Pediatric Lateral Humeral Condyle Fractures: Reliability of a Modified Jakob Classification System and its Impact on Treatment Planning With or Without Arthrography.

BACKGROUND: Various lateral humeral condyle fracture (LHCF) classification systems have been in use since the 1950s, but limited research exists on their reliability. The most widely utilized, yet un-validated system is that of Jakob and colleagues. The purpose of the current study was to analyze the reliability of a modified Jakob classification system and its value in guiding treatment either with or without arthrography. METHODS: Interrater and intrarater reliability studies were performed using radiographs and arthrograms from 32 LHCFs. Radiographs were presented to 3 pediatric orthopaedic surgeons and 6 pediatric orthopaedic surgery residents who were asked to classify the fractures according to a modified Jakob classification system, enunciate their treatment plan, and whether they would utilize arthrography. Classification was repeated within 2 weeks to assess intrarater reliability. The treatment plan using radiographs only and radiographs with arthrography were compared at both rating points. RESULTS: The modified Jakob system had excellent interrater reliability using only radiographs with a kappa value of 0.82 and an overall agreement of 86%. The average kappa for intrarater reliability using only radiographs was 0.88 with a range of 0.79 to 1.00 and an average overall agreement of 91% with a range of 84% to 100%. Interrater and intrarater reliability was poorer using both radiographs and arthrography. On average, arthrography changed the treatment plan in 8% of cases. CONCLUSIONS: The modified Jakob classification system proved to be a reliable classification system for LHCFs, independent of arthrography, given the excellent free-marginal multirater kappa values. LEVEL OF EVIDENCE: Level III-diagnostic.

Proximal Femoral Screw Hemiepiphysiodesis in Children With Cerebral Palsy Improves the Radiographic Measures of Hip Subluxation.

BACKGROUND: Proximal femoral screw hemiepiphysiodesis (PFSH) is a promising technique for treatment of hip subluxation in children with cerebral palsy (CP). The aim of this study is to report radiographic outcomes of PFSH and to evaluate its role in changing the natural history of hip displacement in children with CP. METHODS: This is a single center retrospective chart review of children with CP that underwent PFSH with at least 2 years of radiographic follow-up. Demographic information, surgical details, complications, additional surgical procedures, and need for screw exchange were recorded. Radiographs were assessed for migration percentage (MP), neck shaft angle (NSA), head shaft angle (HSA), and articular trochanter distance preoperatively as well as at 6 months, 1 year, 2 year, and latest follow-up postoperatively. Hips were divided into group 1 (no previous hip surgery) and group 2 (PFSH performed after hip reconstruction). Hips with 2 years of preoperative radiographic data were included in the natural history cohort. RESULTS: Twenty-three patients (44 hips) met inclusion criteria with an average age of 7.3±1.7 years and a mean follow-up of 33.5 months. Group 1 and group 2 had 32 and 12 hips, respectively. Group 1 had significant improvement in all parameters (ΔMP=5%, ΔNSA=13 degrees, ΔHSA=15 degrees) group 2 showed improvements in NSA and HSA (ΔNSA=4 degrees ΔHSA=8 degrees) with only HSA reaching significance and MP remaining unchanged. All radiographic measurements worsened in the 2 years before surgery (N=25, natural history group) and improved after PFSH. Screw exchange occurred in 12 hips (27.2%) at an average of 33 months (range 27 to 42 mo) with 2 hips also undergoing pelvic osteotomy at that time. Three hips had a MP >50% at follow-up with 2 hips in group 1 undergoing hip reconstruction. No complications were noted. CONCLUSION: PFSH effectively alters proximal femoral growth and can improve hip subluxation in children with CP. Screws often need to be exchanged and hips should be carefully monitored. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Can Over-containment Prevent Recurrence in Children With Cerebral Palsy and Hip Dysplasia Undergoing Hip Reconstruction?

