Identifying barriers to obstructive sleep-disordered breathing care: Parental perspectives.

OBJECTIVE: Despite established clinical practice guidelines for pediatric obstructive sleep-disordered breathing (SDB), disparities persist for this common condition. Few studies have investigated parental experiences about challenges faced in obtaining SDB evaluation and tonsillectomy for their children. To better understand parent-perceived barriers to treatment of childhood SDB, we administered a survey to assess parental knowledge of this condition. MATERIALS & METHODS: A cross-sectional survey was designed to be completed by parents of children diagnosed with SDB. Two validated surveys were administered: 1) Barriers to Care Questionnaire and 2) Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents. Logistic regression modeling was performed to assess for predictors of parental barriers to SDB care and knowledge. RESULTS: Eighty parents completed the survey. Mean patient age was 7.4 ± 4.6 years, and 48 (60%) patients were male. The survey response rate was 51%. Patient racial/ethnic categories included 48 (60.0%) non-Hispanic White, 18 (22.5%) non-Hispanic Black, and 14 (17.5%) Other. Parents reported challenges in the 'Pragmatic' domain, including appointment availability and cost of healthcare, as the most frequently described barrier to care. Adjusting for age, sex, race, and education, parents in the middle-income bracket ($26,500 - $79,500) had higher odds of reporting greater barriers to care than parents in the highest (>$79,500) income tier (OR 5.536, 95% CI 1.312-23.359, P = 0.020) and lowest income tier (<$26,500) (OR 3.920, 95% CI 1.096-14.020). Parents whose children had tonsillectomy (n = 40) answered only a mean 55.7% ± 13.3% of questions correctly on the knowledge scale. CONCLUSION: Pragmatic challenges were the most encountered barrier that parents reported in accessing SDB care. Families in the middle-income tier experienced the greatest barriers to SDB care compared to lower and higher income families. In general, parental knowledge of SDB and tonsillectomy was relatively low. These findings represent potential areas of improvement to target interventions to promote equitable care for SDB.

Self-administered, remote assessment of SARS-CoV-2 seroprevalence in health care workers.

BACKGROUND: Our objective was to safely and remotely assess longitudinal SARS-CoV-2 seroprevalence in at-risk health care workers at the onset of the epidemic. METHODS: Self-administered serologic testing was performed every 30 days up to 5 times using a point-of-care, lateral flow SARS-CoV-2 nucleocapsid IgG immunoassay in a cohort of at-risk health care workers (n = 339) and lower-risk controls (n = 100). RESULTS: Subjects were enrolled between 4/14/20-5/6/20 and most were clinicians (41%) or nurses (27%). Of 20 subjects who reported confirmed SARS-CoV-2 infection prior to (n = 5, 1%) or during the study (n = 15, 3%), half (10/20) were seropositive. Five additional subjects were seropositive and did not report documented infection. Estimated infection rates in health care workers did not differ from concurrent community rates. CONCLUSIONS: This remotely conducted, contact-free study did not identify serologic evidence of widespread occupational SARS-CoV-2 infection in health care workers.

A Modification of Time-Driven Activity-Based Costing for Comparing Cost of Telehealth and In-Person Visits.

Introduction: Cost studies of telehealth (TH) and virtual visits are few and report mixed results of the economic impact of virtual care and TH. Largely missing from the literature are studies that identify the cost of delivering TH versus in-person care. The objective was to demonstrate a modified time-driven activity-based costing (TDABC) approach to compare weighted labor cost of an in-person pediatric clinic sick visit before COVID-19 to the same virtual and in-person sick-visit during COVID-19. Methods: We examined visits before and during COVID-19 using: (1) recorded structured interviews with providers; (2) iterative workflow mapping; (3) electronic health records time stamps for validation; (4) standard cost weights for wages; and (5) clinic CPT billing code mix for complexity weighs. We examined the variability in estimated time using a decision tree model and Monte Carlo simulations. Results: Workflow charts were created for the clinic before COVID-19 and during COVID-19. Using TDABC and simulations for varying time, the weighted cost of clinic labor for sick visit before COVID-19 was $54.47 versus $51.55 during COVID-19. Discussion: The estimated mean labor cost for care during the pandemic has not changed from the pre-COVID period; however, this lack of a difference is largely because of the increased use of TH. Conclusions: Our TDABC approach is feasible to use under virtual working conditions; requires minimal provider time for execution; and generates detailed cost estimates that have "face validity" with providers and are relevant for economic evaluation.

