CT esophagogram in the emergency setting: typical findings and suggested workflow.

PURPOSE: Esophageal perforation (EP) can be a diagnostic challenge. Computed tomography (CT) and CT esophagography (CTE) are often used to rule out EP in the emergency setting with promising diagnostic performance, but the standard of care remains fluoroscopic esophagography (FE). We assess the diagnostic performance of CT and CTE when interpreted by expert and generalist radiologists and created an imaging workflow guide. METHODS: Retrospective study of patients presenting with suspected EP. Two expert radiologists independently reviewed blinded CT/CTE studies, recorded CT findings, and assigned an esophageal injury grade. We also collected initial (general radiologist) CT findings and interpretation and FE diagnoses. We assessed inter-reader reliability and diagnostic performance. RESULTS: EP was diagnosed in 46/139 (33%) encounters. The most common CT/CTE findings in EP were esophageal wall thickening (46/46, 100%), pneumomediastinum (42/46, 91%), and mediastinal stranding (39/46, 85%). CT and CTE sensitivity for detecting EP was 89% and 89% for expert radiologists, respectively, and 79% and 82% for general radiologists, compared with 46% for FE. Inter-reader agreement for detecting EP by CT and CTE was kappa 0.35 and 0.42 (both p < .001) between expert and generalist radiologists. We present radiographic images for key CT/CTE findings and a suggested workflow for the evaluation of possible EP. CONCLUSION: CT and CTE are more sensitive than FE for EP in the emergency setting. Due to the rarity of EP and current wide variability in imaging interpretation, an imaging workflow and injury grading system based on esophageal and mediastinal CT findings are offered to help guide management.

A Latent Profile Analysis of the Consensual and Non-Consensual Sexting Experiences among Canadian Adolescents.

Different patterns of sexting behaviors were examined to provide a more nuanced understanding of the context in which sexting occurs among adolescents. Participants were 1,000 Canadian adolescents (50.2% girls) between 12 and 18 years (Mage = 15.21, SD = 2.00) who completed measures of sexting, cyber bullying and victimization, problematic social media use, self-regulation, and demographics. Contrary to our hypotheses, three latent profiles of sexting represented the frequency of sexting rather than whether the sexting was consensual versus non-consensual or with a partner versus non-partner. Participants in the moderate and high sexting profiles representing one fifth of youth, reported less self-regulation, experienced more cyber victimization, and engaged in more cyber bullying and problematic social media use than those in the no/low sexting profile. Our findings support the normalcy approach to education, which considers some sexting among healthy developmental behaviors.

Liposomal bupivacaine in transversus abdominis plane blocks for lower abdominal surgery.

BACKGROUND: Transversus abdominis plane blocks are an established method of postoperative analgesia for abdominopelvic surgeries. Liposomal bupivacaine is an extended-release formulation of bupivacaine providing up to 72 h of analgesia. This study aims to determine if transversus abdominis plane blocks performed with liposomal bupivacaine are associated with reduced opioid consumption and level of pain intensity compared to conventional bupivacaine in patients undergoing lower abdominal surgery. METHODS: This retrospective cohort study was conducted at a single institution between December 2020 and December 2021. After institutional review board approval, we identified patients who underwent lower abdominopelvic surgery with transversus abdominis plane blocks done with liposomal or conventional bupivacaine and collected demographic, clinical, and procedural information for analysis. We compared total opioid consumption over 72-h postoperatively in milligram morphine equivalents (MME), frequency of opioid utilization, and average level of pain intensity between groups. These outcomes were also evaluated after adjusting for covariates. Data were presented as mean ± SD, median [IQR] or frequency (%), as appropriate; p < 0.05 was accepted as significant. RESULTS: A total of 178 patients met inclusion criteria, with 79 patients receiving an admixture of liposomal bupivacaine and conventional bupivacaine and 99 patients receiving conventional bupivacaine. The liposomal bupivacaine group had a median opioid consumption 72-h postoperatively of 47.5 [18-91.8] MME compared to 88 [43.8-160] MME in the conventional bupivacaine group, p = 0.045. Differences in opioid consumption between the groups did not reach statistical significance after adjustment for demographic and clinical characteristics, p = 0.11. There was no significant difference in frequency of opioid use or average pain intensity. CONCLUSION: Transversus abdominis plane blocks using an admixture of liposomal bupivacaine conventional bupivacaine are not associated with decreased opioid consumption or reduced pain up to 72 h following elective abdominopelvic surgery.