INTRODUCTION: Hip reconstruction is often necessary in children with cerebral palsy (CP) but is associated with high failure rates. Over-containment deeply seats the hip within the acetabulum at the time surgical reconstruction. The goal of this study is to evaluate the effect of over-containment on radiographic outcomes and failure rates in children with CP undergoing hip reconstruction. METHODS: This study is a retrospective chart review of children with CP that underwent hip reconstruction between 2010 and 2019 with at least 2 years of radiographic follow-up. Migration percentage (MP), acetabular index (AI), and neck shaft angle (NSA) were recorded preoperatively, postoperatively and throughout follow-up. Failures were defined as a MP at latest follow-up ≥30% or need for revision hip reconstruction. Hips were divided into groups based on postoperative MP-group 1 (over-containment group) had a MP≤0% and group 2 had an MP>0%. Radiographic parameters and failure rates were compared across Gross Motor Functional Classification Score (GMFCS) level, age at the time of surgery, and degree of preoperative subluxation. RESULTS: A cohort of 108 patients (197 hips) with an average age of 7.3±3.2 years met inclusion criteria with an average follow-up of 49.6 months (range: 24 to 118 mo). There were 147 hips in group 1 and 50 hips in group 2. At latest follow-up, group 1 demonstrated lower MP, AI, and NSA in comparison to group 2. The overall failure rate in our cohort was 8.1% (16 hips). Failure rates trended lowest in hips that were over-contained (6.1% v. 14.0%) although not statistically significant. Over-containment resulted in significantly lower failure rates in GMFCS IV/V hips, children under age 6 at the time of surgery and those with a higher degree of preoperative hip displacement (MP>50%). CONCLUSIONS: Over-containment at the time of hip reconstruction can positively affect radiographic outcomes and failure rates in children with CP. Over-containment should be considered in hips at high risk of failure, especially non ambulatory children with significant hip subluxation at an early age. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Improved Clinical and Functional Outcomes in Crouch Gait Following Minimally Invasive Hamstring Lengthening and Serial Casting in Children With Cerebral Palsy.

BACKGROUND: Serial extension casting represents a novel solution for addressing residual knee flexion contractures following hamstring lengthening in children with cerebral palsy. The purpose of this study was to investigate postoperative changes in patients following hamstring lengthening with a serial casting protocol. METHODS: Measures from preoperative and postoperative gait analyses were reviewed retrospectively for 19 patients with cerebral palsy who underwent hamstring lengthening followed by serial extension casting. Postoperative changes in clinical, functional, and kinematic parameters were assessed using paired parametric methods. RESULTS: Improvements were measured in popliteal angle, knee contracture, peak stance phase knee extension, sagittal plane range of motion of the knee during walking, Gait Deviation Index, and pediatric outcomes data collection instrument Global score. Nearly 80% of the cohort (15/19 patients) demonstrated a significant or moderate response to the intervention, whereas 20% demonstrated no improvement. Of note, significantly increased anterior pelvic tilt was also observed. CONCLUSIONS: Hamstring lengthening combined with a serial casting protocol was associated with significant postoperative improvements in a range of clinical (eg, knee contracture), functional (eg, pediatric outcomes data collection instrument Global), and kinematic (eg, knee extension in stance) parameters. Improvements following this minimally invasive surgery were comparable to outcomes from procedures with higher complication rates. LEVEL OF EVIDENCE: This is a Level III Therapeutic Study (retrospective study investigating the results of a treatment).

Screw Anterior Distal Femoral Hemiepiphysiodesis in Children With Cerebral Palsy and Knee Flexion Contractures: A Retrospective Case-control Study.

