesthesia. Bivariate analyses were used. Results: A total of 228 subjects were included, most from Africa (44.3 percent) or Asia (50.0 percent). More Asian refugees had a moderate or high caries risk (64 percent versus 44 percent) and need for urgent treatment (45.6 percent versus 30.7 percent) compared to Africans. Adolescents had more missed appointments, and more two- to five-year-olds needed surgical intervention under general anesthesia compared to other age groups. Conclusion: Asian refugees had a higher caries risk and need for urgent treatment. Younger children were more likely to require general anesthesia for surgical intervention, and adolescents were more likely to miss appointments. These findings can improve triage of pediatric refugees and allocation of resources.

Adverse Childhood Experiences and Protective Factors With School Engagement.

OBJECTIVES: To determine the associations of adverse childhood experiences (ACEs) and protective familial and community factors with school performance and attitudes in children ages 6 to 17. METHODS: A cross-sectional analysis of the 2011-2012 National Survey of Children's Health was performed. All data were demographically weighted and included 65 680 children ages 6 to 17. The survey identified up to 9 ACEs in each child. ACE scores were categorized as 0, 1, 2, 3, and ≥4 ACEs. Children's protective factors (PFs) included the following: safe neighborhood, supportive neighbors, 4 neighborhood amenities, well-kept neighborhood, no household smoking, ≥5 family meals per week, and a parent who can talk to the child. PFs were categorized into ≤3, 4, 5, 6, and 7 PFs. School outcomes included the following: child repeated ≥1 grade; never, rarely, or sometimes completes homework; and never, rarely, or sometimes cares about school. χ2 tests and logistic regressions assessed the relationships between ACEs and school outcomes, PFs and school outcomes, and both ACEs and PFs and school outcomes, adjusting for sex, age, race, ethnicity, and maternal education. RESULTS: Each negative school outcome is associated with higher ACE scores and lower PF scores. After adding PFs into the same model as ACEs, the negative outcomes are reduced. The strongest PF is a parent who can talk to the child about things that matter and share ideas. CONCLUSIONS: As children's ACE scores increase, their school performance and attitudes decline. Conversely, as children's PF scores increase, school outcomes improve. Pediatric providers should consider screening for both ACEs and PFs to identify risks and strengths to guide treatment, referral, and advocacy.

Use of Language Services for Telephone Advice by Limited English Proficiency Families in a Pediatric Primary Care Setting.

BACKGROUND: Families limited in English proficiency (LEP) often do not receive appropriate medical language services, resulting in health disparities. Little is known about the use and effectiveness of language services provided via telephone when families call for medical advice. OBJECTIVE: To characterize language service provision to LEP families calling for medical advice in a pediatric primary care setting. METHODS: A self-administered survey was given to parents of children presenting for sick visits at an urban academic pediatric primary care practice. RESULTS: 277 out of 300 surveys were completed, 92% in English and 8% in Spanish. 7% (19/271) of those who answered the language proficiency question reported LEP (spoke English "not well," or "not at all"). Among LEP parents, 68% calling for advice during clinic hours received appropriate language services (a trained interpreter or a bilingual provider). 53% received these services when calling after hours. CONCLUSIONS: Over half of LEP families seeking telephone advice from their pediatric primary care office received adequate language services. Future research should identify barriers to providing telephone language services to LEP families.

The changing face of women living with HIV in western Ukraine.

Ukraine has the second largest HIV epidemic in Eastern Europe/Central Asia. This study characterizes the demographics of HIV-infected women in the Lviv region of western Ukraine, patterns in their clinical presentation, and factors associated with delays in seeking care. A retrospective chart review was conducted of 622 HIV-infected women who registered for HIV treatment at the Lviv AIDS Center between 2008 and 2013. A total of 81.6% of women were infected through heterosexual transmission and the remaining 18.4% through intravenous drug use. Slightly less than half (45.4%) was between 26 and 35 years old. Slightly more than half (56.7%) listed their residence in a city, 22.6% in villages. One-third (30.0%) of all women presented with AIDS, and 37.7% presented with symptomatic conditions. Women diagnosed with HIV during antenatal care experienced a median delay of 34 days between diagnosis and registration, compared to 87.5 days for nonpregnant women tested in the context of intravenous drug use. Overall, HIV-infected women in western Ukraine experience time delays in care, and often present with advanced HIV disease and secondary complications. Linkage to care in a timely manner is a high priority and substantial challenge for women, particularly for intravenous drug users who may face stigma and other additional barriers.

Adherence to Latent Tuberculosis Infection Treatment in a Population with a High Number of Refugee Children.