Teen perceptions of adolescent dating violence.

INTRODUCTION: Previous research shows that adolescents who experience dating violence most often disclose their victimization to a peer or friend, more so than to other sources of support. However, surprisingly little research has explored how adolescents respond to peer disclosures of dating violence. Addressing this gap, the present study assessed variations in adolescents' perceptions of blame, interpretations of the incident as violence, and intentions to respond across physical, psychological, sexual, cyber-psychological, and cyber-sexual dating violence scenarios. METHODS: As part of a national research project across Canada, 663 high school adolescents (432 girls, 65.2%) between the ages of 14-17 were randomly assigned to complete a questionnaire which included one of five different hypothetical dating violence scenarios. Next, participants responded to questions about their perceptions of the incident, as well as victim and perpetrator blame and responsibility, and their intentions to respond. RESULTS: Results indicated that the type of dating violence experienced and the age and gender of participants all played a role in perceptions of blame, understandings of violence, and intentions to respond. CONCLUSIONS: As one of the first studies to explore how adolescents perceived and responded to dating violence, considering both in-person and cyber forms of dating violence, this study fills an important gap in the literature. Findings underscore the uniqueness of cyber forms of dating violence and how pre/intervention programs must address the specific contexts and issues unique to each type of dating violence.

The Development and Preliminary Validation of a Measure of Victimization within the Friendships of Emerging Adults.

For emerging adults, high-quality friendships can be an important source of companionship and support. The most commonly studied negative interaction between friends is conflict, yet work with youth suggests more serious victimization also occurs in friendship. In the current study, we developed and obtained preliminary psychometric evidence for the Friendship Victimization Scale, a measure that assesses physical, sexual, relational, and verbal forms of victimization in the friendships of emerging adults, as well as coercive and controlling behaviors. Emerging adults (N = 316, Mage = 21.27 years, SD = 1.47; 60.4% women, 37.0% men; 59.2% White) completed the Friendship Victimization Scale along with measures to examine construct validity. The majority of the sample reported experiencing at least one act of victimization by a friend, and men reported more victimization than did women. Results supported a 2-factor structure, with relational and verbal victimization loading on one factor and physical and sexual victimization and controlling behaviors loading on the other. Cronbach's alphas exceeded .90 for the total score and both subscales. Greater friendship victimization was predicted by negative features in each of a best and a challenging friendship, even after accounting for negative features in a dating relationship, and was unrelated to positive features in any of these relationships. Overall, results indicate that victimization is common in emerging adults' friendships. The findings provide preliminary evidence for the utility of the Friendship Victimization Scale as a measure of this understudied source of risk in the interpersonal lives of emerging adults.

Transient Idiopathic Polyhydramnios: Maternal and Perinatal Outcomes: Maternal and Perinatal Outcomes.

OBJECTIVES: To compare maternal and perinatal outcomes in pregnancies with transient and persistent idiopathic polyhydramnios to those with normal amniotic fluid volume. METHODS: This retrospective cohort study included subjects delivering a singleton pregnancy between January 1, 2015, and June 30, 2020, with sonography ≥26 weeks' gestation demonstrating transient or persistent idiopathic polyhydramnios (amniotic fluid index [AFI] ≥24.0 cm) or normal AFI (referent group). The primary maternal outcome was a composite of spontaneous preterm delivery <37 weeks, cesarean delivery for malpresentation, abnormal labor progress, or nonreassuring fetal status, operative vaginal delivery, hemorrhage requiring transfusion, and umbilical cord prolapse. The primary perinatal outcome was a composite of birthweight >4500 g, fetal or neonatal death, 5-minute Apgar score <7, and neonatal intensive care unit admission for >24 hours. RESULTS: Patients with transient polyhydramnios (n = 259) exhibited maternal outcomes similar to those of the referent group (n = 435) but had significantly increased odds for the primary perinatal outcome (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.15-2.53; P = .008) and for birthweight ≥4500 g (OR 8.70, 95% CI 1.89-40.0; P = .005). Persistent polyhydramnios (n = 176) was significantly associated with both the primary maternal (OR 1.93, 95% CI 1.27-2.95, P = .002) and primary perinatal outcome (OR 2.15, 95% CI 1.40-3.30; P < .001), and individually with cesarean delivery for abnormal labor (OR 3.22, 95% CI 1.55-6.68; P = .002) and birthweight ≥4500 g (OR 8.97, 95% CI 1.84-43.6; P = .007). CONCLUSIONS: Transient idiopathic polyhydramnios does not impact maternal outcomes but is associated with increased odds of newborn birthweight >4500 g. Persistent polyhydramnios is associated with both adverse maternal and perinatal outcomes.