BACKGROUND: In children with cerebral palsy who demonstrate hamstring tightness, increasing attention is being paid to less invasive methods of correcting knee flexion contractures. Guided growth principles represent one such approach, and in tandem with a serial extension casting protocol, may provide a less invasive method of addressing these contractures. To date, no evidence is available on this combination of procedures. The purpose of this study was to investigate the effectiveness of a combined lengthening/guided growth procedure (hamstring lengthening, percutaneous anterior screw hemiepiphysiodesis, and serial extension casting) in addressing knee flexion contracture, and to compare this approach to hamstring lengthening and serial extension casting alone. METHODS: Measures from preoperative and postoperative gait analyses were reviewed retrospectively for 10 patients with cerebral palsy who underwent anterior screw hemiepiphysiodesis and hamstring lengthening followed by serial extension casting [anterior epiphysiodesis (AE) group]. These findings were compared with measures from 19 patients with cerebral palsy who underwent hamstring lengthening followed by serial extension casting [no anterior epiphysiodesis (NAE) group]. Postoperative changes in clinical, functional, and kinematic parameters were assessed. Radiographic parameters were also assessed for the AE group. RESULTS: In the AE group, improvements were measured in knee contracture, popliteal angle, peak stance phase knee extension, knee range of motion, and Gait Deviation Index. Similar results were observed in the NAE group. In the AE group, the lateral distal femoral angle increased into extension by 20.9 degrees at an average of 26-month follow-up. Both groups showed an increase in pelvic tilt postoperatively. There were no surgical complications associated with the screw anterior hemiepiphysiodesis. Four patients did have complaints of knee pain, but the pain was attributable to the implants in only one patient. DISCUSSION: The AE group demonstrated statistically greater postoperative improvement in popliteal angle, knee flexion contracture, and peak knee extension during stance than the NAE group. Both procedures led to improvements in clinical and functional measures, indicating the validity of this approach as a means of correcting flexion contracture that is less invasive and allows immediate weight bearing. LEVEL OF EVIDENCE: Level III-therapeutic study.

Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association.

The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a national process to develop and implement evidence-based guidelines for cardiac resuscitation systems of care. Significant experience has been gained with implementing these systems, and new evidence has accumulated. This update describes recent advances in the science of cardiac resuscitation systems and evidence of their effectiveness, as well as recent progress in dissemination and implementation throughout the United States. Emphasis is placed on evidence published since the original recommendations (ie, including and since 2010).

Impact of Regionalization of ST-Segment-Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services-Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention: Mission: Lifeline Accelerator-2.

BACKGROUND: Regional variations in reperfusion times and mortality in patients with ST-segment-elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts. METHODS: Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention-capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period. RESULTS: During the study period, 10 730 patients were transported to percutaneous coronary intervention-capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%-74%; P<0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%-56%; P<0.0001), and emergency department dwell time of ≤20 minutes (33%-43%; P<0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%-2.3%; P=0.001) that was not apparent in hospitals not participating in the project during the same time period. CONCLUSIONS: Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment-elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment-elevation myocardial infarction.

The care of VIPs in the emergency department: Triage, treatment and ethics.

People identified as Very Important Persons (VIPs) often present or are referred to the Emergency Department (ED). Celebrities are a small subset of this group, but many others are included. Triage of these patients, including occasional prioritization, creates practical and ethical challenges. Treatment also provides challenges with the risks of over testing, overtreatment, over consultation, and over or under admission to the hospital. This article presents a practical and ethical framework for addressing the care of VIPs in the ED.

Complication Rates After Bone Morphogenetic Protein (BMP) Use in Orthopaedic Surgery in Children: A Concise Multicenter Retrospective Cohort Study.

BACKGROUND: The use of bone morphogenetic protein (BMP) has been associated with a number of complications in adult patients. However, this association is less established in children. The aim of this study was to evaluate the safety of BMP use in children by determining the complication rates after BMP use at multiple institutions. METHODS: In a retrospective study (2000 to 2013), the medical records of all patients who received BMP at any of the 5 institutions were reviewed. Demographic information, preoperative data, and postoperative follow-up data were collected on those patients who were under the age of 18 at the time of surgery. RESULTS: A total of 312 pediatric patients underwent surgery with BMP application during the study period. The surgical procedures consisted of 228 spinal fusions, 39 pars repairs, 33 nonunion repair, and 12 other various procedures. Overall 21% (65/312) of patients who had BMP utilized had a complication. Fifty-five percent (36/65) of patients with a complication required a revision surgery. The average follow-up was 27 months (range, 3 to 96 mo); 80% of patients had a follow-up period of >12 months. The average age at the time of surgery was 13 years (range, 1 to 17 y). Males and females were almost equally represented in the study: 143 males (46%) and 168 females (54%). Of the patients who received BMP, 9% had minor complications and 13% had major complications. Wound dehiscence without infection was the most common minor complication and occurred in 59% (16/27) of patients with minor complications. Infection and implant failures were the most frequent major complications, occurring in 38% (15/39) and 33% (13/39) of patients with major complications, respectively. Five of 312 (2%) patients had neurological injury, 3 of which were only temporary. CONCLUSIONS: This multicenter study demonstrates a relatively high rate of complications after the use of BMP in children. However, further study is needed to attribute the complications directly to the use of BMP. LEVEL OF EVIDENCE: Level IV.

Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction.

OBJECTIVES: We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST-PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST-elevation myocardial infarction (STEMI). BACKGROUND: Current standard therapy for STEMI is PPCI. However, FAST-PCI may shorten ischemic time (IT) and improve outcomes. METHODS: Eligible STEMI patients received prehospital, reduced dose fibrinolysis along with standard therapy, and were transported for urgent percutaneous coronary intervention, or else they received usual treatment without prehospital fibrinolysis. Patients were divided retrospectively into four groups based on IT (<120, 120-179, 180-239 min, ≥240) for a mortality analysis cohort, and into three groups (<120, 120-179, ≥180 min) for a CMR analysis cohort. Within each IT group, patients were compared by FAST-PCI vs. PPCI strategy. RESULTS: Between 1/2007 and 2/2014, 1,112 STEMI patients were treated. FAST-PCI was employed in 551 and PPCI in 561. Of these, 357 (32.1%) underwent CMR. The treatment groups were well matched. In STEMI patients with short IT (<120 and 120-179 min groups), those treated by FAST-PCI had lower 30-day mortality and myocardial scar sizes compared with PPCI treatment. For IT ≥180 min, the mortalities and myocardial scar sizes were equivalent for both groups. CONCLUSIONS: In STEMI patients with IT <180 min, FAST-PCI may reduce 30-day mortality and myocardial scar size compared with PPCI. This suggests that infarct interventions must be instituted within 3 hr of symptom onset in order to detect an optimal beneficial effect both clinically and by CMR measurement. © 2016 Wiley Periodicals, Inc.

Ischemic time is a better predictor than door-to-balloon time for mortality and infarct size in ST-elevation myocardial infarction.

BACKGROUND: Current guidelines for ST-elevation myocardial infarction (STEMI) recommend early revascularization with optimal ischemic time (IT) < 120 min and door-to-balloon (D2B) time < 90 min. The focus of most studies has been D2B time, while IT is not frequently reported. We tested the hypothesis that total IT is a better predictor than D2B time for mortality and infarct size. METHODS AND RESULTS: Between December 2008 and April 2013, 786 patients with STEMI were treated in our STEMI center, and 262 of these had cardiac magnetic resonance imaging 3-5 days after the index event. Total IT was defined as time from symptom onset to device activation, while D2B time was defined as hospital arrival to device activation. Patients were divided into three groups according to IT (<120, 120-239, ≥240 min) and into four groups according to D2B time (<30, 30-59, 60-89, ≥90 min). Baseline demographics including age, cardiac risk factors, and LAD infarct location were similar between groups. The 30-day mortality rate significantly increased across IT groups but did not correlate with D2B time groups. Similarly, infarct size significantly increased across IT groups but did not correlate with D2B time groups. CONCLUSIONS: In STEMI patients, IT was a better predictor than D2B time for 30-day mortality and infarct size. Our findings suggest that the focus of STEMI care should be directed at early initiation of therapy and minimizing IT rather than on D2B time alone. The potential impact of IT reporting in current STEMI registries merits further consideration. © 2015 Wiley Periodicals, Inc.

POSNA Quality, Safety, Value Initiative 3 Years Old and Growing Strong. POSNA Precourse 2014.

The purpose of this paper is to summarize the Pediatric Orthopaedic Society of North America (POSNA) quality, safety, and value initiative (QSVI). Specifically, it will outline the history of the program, describe typical quality improvement techniques, and how they differ from traditional research techniques, and, finally, describe some of the many projects completed, currently underway, or in planning for POSNA QSVI.

Validation of sepsis screening tool using StO2 in emergency department patients.