Differences in rituximab use between pediatric rheumatologists and nephrologists for the treatment of refractory lupus nephritis and renal flare in childhood-onset SLE.

BACKGROUND: Consensus treatment plans have been developed for induction therapy of newly diagnosed proliferative lupus nephritis (LN) in childhood-onset systemic lupus erythematosus. However, patients who do not respond to initial therapy, or who develop renal flare after remission, warrant escalation of treatment. Our objective was to assess current practices of pediatric nephrologists and rheumatologists in North America in treatment of refractory proliferative LN and flare. METHODS: Members of Childhood Arthritis and Rheumatology Research Alliance (CARRA) and the American Society for Pediatric Nephrology (ASPN) were surveyed in November 2015 to assess therapy choices (other than modifying steroid dosing) and level of agreement between rheumatologists and nephrologists for proliferative LN patients. Two cases were presented: (1) refractory disease after induction treatment with corticosteroid and cyclophosphamide (CYC) and (2) nephritis flare after initial response to treatment. Survey respondents chose treatments for three follow up scenarios for each case that varied by severity of presentation. Treatment options included CYC, mycophenolate mofetil (MMF), rituximab (RTX), and others, alone or in combination. RESULTS: Seventy-six respondents from ASPN and foty-one respondents from CARRA represented approximately 15 % of the eligible members from each organization. Treatment choices between nephrologists and rheumatologists were highly variable and received greater than 50 % agreement for an individual treatment choice in only the following 2 of 6 follow up scenarios: 59 % of nephrologists, but only 38 % of rheumatologists, chose increasing dose of MMF in the case of LN refractory to induction therapy with proteinuria, hematuria, and improved serum creatinine. In a follow up scenario showing severe renal flare after achieving remission with induction therapy, 58 % of rheumatologists chose CYC and RTX combination therapy, whereas the top choice for nephrologists (43 %) was CYC alone. Rheumatologists in comparison to nephrologists chose more therapy options that contained RTX in all follow up scenarios except one (p < 0.05). CONCLUSIONS: Therapy choices for pediatric rheumatologists and nephrologists in the treatment of refractory LN or LN flare were highly variable with rheumatologists more often choosing rituximab. Further investigation is necessary to delineate the reasons behind this finding. This study highlights the importance of collaborative efforts in developing consensus treatment plans for pediatric LN.

Propensity score matching for multilevel spatial data: accounting for geographic confounding in health disparity studies.

BACKGROUND: Diabetes is a public health burden that disproportionately affects military veterans and racial minorities. Studies of racial disparities are inherently observational, and thus may require the use of methods such as Propensity Score Analysis (PSA). While traditional PSA accounts for patient-level factors, this may not be sufficient when patients are clustered at the geographic level and thus important confounders, whether observed or unobserved, vary by geographic location. METHODS: We employ a spatial propensity score matching method to account for "geographic confounding", which occurs when the confounding factors, whether observed or unobserved, vary by geographic region. We augment the propensity score and outcome models with spatial random effects, which are assigned scaled Besag-York-Mollié priors to address spatial clustering and improve inferences by borrowing information across neighboring geographic regions. We apply this approach to a study exploring racial disparities in diabetes specialty care between non-Hispanic black and non-Hispanic white veterans. We construct multiple global estimates of the risk difference in diabetes care: a crude unadjusted estimate, an estimate based solely on patient-level matching, and an estimate that incorporates both patient and spatial information. RESULTS: In simulation we show that in the presence of an unmeasured geographic confounder, ignoring spatial heterogeneity results in increased relative bias and mean squared error, whereas incorporating spatial random effects improves inferences. In our study of racial disparities in diabetes specialty care, the crude unadjusted estimate suggests that specialty care is more prevalent among non-Hispanic blacks, while patient-level matching indicates that it is less prevalent. Hierarchical spatial matching supports the latter conclusion, with a further increase in the magnitude of the disparity. CONCLUSIONS: These results highlight the importance of accounting for spatial heterogeneity in propensity score analysis, and suggest the need for clinical care and management strategies that are culturally sensitive and racially inclusive.