Adolescent social media use and its association with relationships and connections: Canadian Health Behaviour in School-aged Children, 2017/2018.

Background: The development of healthy relationships and connections is of fundamental importance to adolescent well-being. The use of social media plays a vital role in the lives of young Canadians, yet the association between different types of social media use and the quality of relationships and connections remains unknown, and most existing analyses on this topic are based on modest and non-representative samples. Data and methods: Using 2017/2018 reports from the nationally representative Health Behaviour in School-aged Children study (n=17,149; ages 11 to 15 years), the strength, consistency and significance of associations was examined between intensive (frequent use to connect with other people) and problematic (use that depicts addictive qualities) social media use and available measures of adolescent relationships and connections. Results: Overall, intensive use (online communication with others almost all of the time) and problematic use (potential addiction to social media) were more common in girls than boys (38% of girls versus 30% of boys and 7.7% of girls versus 5.2% of boys, respectively), with prevalence levels that rose with age. Intensive use was associated with more positive social relationships with friends, especially among girls (relative risk [RR] = 1.40 [95% confidence interval (CI) 1.28 - 1.54]), while problematic use was consistently and negatively associated with strong relationships and connections in all groups in the study. Notably, problematic use was negatively associated with strong family relationships in boys (RR = 0.58 [95% CI 0.42 to 0.79]) and girls (RR=0.48 [95% CI 0.36 to 0.63]). Interpretation: Intensive use of social media has the potential to strengthen relationships and connections in adolescents. However, when social media use becomes addictive or "problematic", it is highly correlated with weaker relationships and a sense of social disconnection. Public health initiatives related to social media use should consider how different types of social media use have the potential to impact on different aspects of health.

Family relationship quality during the COVID-19 pandemic: The value of adolescent perceptions of change.

INTRODUCTION: Adolescents typically spend decreasing amounts of time with family members, but the COVID-19 pandemic changed this pattern for many youth. The objective of the current study was to better understand adolescents' perceived change in family relationship quality, and how these perceptions were related to psychosocial functioning during the COVID-19 pandemic, accounting for more traditional measures of family relationship quality. Understanding how adolescents perceived change in relationship quality with family members during the pandemic offers novel insight into adolescents' relationships with their families and psychosocial functioning during this period. METHOD: A sample of Canadian adolescents (N = 605, ages 14 to 18, 53% girls), was employed to examine patterns of adolescents' perceived change in relationship quality with parents and siblings since the start of the pandemic, accounting for relationship quality, pandemic-related characteristics, and demographic variables. RESULTS: Four latent profiles were identified: youth who perceived (1) low change, (2) improvement only, (3) moderate instability and (4) high instability in relationship quality. Higher perceived instability was associated with poorer functioning, with youth who reported only improvement reporting the highest overall level of functioning. CONCLUSIONS: Adolescent perceptions of change in relationship quality were heterogeneous, and contribute to psychosocial functioning over and above their general evaluations of relationship quality. In particular, youth who perceive considerable change in their relationships with siblings and parents may require additional support in response to the COVID-19 pandemic.

Factors associated with interprofessional engagement in debriefing following pediatric simulation-based team training.