BACKGROUND: Sepsis is a deleterious systemic response to an infection with a high incidence of morbidity and mortality, affecting more than a million patients a year in the US. The purpose of this study was to develop a screening tool for the early identification of sepsis in emergency department patients using readily available information at triage. MATERIALS AND METHODS: This prospective, observational study took place at an academic tertiary referral hospital. Over a period of 10 wk, all patients who were seen at triage were screened for study enrollment. Inclusion criteria were adult (age≥18 y) nontrauma patients and exclusion criteria were prisoners and pregnant women. Using a Spot Check StO2 device to measure StO2 value, heart rate, respiratory rate, and temperature, these values were used to generate a cumulative screening score indicating whether a patient may have sepsis. RESULTS: A total of 500 patients were screened. The incidence of sepsis in the present study population was 8.4%. The screening tool yielded a sensitivity of 85.7%, a specificity of 78.4%, a positive predictive value of 26.7%, and a negative predictive value of 98.4%. CONCLUSIONS: Heart rate, respiratory rate, and temperature have good diagnostic potential for the early identification of sepsis among emergency department triage personnel. Additionally, early evidence suggests StO2 may play a complementary and synergistic role in the early identification of sepsis by triage personnel.

Maintenance of acetabular correction following PAO: a multicenter study comparing stainless-steel and titanium screws.

Stainless-steel screws are commonly used for fragment fixation during periacetabular osteotomy (PAO) at our institutions. Titanium is reserved for patients with documented nickel allergies. Titanium screws possess a significantly lower Young's modulus than stainless steel and, therefore, potentially less resistance to physiologic loading. Thus, we hypothesized that the use of titanium screws might be associated with changes in acetabular correction prior to healing. The aim of this study was to compare the maintenance of acetabular correction following PAO using stainless-steel or titanium screws. A documented nickel allergy was confirmed with an allergy specialist. Patients' age at surgery, gender and BMI were collected. The lateral center-edge angle of Wiberg (LCEA), medial center-edge angle (MCEA), anterior wall index (AWI), posterior wall index (PWI) and Tönnis angle were measured. The delta value for radiographic parameters was calculated as the difference between values immediately post-operation and at 6 months post-operation. Only age at surgery (P < 0.001) and the pre-operative LCEA (P = 0.013) were significantly different between groups (Tables I and II). The remaining pre- and post-operative radiological measurements were similar (Table II). Comparison of delta values at 6 months follow-up indicated no significant differences between screw types (Table III). No patients in the titanium group had a trans-iliac retrograde screw included in their construct (P = 0.003). All patients healed from their osteotomies. The use of titanium screws in patients with an allergy to nickel was not associated with differences in acetabular correction or the rate of osseous union rates despite its lower inherent mechanical properties.

Limb Lengthening and Reconstruction Society AIM index reliably assesses lower limb deformity.

BACKGROUND: Although several systems exist for classifying specific limb deformities, there currently are no validated rating scales for evaluating the complexity of general lower limb deformities. Accurate assessment of the complexity of a limb deformity is essential for successful treatment. A committee of the Limb Lengthening and Reconstruction Society (LLRS) therefore developed the LLRS AIM Index to quantify the severity of a broad range of lower extremity deformities in seven domains. QUESTIONS/PURPOSES: We addressed two questions: (1) Does the LLRS AIM Index show construct validity by correlating with rankings of case complexity? (2) Does the LLRS AIM Index show sufficient interrater and intrarater reliabilities? METHODS: We had eight surgeons evaluate 10 fictionalized patients with various lower limb deformities. First, they ranked the cases from simplest to most complex, and then they rated the cases using the LLRS AIM Index. Two or more weeks later, they rated the cases again. We assessed reliability using the Kendall's W test. RESULTS: Raters were consistent in their rankings of case complexity (W = 0.33). Patient rankings also correlated with both sets of LLRS AIM ratings (r(2) = 0.25; r(2) = 0.23). The LLRS AIM Index showed interrater reliability with an intraclass correlation (ICC) of 0.97 for Trial 1 and 0.98 for Trial 2 and intrarater reliability with an ICC of 0.94. The LLRS AIM Index ratings also were highly consistent between the attending surgeons and surgeons-in-training (ICC = 0.91). CONCLUSIONS: Our preliminarily observations suggest that the LLRS AIM Index reliably classifies the complexity of lower limb deformities in and between observers.