Minimally important difference in cost savings: Is it possible to identify an MID for cost savings?

As healthcare costs continue to increase, studies assessing costs are becoming increasingly common, but researchers planning for studies that measure costs differences (savings) encounter a lack of literature or consensus among researchers on what constitutes "small" or "large" cost savings for common measures of resource use.  Other fields of research have developed approaches to solve this type of problem. Researchers measuring improvement in quality of life or clinical assessments have defined minimally important differences (MID) which are then used to define magnitudes when planning studies. Also, studies that measure cost effectiveness use benchmarks, such as cost/QALY, but do not provide benchmarks for cost differences. In a review of the literature, we found no publications identifying indicators of magnitude for costs. However, the literature describes three approaches used to identify minimally important outcome differences: (1) anchor-based, (2) distribution-based, and (3) a consensus-based Delphi methods. In this exploratory study, we used these three approaches to derive MID for two types of resource measures common in costing studies for: (1) hospital admissions (high cost); and (2) clinic visits (low cost). We used data from two (unpublished) studies to implement the MID estimation. Because the distributional characteristics of cost measures may require substantial samples, we performed power analyses on all our estimates to illustrate the effect that the definitions of "small" and "large" costs may be expected to have on power and sample size requirements for studies. The anchor-based method, while logical and simple to implement, may be of limited value in cases where it is difficult to identify appropriate anchors. We observed some commonalities and differences for the distribution and consensus-based approaches, which require further examination. We recommend that in cases where acceptable anchors are not available, both the Delphi and the distribution-method of MID for costs be explored for convergence.

Race disparity in blood sphingolipidomics associated with lupus cardiovascular comorbidity.

Systemic lupus erythematous (SLE) is a chronic multi-organ autoimmune disease. Genetic and environmental factors contribute to disease onset and severity. Sphingolipids are signaling molecules involved in regulating cell functions and have been associated with multiple genetic disease processes. African-Americans are more likely to suffer from SLE morbidity than Whites. The Medical University of South Carolina has banked plasma samples from a well-characterized lupus cohort that includes African-Americans and Whites. This study examined the influence of race on plasma sphingolipid profiles in SLE patients and association of sphingolipid levels with comorbid atherosclerosis and SLE disease activity. Mass spectrometry revealed that healthy African-Americans had higher sphingomyelin levels and lower lactosylcermide levels compared to healthy Whites. SLE patients, irrespective of race, had higher levels of ceramides, and sphingoid bases (sphingosine and dihydrosphingosine) and their phosphates compared to healthy subjects. Compared to African-American controls, African-American SLE patients had higher levels of ceramides, hexosylceramides, sphingosine and dihydrosphingosine 1-phosphate. Compared to White controls, White SLE patients exhibited higher levels of sphingoid bases and their phosphates, but lower ratios of C16:0 ceramide/sphingosine 1-phosphate and C24:1 ceramide/sphingosine 1-phosphate. White SLE patients with atherosclerosis exhibited lower levels of sphingoid bases compared to White SLE patients without atherosclerosis. In contrast, African-American SLE patients with atherosclerosis had higher levels of sphingoid bases and sphingomyelins compared to African-American SLE patients without atherosclerosis. Compared to White SLE patients with atherosclerosis, African-American SLE patients with atherosclerosis had higher levels of select sphingolipids. Plasma levels of sphingosine, C16:0 ceramide/sphingosine 1-phosphate ratio and C24:1 ceramide/sphingosine 1-phosphate ratio significantly correlated with SLEDAI in the African-American but not White SLE patients. The C16:0 ceramide/sphingosine 1-phosphate ratio in SLE patients, and levels of C18:1 and C26:1 lactosylcermides, C20:0 hexosylceramide, and sphingoid bases in SLE patients with atherosclerosis could be dependent on race. Further ethnic studies in SLE cohorts are necessary to verify use of sphingolipidomics as complementary diagnostic tool.

Addressing geographic confounding through spatial propensity scores: a study of racial disparities in diabetes.