Simulation offers a high fidelity modality to deliver and study team-based interprofessional education. Debriefing the following simulated scenarios is a critical component of this training. Little data exist to inform best practices to optimize interprofessional engagement during debriefing. This pilot study analyzed interprofessional debriefing events following 20 pediatric simulation-based team trainings to identify associations between modifiable factors and learner engagement. Reviewers observed a total of 236 learners, using a previously published tool to assess learner engagement. Data related to the scenario, debriefing, learners, and facilitators were collected. Spearman's correlation was used to analyze the association between factors of interest and average learner engagement scores for each debriefing event. Mean engagement did not differ between physicians and nurses, but was lower for other professionals. Average learner engagement was inversely related to learner group size, but not to the proportion of learners in each profession. Oral participation differed significantly between professions for both learners and co-facilitators, with physicians speaking more in both groups. Students of all professions had lower engagement and spoke less frequently. This study identifies several modifiable factors, including total group size, learner level, and facilitator behavior that were associated with interprofessional engagement during debriefing following simulation-based team training.

Second-Trimester Ultrasound-Measured Umbilical Cord Insertion-to-Placental Edge Distance: Determining an Outcome-Based Threshold for Identifying Marginal Cord Insertions.

OBJECTIVES: We sought to study potential diagnostic criteria for marginal placental cord insertions as determined by associations with obstetric outcomes. METHODS: This single-center retrospective cohort investigation included singleton gestations delivering from January 1, 2012, to December 31, 2016, and having a standard or detailed fetal ultrasound examination from 18 weeks to 21 weeks 6 days. Cord insertion-to-placental edge distances were used to create a referent comparison group and 3 patient groups: greater than 3.0 cm (comparison); greater than 2.0 to 3.0 cm (group 1); greater than 1.0 to 2.0 cm (group 2); and 1.0 cm or less (group 3). The primary outcome consisted of any one of spontaneous delivery before 37 weeks, fetal growth restriction, oligohydramnios, placental abruption, or intrauterine fetal demise. RESULTS: The numbers of participants and mean distances ± SDs for the comparison group and groups 1 to 3, respectively, were 628 and 4.68 ± 1.17 cm, 106 and 2.52 ± 0.26 cm, 131 and 1.60 ± 0.29 cm, and 77 and 0.36 ± 0.37 cm, respectively. The primary outcome was significantly associated only with cord insertion-to-placental edge distances of 1.0 cm or less (adjusted odds ratio, 3.05; 95% confidence interval, 1.73-5.38). CONCLUSIONS: Marginal cord insertions may be diagnosed when the cord insertion-to-placental edge distance is 1.0 cm or less.

Integrating Screening, Brief Intervention and Referral to Treatment (SBIRT) for Substance Use into Prenatal Care.

OBJECTIVES: Universal screening for substance use during pregnancy, brief intervention, and referral to treatment (SBIRT) is recommended by ACOG and the USPSTF. Here we present the implementation of SBIRT into the electronic health record (EHR) to inform clinical intervention and collect data on the prevalence of substance use during pregnancy at three prenatal clinics. METHODS: A literature-based SBIRT instrument was developed. The tool was integrated into the EHR of a resident Ob/Gyn clinic, an MFM practice, and an Ob/Gyn generalist practice at our institution, an academic, tertiary care medical center in an urban area, and automated reports of aggregate retrospective EHR data were used to monitor patient responses to SBIRT over time. Data reports included patient responses to screening for substance use, brief intervention, and referral to treatment from January to December 2018 RESULTS: An interprofessional team of health care providers and systems analysts guided the SBIRT implementation process. As of December 2018, overall SBIRT performance during prenatal care encounters was 1797/2619 (69%), 432/1350 (32%), and 1290/1518 (85%) in the resident clinic, MFM practice, and generalist practice, respectively. Eighty (5.1%) women in the resident clinic, 2 (0.5%) in the MFM practice and 14 (1%) in the generalist practice reported past or present substance use. CONCLUSIONS FOR PRACTICE: Integrating universal SBIRT into prenatal care using the EHR requires a multi-disciplinary approach. The SBIRT tool facilitates reportable substance use screening, brief intervention, and referral to treatment during prenatal care. Future reports will further characterize substance use in our prenatal practices and inform intervention strategies in this population.