Should all unstable slipped capital femoral epiphysis be treated open?

Historically, in situ fixation has been considered the gold standard for the treatment of unstable slipped capital femoral epiphysis (SCFE). Open treatments can be considered in an attempt to improve outcome, primarily in an effort to decompress the hip or decrease residual deformity. For moderate and severe unstable slips, surgical hip dislocation followed by subcapital realignment has been proposed to address the metaphyseal prominence and prevent impingement. More recently, the natural history of mild slips after in situ pinning has also been questioned and new recommendations involving management with arthroscopic or mini open procedures have been proposed. The purpose of this manuscript is to review the current treatment options and to address the need for open treatments in unstable slipped capital femoral epiphysis.

Kwashiorkor in an 8-Month-Old Infant Due to Homemade Formula Use.

INTRODUCTION: Kwashiorkor is a malnutrition syndrome most commonly seen in the United States among patients with malabsorptive conditions. While it is rare in otherwise healthy individuals, cases can develop where low nutritional literacy or unorthodox diets are a factor. CASE PRESENTATION: We present an 8-month-old infant who developed kwashiorkor after transitioning to homemade infant formula. DISCUSSION: This patient developed severe malnutrition due to consumption of homemade formula that did not meet nutritional standards. The recipe was promoted by an alternative health organization as a healthy option, and the difficulty in identifying reliable health information online also played a significant role. CONCLUSIONS: Families of young children face many challenges, particularly during the recent infant formula shortage. Maintaining strong relationships and open communication with trusted health care professionals is vital to combating health misinformation and helping patients and families navigate these challenges safely.

Med-Peds Residents' Career Plans and the Impact of Pediatric Hospital Medicine Fellowship: A Nationwide Survey.

BACKGROUND: The establishment of pediatric hospital medicine (PHM) as a fellowship-trained subspecialty represents a major change in the practice landscape, particularly for combined internal medicine-pediatrics (med-peds) residents. The most recent literature on med-peds residents' career choices predates PHM fellowship and its impact has not been well studied. We aimed characterize med-peds residents' career plans and the factors influencing their choices. METHODS: We distributed an electronic survey to the 1,505 resident members of the National Med-Peds Resident Association. In addition to sociodemographic data, participants reported their career plans, how well their residency prepared them for various aspects of practice, and their perceptions of PHM fellowship and its effect on their career choices. RESULTS: Among the 228 participants, the most planned careers were combined hospital medicine (36.8%, 84/228), combined subspecialty practice (32.5%, 74/228), and primary care (31.1%, 71/228). Residents felt well prepared for patient care and significantly more prepared for inpatient practice than for primary care. Participants rated the potential disadvantages of PHM fellowship as major deterrents and did not view the possible advantages as strong incentives. Among those who had considered a hospital medicine careers, 91.2% (186/203) were less likely to pursue PHM after its certification as a subspecialty. CONCLUSION: Med-peds residents have a wide range of career interests but fellowship has made them less likely to pursue PHM careers. These findings emphasize the importance of addressing the needs of med-peds trained providers as PHM certification pathways and fellowship curricula develop to avoid adverse effects on the workforce.

Public Health Interventions Guided by Houston's Wastewater Surveillance Program During the COVID-19 Pandemic.

Since the start of the COVID-19 pandemic, wastewater surveillance has emerged as a powerful tool used by public health authorities to track SARS-CoV-2 infections in communities. In May 2020, the Houston Health Department began working with a coalition of municipal and academic partners to develop a wastewater monitoring and reporting system for the city of Houston, Texas. Data collected from the system are integrated with other COVID-19 surveillance data and communicated through different channels to local authorities and the general public. This information is used to shape policies and inform actions to mitigate and prevent the spread of COVID-19 at municipal, institutional, and individual levels. Based on the success of this monitoring and reporting system to drive public health protection efforts, the wastewater surveillance program is likely to become a standard part of the public health toolkit for responding to infectious diseases and, potentially, other disease-causing outbreaks.