Motivated by a study exploring differences in glycemic control between non-Hispanic black and non-Hispanic white veterans with type 2 diabetes, we aim to address a type of confounding that arises in spatially referenced observational studies. Specifically, we develop a spatial doubly robust propensity score estimator to reduce bias associated with geographic confounding, which occurs when measured or unmeasured confounding factors vary by geographic location, leading to imbalanced group comparisons. We augment the doubly robust estimator with spatial random effects, which are assigned conditionally autoregressive priors to improve inferences by borrowing information across neighboring geographic regions. Through a series of simulations, we show that ignoring spatial variation results in increased absolute bias and mean squared error, while the spatial doubly robust estimator performs well under various levels of spatial heterogeneity and moderate sample sizes. In the motivating application, we construct three global estimates of the risk difference between race groups: an unadjusted estimate, a doubly robust estimate that adjusts only for patient-level information, and a hierarchical spatial doubly robust estimate. Results indicate a gradual reduction in the risk difference at each stage, with the inclusion of spatial random effects providing a 20% reduction compared to an estimate that ignores spatial heterogeneity. Smoothed maps indicate poor glycemic control across Alabama and southern Georgia, areas comprising the so-called "stroke belt." These results suggest the need for community-specific interventions to target diabetes in geographic areas of greatest need.

Racial Disparities in Arterial Stiffness Between Healthy Whites and African Americans in the United States: A Meta-analysis.

BACKGROUND: African Americans (AAs) present with cardiovascular disease (CVD) risk factors at younger ages than whites. Consequently, CVD and stroke occur at a higher incidence and at earlier decades in life in AA populations. Arterial stiffness is a predictor of CVD outcomes and partially explains the CVD risk experienced by racial minorities. We evaluated the differences in arterial stiffness observed in AAs and whites through a systematic review and meta-analysis. METHODS: We searched PubMed and SCOPUS for comparative studies published March 1995 to November 29, 2017 comparing arterial stiffness assessments (pulse wave velocity, augmentation index, and central blood pressure) between AAs and whites. Two independent reviewers examined 195 titles/abstracts, 85 full text articles and 11 articles were included in the meta-analysis using random effects modeling approaches. MAIN RESULTS: A total of 5060 white and 3225 AAs were included across 11 relevant studies. Carotid-femoral pulse wave velocity (cfPWV) measures were statistically different between AAs and whites (mean difference = -0.44, 95% confidence interval [CI]: -[-0.67, -0.21], p = 0.0002). Aortic femoral pulse wave velocity was significantly different between AAs and whites (mean difference = -0.21, [95% CI] -0.35, -0.07, p = 0.003) regardless of sex. Augmentation index (AIx) and Augmentation index at a 75 beats per minutes heart rate (AIx @75) was also significantly different between AA and whites (mean difference = -4.36 [95% CI] = -6.59, -2,12, p = 0.0001 and -6.26, [95% CI] = -9.19, -3.33, p < 0.0001, respectively). CONCLUSIONS: Racial disparities in arterial stiffness persist among African American racial groups in the United States. The lack of homogeneity in studies capturing racial disparities in cfPWV suggest that additional studies are needed to understand the magnitude of racial differences in African Americans and whites that might be clinically relevant.

Assessment Tools for Use During Anesthesia-Centric Pediatric Advanced Life Support Training and Evaluation.

BACKGROUND: Pediatric perioperative cardiac arrests are rare events that require rapid, skilled and coordinated efforts to optimize outcomes. We developed an assessment tool for assessing clinician performance during perioperative critical events termed Anesthesia-centric Pediatric Advanced Life Support (A-PALS). Here, we describe the development and evaluation of the A-PALS scoring instrument. METHODS: A group of raters scored videos of a perioperative team managing simulated events representing a range of scenarios and competency. We assessed agreement with the reference standard grading, as well as interrater and intrarater reliability. RESULTS: Overall, raters agreed with the reference standard 86.2% of the time. Rater scores concerning scenarios that depicted highly competent performance correlated better with the reference standard than scores from scenarios that depicted low clinical competence (P < 0.0001). Agreement with the reference standard was significantly (P < 0.0001) associated with scenario type, item category, level of competency displayed in the scenario, correct versus incorrect actions and whether the action was performed versus not performed. Kappa values were significantly (P < 0.0001) higher for highly competent performances as compared to lesser competent performances (good: mean = 0.83 [standard deviation = 0.07] versus poor: mean = 0.61 [standard deviation = 0.14]). The intraclass correlation coefficient (interrater reliability) was 0.97 for the raters' composite scores on correct actions and 0.98 for their composite scores on incorrect actions. CONCLUSIONS: This study provides evidence for the validity of the A-PALS scoring instrument and demonstrates that the scoring instrument can provide reliable scores, although clinician performance affects reliability.