Peer victimization through a trauma lens: Identifying who is at risk for negative outcomes.

Peer victimization is a chronic stressor that occurs within the context of peer interactions and has been robustly associated with numerous negative psychological and social adjustment problems. Although increased frequency of peer victimization has been linked to psychosocial problems, few researchers have studied the role of duration and pervasiveness of victimization (i.e., number of places it occurs). The objective of this study was to examine how frequency, duration, and pervasiveness of peer victimization are associated with youth adjustment. Canadian adolescents (N = 879), ages 12-18 completed an online survey about experiences with peer victimization. Youth also answered questions about internalizing problems, distress, relationship quality with family, friends, and adults in their school and community, as well as academic functioning. Data were analyzed using multinomial logistic regression modeling. Both duration and pervasiveness of peer victimization were predictive of increased internalizing problems, distress, relationship problems, and academic difficulties. Duration and pervasiveness of peer victimization were identified as important factors to consider when predicting youth psychosocial adjustment. By asking questions about these situational factors, parents, teachers, and healthcare providers may more effectively identify youth who are at risk for experiencing mental health problems associated with peer victimization.

Phenylephrine infusion impact on surgical site infections after lower extremity bypass surgery.

OBJECTIVE: Lower extremity bypass (LEB) operations have high rates of surgical site infections (SSI). Phenylephrine is a commonly used vasoconstrictor which may reduce skin blood flow and increase the likelihood of SSI in these patients. We studied the potential effect of phenylephrine infusion during LEB surgery on SSI. METHODS: LEB cases and their demographic data were identified through the Vascular Quality Initiative registry. SSI in this population was identified using the hospital epidemiology surveillance database. Phenylephrine use in this population was identified through chart review. RESULTS: We identified 699 patients who underwent LEB; 82 (11.7%) developed an SSI, and 244 of 698 (35.0%) were treated with phenylephrine infusion. In bivariate analysis, higher body mass index (28.8 kg/m2 vs 27.3 kg/m2; P = .034), diabetes (14.6% vs 9.4%; P = .035), hypertension (12.6% vs 4.7%; P = .038), groin incision (13.2 vs 5.4%; P = .013) and longer procedure times (17.1% for >220 minutes and 8.9% for ≤220 minutes; P = .003) were associated with higher rates of SSI. Whereas phenylephrine infusion exhibited a trend toward a higher rate (14.8% vs 9.9%; P = .057). In the logistic regression model, diabetes (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.0-3.2; P = .032), total procedure time (OR, 1.85; 95% CI, 1.1-3.1; P = .026) and vertical groin incision (OR, 2.6; 95% CI, 1.1-6.5; P = .035) were independent predictors of increased SSI rates, whereas body mass index (OR, 1.04; 95% CI, 0.99-1.08; P = .09), hypertension (OR, 2.5; 95% CI, 0.6-10.9; P = .22), and phenylephrine infusion (OR, 1.08; 95% CI, 0.63-1.85; P = .78) were not independent predictors of increased SSI rates. CONCLUSIONS: Phenylephrine infusion did not increase the risk of SSI in patients who underwent LEB.

Perinatal Outcomes Associated With Isolated Velamentous Cord Insertion in Singleton and Twin Pregnancies.