BACKGROUND: Refugee populations in the US have a higher reported prevalence of latent tuberculosis infection (LTBI). The objective of this study was to assess adherence to LTBI treatment in refugee and non-refugee children living in Rhode Island. METHODS: This was a retrospective review of LTBI patients seen in the Hasbro Pediatric Tuberculosis Clinic between August 2009 and September 2011. RESULTS: Of 120 patients with LTBI, 93% were foreign-born and 30% were refugees. Overall, 94 children (78.3%) completed therapy. Higher rates of treatment completion were seen among patients who were female, referred within the same hospital system, used an interpreter, and did not report side effects. Refugees attended more scheduled visits compared to non-refugees (p=0.019). CONCLUSIONS: Overall rates of completion of LTBI treatment were high in this population. Better adherence to clinic visits, likely due to the increased support and care coordination provided to the refugee children, improved treatment completion rates. [Full article available at http://rimed.org/rimedicaljournal-2017-02.asp].

Factors associated with increased charges for hysterectomy.

OBJECTIVE: To evaluate factors associated with increased hospital charges for hysterectomy with specific attention to differences based on surgical approach. METHODS: We performed a retrospective cohort study of 686 patients who underwent hysterectomy between January 1997 and September 1997 using medical chart review and hospital financial information. Demographic information, surgical approach (abdominal, vaginal, or laparoscopic), and surgical and postoperative factors were extracted from the medical record. Hospital charges were obtained from the hospital billing database. Relationships between charges and various clinical and demographic variables were examined using chi(2), Fisher exact test, t tests, or analysis of variance, where appropriate. Logistic regression was used to estimate odds ratios while controlling for important confounding variables. RESULTS: In our logistic regression model, blood loss greater than 1,000 mL (odds ratio [OR] 11.8, 95% confidence interval [CI] 4.2-33.2) and operative time 105 minutes or more (OR 14.2, CI 5.8-34.5) were strongly associated with higher charges for hysterectomy. Other factors associated with higher charges included: postoperative fever (OR 2.2, CI 1.1-4.5), increasing length of hospitalization (OR 5.3, CI 3.7-7.7), the use of prophylactic antibiotics (OR 3.0, CI 1.3-6.6), and the laparoscopic surgical approach compared with vaginal hysterectomy (OR 2.7, CI 1.0-7.0). CONCLUSION: Surgical factors such as operative time and blood loss were strongly associated with increased hospital charges for hysterectomy.

Voices of the "99 Percent": The Role of Online Narrative to Improve Health Care.

CONTEXT: Communal blogs facilitate online narratives by providing opportunities for individuals to co-construct meaning and to engage in discussion about lived health experiences. OBJECTIVE: To examine the role of health as a connective narrative among individuals organizing collectively in an online community. The "We are the 99 percent" Tumblr blog emerged as a spontaneous community platform of the Occupy Wall Street movement in the US. DESIGN: Researchers conducted a qualitative content analysis of a total of 2003 blog posts. MAIN OUTCOME MEASURES: Data analysis included a process of data reduction, display, and conclusion drawing and verification. RESULTS: Bloggers discussed medical crises and the role of injury and illness in maintaining financial solvency. The difficulty of obtaining health care and the lack of accessible quality care emerged as themes. In particular, unemployment and underemployment limited access to health insurance coverage. The bloggers expressed dissatisfaction with the health care system and the impact of financial status on health. These challenges were exacerbated for marginalized populations, such as women and veterans. CONCLUSION: Findings offer implications for the value of online narrative to improve health care initiatives and to provide insight to integrated health care systems, including health care practitioners, nonprofit organizations, hospitals, and policy makers. Results suggest opportunities to address the health care gaps of marginalized populations and to develop public health policy.

Sustaining improvement in surgical infection prevention measures for hysterectomy.

Studies have shown that administering prophylactic antibiotics within 60 minutes of a surgical incision decreases the chance of postoperative infection. A large women's hospital that performs 8,000 surgical procedures per year committed to preventing infection by participating in a study. The study participants were patients who had undergone an abdominal hysterectomy. For testing and implementing improvements, the Plan-Do-Study-Act cycle performance improvement method was used. In order to benchmark and to share best practices, the hospital joined the Surgical Infection Prevention Collaborative. The result of the study was antibiotic prophylactic delivery 60 minutes prior to incision in the abdominal hysterectomy population from a baseline of 10% to greater than 90% from 2003 to 2005. This result could not have been accomplished without the dedication and teamwork the hospital staff demonstrated. Quality improvement strategies, staff education, and communication of data have resulted in this sustained improvement.