A systematic review of lifestyle counseling for diverse patients in primary care.

Prior research and systematic reviews have examined strategies related to weight management, less is known about lifestyle and behavioral counseling interventions optimally suited for implementation in primary care practices generally, and among racial and ethnic patient populations. Primary care practitioners may find it difficult to access and use available research findings on effective behavioral and lifestyle counseling strategies and to assess their effects on health behaviors among their patients. This systematic review compiled existing evidence from randomized trials to inform primary care providers about which lifestyle and behavioral change interventions are shown to be effective for changing patients' diet, physical activity and weight outcomes. Searches identified 444 abstracts from all sources (01/01/2004-05/15/2014). Duplicate abstracts were removed, selection criteria applied and dual abstractions conducted for 106 full text articles. As of June 12, 2015, 29 articles were retained for inclusion in the body of evidence. Randomized trials tested heterogeneous multi-component behavioral interventions for an equally wide array of outcomes in three population groups: diverse patient populations (23 studies), African American patients only (4 studies), and Hispanic/Mexican American/Latino patients only (2 studies). Significant and consistent findings among diverse populations showed that weight and physical activity related outcomes were more amenable to change via lifestyle and behavioral counseling interventions than those associated with diet modification. Evidence to support specific interventions for racial and ethnic minorities was promising, but insufficient based on the small number of studies.

Initial Assessment of Stewards of Children Program Effects on Child Sexual Abuse Reporting Rates in Selected South Carolina Counties.

Child sexual abuse (CSA) prevention programs often include a focus on increased reporting of suspected abuse, in addition to other prevention components such as helping trainees recognize suspected abusive situations. This study aimed to determine whether the Stewards of Children prevention program is associated with increased CSA reporting. Analyses examined whether rates of CSA allegations increased over time in three counties in South Carolina (SC) targeted with program dissemination efforts and whether CSA reporting trends differed between the three targeted counties and three comparison counties that did not experience substantial program dissemination. CSA allegation data were obtained by county and year for predissemination and postdissemination periods from the SC Department of Social Services. Results indicated that, for the targeted counties but not the nontargeted counties, estimated allegation rates increased significantly over time, corresponding with the onset of significant program dissemination efforts. Results also indicated significant between-groups differences in allegation trends for targeted versus nontargeted counties. These findings suggest that the Stewards prevention intervention may be associated with increased CSA allegations. However, results require replication with randomization of counties. Moreover, whether increased reporting is associated with decreased CSA incidence remains unknown.

Master Settlement Agreement (MSA) spending and tobacco control efforts.

We investigate whether the distributions to the states from the Tobacco Master Settlement Agreement (MSA) in 1998 is associated with stronger tobacco control efforts. We use state level data from 50 states and the District of Columbia from four time periods post MSA (1999, 2002, 2004, and 2006) for the analysis. Using fixed effect regression models, we estimate the relationship between MSA disbursements and a new aggregate measure of strength of state tobacco control known as the Strength of Tobacco Control (SoTC) Index. Results show an increase of $1 in the annual per capita MSA disbursement to a state is associated with a decrease of -0.316 in the SoTC mean value, indicating higher MSA payments were associated with weaker tobacco control measures within states. In order to achieve the initial objectives of the MSA payments, policy makers should focus on utilizing MSA payments strictly on tobacco control activities across states.

Validity and reliability assessment of detailed scoring checklists for use during perioperative emergency simulation training.