OBJECTIVES: To evaluate perinatal outcomes in singleton and twin pregnancies with pathologically confirmed velamentous cord insertion without vasa previa. METHODS: This retrospective case-control study included all nonanomalous singleton and twin pregnancies with pathologically confirmed velamentous cord insertion delivered in a single institution between January 1, 2005, and July 1, 2015, and having an ultrasound examination by maternal-fetal medicine. For each case, the next 2 consecutive deliveries matched for gestational age at delivery ± 1 week and, in twins, amnionicity and chorionicity served as controls. Primary outcomes included surgical delivery for a nonreassuring intrapartum fetal heart rate tracing, umbilical arterial cord pH of less than 7.2, 5-minute Apgar score of less than 7, birth weight below the 10th percentile, neonatal intensive care unit admission, fetal or neonatal death, and cord avulsion necessitating manual placental extraction. RESULTS: Outcomes were available for 53 singletons with 103 matched controls and 33 twin pregnancies with 65 matched controls. In singletons, velamentous cord insertion was associated with cord pH of less than 7.2 (odds ratio [OR] 3.5; 95% confidence interval [CI], 1.1-11.2; P = .039), 5-minute Apgar score of less than 7 (OR, 5.3; 95% CI, 0.99-28.1; P = .045), and cord avulsion requiring manual placental extraction (7.5% versus 0%; P = .012). Associations were suggested with increased surgical delivery for a nonreassuring intrapartum fetal heart rate tracing (OR, 2.4; 95% CI, 0.9-6.9; P = .14), birth weight below the 10th percentile (OR, 2.1; 95% CI, 0.8-5.9; P = .21), and fetal or neonatal death (3.8% versus 0%; P = .11). Velamentous cord insertions were also associated with placental abruption in singletons (7.5% versus 0%; P = .013). Among twins, velamentous cord insertion was associated with fetal or neonatal death (9.1% versus 0%; P = .036). CONCLUSIONS: Isolated confirmed velamentous cord insertion is associated with adverse perinatal outcomes in singleton and twin gestations.

Does Pain Reduction with Oral Steroids Predict Pain Reduction after a First-Time Cervical Epidural Steroid Injection in Patients with Cervical Radicular Pain? A Pilot Study.

OBJECTIVE: Oral and injected steroids are used commonly in the treatment of cervical radicular pain despite a paucity of data demonstrating their efficacy. The purpose of this study is to assess whether the response to orally administered steroids among patients with acute cervical radicular pain who develop recurrent pain is associated with their subsequent response to cervical epidural steroid injections. METHODS: Patients referred to our center were evaluated and then referred for cervical epidural steroid injections at the clinical discretion of the provider; those who met inclusion criteria were offered participation in the study. After the injection was administered, patients were contacted by telephone and asked to complete the Brief Pain Inventory Short Form at one week, one month, three months, and six months postinjection. RESULTS: Pain reduction after cervical steroid injection was not significantly different between 49 patients who reported pain reduction with a prior course of oral steroids and 22 patients who reported no pain reduction. Average pain scores decreased over six months (P < 0.001) among 72 patients treated with epidural steroid injection for cervical radicular pain. Of the 55 who provided baseline and six-month data, 14 (25.5%) reported complete relief at six months and 20 (36.4%) reported decreased pain. CONCLUSIONS: Patients can be reassured that they may experience pain reduction after a cervical epidural steroid injection even if oral steroid therapy was not effective. The majority of patients treated for cervical radicular pain with epidural steroid injection have reduced or absent pain for at least six months after treatment.

Ethical issues raised by thyroid cancer overdiagnosis: A matter for public health?

Current practices of identifying and treating small indolent thyroid cancers constitute an important but in some ways unusual form of overdiagnosis. Overdiagnosis refers to diagnoses that generally harm rather than benefit patients, primarily because the diagnosed condition is not a harmful form of disease. Patients who are overdiagnosed with thyroid cancer are harmed by the psycho-social impact of a cancer diagnosis, as well as treatment interventions such partial or total thyroidectomy, lifelong thyroid replacement hormone, monitoring, surgical complications and other side effects. These harms seem to outweigh any putative benefit of knowing about a cancer that would not have caused problems if left undiscovered. In addition to harms to patients, thyroid cancer overdiagnosis leads to significant opportunity costs at a societal level, due to costs of diagnosis and treatment. Unlike many other overdiagnosed cancers, accurate risk stratification is possible with thyroid cancer. At the individual patient level, use of this risk information might support informed choice and/or shared decision-making, as mandated by clinical ethics frameworks. And this approach might, to some extent, help to reduce rates of diagnosis and intervention. In practice, however, it is unlikely to stem the rising incidence and associated harms and costs of overdiagnosed thyroid cancer, especially in situations where health professionals have conflicts of interest. We argue in this article that thyroid cancer overdiagnosis may be usefully understood as a public health problem, and that some public health approaches will be readily justifiable and are more likely to be effective in minimising its harms.