INTRODUCTION: Few valid and reliable grading checklists have been published for the evaluation of performance during simulated high-stakes perioperative event management. As such, the purposes of this study were to construct valid scoring checklists for a variety of perioperative emergencies and to determine the reliability of scores produced by these checklists during continuous video review. METHODS: A group of anesthesiologists, intensivists, and educators created a set of simulation grading checklists for the assessment of the following scenarios: severe anaphylaxis, cerebrovascular accident, hyperkalemic arrest, malignant hyperthermia, and acute coronary syndrome. Checklist items were coded as critical or noncritical. Nonexpert raters evaluated 10 simulation videos in a random order, with each video being graded 4 times. A group of faculty experts also graded the videos to create a reference standard to which nonexpert ratings were compared. P < 0.05 was considered significant. RESULTS: Team leaders in the simulation videos were scored by the expert panel as having performed 56.5% of all items on the checklist (range, 43.8%-84.0%), and 67.2% of the critical items (range, 30.0%-100%). Nonexpert raters agreed with the expert assessment 89.6% of the time (95% confidence interval, 87.2%-91.6%). No learning curve development was found with repetitive video assessment or checklist use. The κ values comparing nonexpert rater assessments to the reference standard averaged 0.76 (95% confidence interval, 0.71-0.81). CONCLUSIONS: The findings indicate that the grading checklists described are valid, are reliable, and could be used in perioperative crisis management assessment.

The growing gap in hypertension control between insured and uninsured adults: National Health and Nutrition Examination Survey 1988 to 2010.

Hypertension awareness, treatment, and control are lower among uninsured than insured adults. Time trends in differences and underlying modifiable factors are important for informing strategies to improve health equity. National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 data in adults aged 18 to 64 years were analyzed to explore this opportunity. The proportion of adults with hypertension who were uninsured increased from 12.3% in 1988 to 1994 to 17.4% in 2005 to 2010. In 1988 to 1994, hypertension awareness, treatment, and control to <140/<90 mm Hg (30.1% versus 26.5%; P=0.27) were similar in insured and uninsured adults. By 2005 to 2010, the absolute gap in hypertension control between uninsured and insured adults of 21.9% (52.5% versus 30.6%; P<0.001) was explained approximately equally by lower awareness (65.2% versus 80.7%), fewer aware adults treated (75.2% versus 88.5%), and fewer treated adults controlled (63.1% versus 73.5%; all P<0.001). Publicly insured and uninsured adults had similar income. Yet, hypertension control was similar across time periods in publicly and privately insured adults, despite lower income and education in the former. In multivariable analysis, hypertension control in 2005 to 2010 was associated with visit frequency (odds ratio, 3.4 [95% confidence interval, 2.4-4.8]), statin therapy (1.8 [1.4-2.3]), and healthcare insurance (1.6 [1.2-2.2]) but not poverty index (1.04 [0.96-1.12]). Public or private insurance linked to more frequent healthcare, greater awareness and effective treatment of hypertension, and appropriate statin use could reverse a long-term trend of growing inequity in hypertension control between insured and uninsured adults.

Effect of a cognitive aid on adherence to perioperative assessment and management guidelines for the cardiac evaluation of noncardiac surgical patients.

BACKGROUND: The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. METHODS: Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. RESULTS: All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). CONCLUSIONS: Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.

A composite outcome for neonatal cardiac surgery research.

OBJECTIVE: The objective of this study was to determine whether a composite outcome, derived of objective signs of inadequate cardiac output, would be associated with other important measures of outcomes and therefore be an appropriate end point for clinical trials in neonatal cardiac surgery. METHODS: Neonates (n = 76) undergoing cardiac operations requiring cardiopulmonary bypass were prospectively enrolled. Patients were defined to have met the composite outcome if they had any of the following events before hospital discharge: death, the use of mechanical circulatory support, cardiac arrest requiring chest compressions, hepatic injury (2 times the upper limit of normal for aspartate aminotransferase or alanine aminotransferase), renal injury (creatinine >1.5 mg/dL), or lactic acidosis (an increasing lactate >5 mmol/L in the postoperative period). Associations between the composite outcome and the duration of mechanical ventilation, intensive care unit stay, hospital stay, and total hospital charges were determined. RESULTS: The median age at the time of surgery was 7 days, and the median weight was 3.2 kg. The composite outcome was met in 39% of patients (30/76). Patients who met the composite outcome compared with those who did not had a longer duration of mechanical ventilation (4.9 vs 2.9 days, P < .01), intensive care unit stay (8.8 vs 5.7 days, P < .01), hospital stay (23 vs 12 days, P < .01), and increased hospital charges ($258,000 vs $170,000, P < .01). In linear regression analysis, controlling for surgical complexity, these differences remained significant (R(2) = 0.29-0.42, P < .01). CONCLUSIONS: The composite outcome is highly associated with important early operative outcomes and may serve as a useful end point for future clinical research in neonates undergoing cardiac operations.

Simulation curriculum can improve medical student assessment and management of acute coronary syndrome during a clinical practice exam.

BACKGROUND: It has been noted that increased focus on learning acute care skills is needed in undergraduate medical curricula. This study investigated whether a simulation-based curriculum improved a senior medical student's ability to manage acute coronary syndrome as measured during a clinical performance examination (CPX). The authors hypothesized that simulation training would improve overall performance when compared with targeted didactics or historical controls. METHODS: All 4th-year medical students (n = 291) over 2 years at the authors' institution were included in this study. In the 3rd year of medical school, the "control" group received no intervention, the "didactic" group received a targeted didactic curriculum, and the "simulation" group participated in small group simulation training and the didactic curriculum. For intergroup comparison on the CPX, the authors calculated the percentage of correct actions completed by the student. Data are presented as mean ± standard deviation with significance defined as P < 0.05. RESULTS: There was a significant improvement in overall performance with simulation versus both didactics and control (P < 0.001). Performance on the physical examination component was significantly better in simulation versus both didactics and control, as was for diagnosis: simulation versus both didactics and control (P < 0.02 for all comparisons). CONCLUSIONS: Simulation training had a modest impact on overall CPX performance in the management of a simulated acute coronary syndrome. Additional studies are needed to evaluate how to further improve curricula regarding unstable patients.

Preventive services delivery in patients with chronic illnesses: parallel opportunities rather than competing obligations.

PURPOSE: Whether patients with 1 or more chronic illnesses are more or less likely to receive recommended preventive services is unclear and an important public health and health care system issue. We addressed this issue in a large national practice-based research network (PBRN) that maintains a longitudinal database derived from electronic health records. METHODS: We conducted a cross-sectional study as of October 1, 2011, of the association between being up to date with 10 preventive services and the prevalence of 24 chronic illnesses among 667,379 active patients aged 18 years or older in 148 member practices in a national PBRN. We used generalized linear mixed models to assess for the association of being up to date with each preventive service as a function of the patient's number of chronic conditions, adjusted for patient age and encounter frequency. RESULTS: Of the patients 65.4% had at least 1 of the 24 chronic illnesses. For 9 of the 10 preventive services there were strong associations between the odds of being up to date and the presence of chronic illness, even after adjustment for visit frequency and patient age. Odds ratios increased with the number of chronic conditions for 5 of the preventive services. CONCLUSIONS: Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services in this large national PBRN. This finding supports the notion that modern primary care practice can effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.

Racial differences between blacks and whites with systemic sclerosis.

PURPOSE OF REVIEW: Racial disparities appear to exist in the susceptibility and severity of systemic sclerosis (SSc, scleroderma) and are responsible for a greater health burden in blacks as compared with whites. Disparities in socioeconomic status and access to healthcare do not sufficiently explain the observed differences in prevalence and mortality. It is important to determine whether there might be a biologic basis for the racial disparities observed in SSc. RECENT FINDINGS: We present data to suggest that the increased susceptibility and severity of SSc in blacks may result in part from an imbalance of profibrotic and antifibrotic factors. Racial differences in the expression of transforming growth factor-ß1 (TGF-ß1) and caveolin-1, as well as differences in the expression of hepatocyte growth factor and PPAR-γ, have been demonstrated in blacks with SSc, as well as in normal black individuals. A genetic predisposition to fibrosis may account for much of the racial disparities between black and white patients with SSc. SUMMARY: A better understanding of the biologic basis for the racial disparities observed in SSc may lead to improved therapies, along with the recognition that different therapies may need to be adapted for different groups of patients.