Optimizing Education During Pediatric Resident Mock Code Sessions.

INTRODUCTION: Most pediatric residents have limited opportunities to manage cardiac arrest. We used simulation to fill that educational void. Given work hours and other obligations, resident education sessions must be high-yield. We examined the effectiveness of adding varying amounts of formal education to a mock code session on resident knowledge and confidence in managing pediatric cardiac arrest compared with participation alone. METHODS: Convenient groups of 3 to 8 pediatric residents completed a simulation session with the identical scenario: a 3-month-old infant with pulseless ventricular tachycardia and then pulseless electrical activity. All residents completed pretests and posttests, which consisted of open-ended knowledge questions from the American Heart Association Pediatric Advanced Life Support guidelines and confidence Likert scale assessments. Resident groups were assigned to 1 of 3 educational models: experiential-only: participation in the mock, traditional: mock code participation with standardized education after the mock code, or reinforced: standardized education before and after mock code participation. RESULTS: Ninety-five residents participated. Collectively, residents demonstrated a median 2-point (interquartile range, 1-4) increase in knowledge (test maximum score, 10) after they attended a mock code simulation session ( P < 0.0001); however, there were no statistically significant differences noted between educational modalities. All residents also demonstrated a 4-point median increase in confidence (test maximum score, 25) after completing their simulation session (interquartile range, 3-6) ( P < 0.001), but no differences were seen by type or amount of accompanying education. CONCLUSIONS: Residents had gains in confidence and knowledge of pediatric cardiac arrest management after participation in the mock code. Formal educational sessions and reinforced formal education sessions accompanying the mock code did not significantly increase knowledge or confidence.

First-Person Point-of-View Instructional Video on Lumbar Puncture Procedure.

OBJECTIVES: Tutorial videos filmed from a first-person point of view (FP-POV) are generally well received. Pediatric residents are expected to be competent in performing the lumbar puncture (LP). The educational effectiveness of a FP-POV in lumbar puncture procedure training for resident physicians has yet to be evaluated. We compared a FPPOV LP video with a standard in-person demonstration of the LP. METHODS: We designed an assigned cohort study to compare a FP-POV procedural instructional video of a simulated pediatric LP to the standard in-person procedure demonstration.After the intervention, residents completed an LP observed by one of two blinded reviewers who assessed the procedure using a modified, published assessment tool.Participants completed preintervention and postintervention surveys to rate self-confidence and usefulness of the FP-POV educational method. The data was analyzed using a Wilcoxon Rank sum test. z Scores were calculated on the raw assessment scores. RESULTS: Eighteen first year pediatric residents participated, nine in each group. The median modified assessment tool score was 17 in the FP-POV group (min, 14; max, 17; IQR:, 1.5) and 14 in the standard demonstration group (min, 6; max, 17; IQR, 4.5), with the higher score being more successful. There was a statistical difference between the assessment scores between the 2 groups (z score = 2.18, P = 0.04). Postintervention survey data demonstrated relative satisfaction with the FPPOV educational method. CONCLUSIONS: This study supports the educational effectiveness of a FP-POV procedure tutorial.Future studies with a larger sample size are needed.

Emergence of Extended-Spectrum ß-Lactamase-Producing Pathogens in Community-Acquired Urinary Tract Infections Among Infants at a Pediatric Emergency Department.

BACKGROUND: Extended-spectrum ß-lactamase (ESBL)-producing pathogens are common among adults and are associated with extended and multiple hospitalizations. They cause urinary tract infections (UTIs) among children with known risk factors such as urinary tract abnormalities and antimicrobial prophylaxis. The emergence of UTIs caused by ESBL-producing organisms among infants has not been well characterized. OBJECTIVE: We sought to describe the incidence and current clinical management of infants who were diagnosed with UTIs caused by ESBL-producing organisms at a pediatric emergency department (ED). In addition, we sought to describe risk factors associated with inpatient hospitalization for UTIs caused by ESBL-producing organisms. METHODS: We retrospectively identified infants who were treated in the ED from 2013 to 2017 and who had positive urinalyses and urine cultures positive for greater than 50,000 colony-forming unit per milliliter of a single ESBL-producing urinary pathogen. We abstracted details of clinical management and known previous risk factors, including prior neonatal intensive care unit hospitalization stay, prior UTI caused by an ESBL-producing organism, and known urologic abnormalities. RESULTS: Forty-five UTIs caused by ESBL-producing organisms occurred in 43 patients (mean age of 5.9 months and 59% female)-ESBL Escherichia coli represented the majority (42/45). The incidence of UTIs caused by ESBL-producing organisms ranged from 0.9% to 4.5% during the 5-year study period. The 13 patients (26%) admitted from the ED were significantly younger than discharged patients (1.9 vs 6.7 months, P = 0.016) and more likely to have had prior neonatal intensive care unit hospitalizations (50% vs 15.6%, P = 0.0456). Of the 33 visits (77%) resulting in initial outpatient management, 5 were followed by readmission for parenteral antibiotic treatment. Of those who were readmitted, 40% (n = 2) were afebrile at the time of admission. The remainder (28/33) completed outpatient oral antibiotic courses guided by susceptibilities. Two patients (4%) had negative repeat urine cultures despite in vitro resistance to initial antibiotic coverage. CONCLUSIONS: Extended spectrum ß-lactamase-producing organisms are an increasing cause of UTIs in infants presenting at a pediatric ED, and outpatient management may be reasonable for infants older than 2 months.

Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department.

OBJECTIVES: Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED. METHODS: We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment. RESULTS: In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97). CONCLUSIONS: Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.

Tablet Computer as a Distraction Tool During Facial Laceration Repair: A Randomized Trial.

OBJECTIVES: Child life interventions reduce the anxiety of medical procedures but are not always available in emergency departments. In this study, we determined the effect of parent-directed tablet computer use without child life direction on patient anxiety and on parent and suturing clinician experience during pediatric facial laceration repair. METHODS: In a children's hospital emergency department, we enrolled children 2 to 12 years of age undergoing unsedated facial laceration repairs and randomized them to parent-directed tablet computer distraction or standard supportive care. We measured anxiety using the Observational Scale of Behavioral Distress-Revised (OSBD-R) for 5 procedure phases from videotaped laceration repairs. We compared OSBD-R scores for 5 phases and weighted averages between the tablet and standard care groups. Parents and suturing clinicians completed surveys about their experiences after the procedures. RESULTS: From April 2014 to July 2015, 77 patients (39 tablet, 38 standard) underwent repairs. Age, use of restraint, procedure duration, and number of sutures were similar between the 2 groups. The groups did not differ in procedure phase or weighted-average OSBD-R scores. Parents in the tablet group reported less personal anxiety compared with parents in the standard group (P = 0.01). In a post hoc subgroup analysis, subjects in the unrestrained tablet group had lower OSBD-R scores during the anesthetic injection phase than did subjects in the unrestrained standard group (P = 0.04). If restrained, subjects in the tablet group had higher OSBD-R scores during the anesthetic injection phase than did subjects in the standard group (P = 0.048). CONCLUSIONS: Unrestrained children may benefit from parent-directed tablet computer distraction. Parents who operate the device are less anxious during their children's procedures.

Comparison of pediatric post-reduction fluoroscopic- and ultrasound forearm fracture images.

OBJECTIVE: Emergency department (ED) reduction of pediatric fractures occurs most commonly in the forearm and can be challenging if fluoroscopy is not available. We sought to assess the ability of point of-care ultrasonography (POCUS) to predict adequacy of reduction by fluoroscopy. METHODS: We prospectively enrolled ED patients 0-17 years of age with radial and/or ulnar fractures requiring reduction under fluoroscopic guidance. Post-reduction POCUS (probe dorsal, volar, and coronal) and fluoroscopic (AP and lateral) fracture images were recorded. Fracture angles were compared between blinded POCUS and fluoroscopic measurements and between POCUS measurements by a blinded emergency physician and a blinded radiologist, reporting mean differences and 95% confidence intervals. We calculated sensitivity, specificity, and likelihood ratios of POCUS in the prediction of fluoroscopically detected post-reduction malalignment, as interpreted by a blinded pediatric orthopaedist. RESULTS: The 58 patients were 7.9 ±â€¯3.5 years of age and had 21 radial (36%), 1 ulnar (2%), and 36 radioulnar (62%) fractures. Fluoroscopy and POCUS angles were within a mean of 0.1°-3.2°, depending on the site and surface measured. Radiologist- and emergency physician-interpreted POCUS measurements were within a mean of 1° in all dimensions. POCUS identified inadequate reductions with 100% sensitivity and 92-93% specificity. CONCLUSIONS: Blinded emergency medicine and radiology interpretations of post-reduction POCUS fracture images agree closely. Post-reduction POCUS measurements are comparable to those obtained by fluoroscopy and accurately predict adequacy of reduction. POCUS can be used to guide pediatric fracture reduction when bedside fluoroscopy is not available in the ED.

A Specialized Pediatric Emergency Medicine Track Decreases Computed Tomography in Head Injured Patients.

BACKGROUND: There is an increased emphasis on reducing exposure to ionizing radiation in pediatric patients. Guidelines from the Pediatric Emergency Care Applied Research Network help practitioners identify patients at low risk for clinically important traumatic brain injury after head injury. OBJECTIVES: We seek to determine whether the institution of a pediatric track staffed by pediatric emergency medicine physicians (PEMs) within a community emergency department (ED) impacts the overall utilization of head computed tomography (CT) on children younger than 15 years with head injury. METHODS: We used a retrospective cohort analysis of patients under the age of 15 years presenting to a community ED in the year before and the year of institution of a pediatric emergency track. Relative risk estimates were used to determine the risk of CT use associated with nonpediatric-trained emergency providers. RESULTS: The community ED saw 11,094 patients and 14,639 patients younger than 15 years in fiscal years 2014-2015 and 2015-2016, respectively. In the year before PEMs, there were 312 children younger than 15 years seen for head injury; 47.09% received head CTs. After PEM coverage, there were 396 children younger than 15 years seen for head injury; 17.17% received head CTs. Pediatric patients with head injury were 2.2 times more likely to receive CTs before the institution of the pediatric track (95% confidence interval, 1.8-2.6). CONCLUSION: The implementation of a pediatric emergency track demonstrated a significant decrease in CT utilization for head injury. Continued development of pediatric tracks in community EDs can lead to reduction of CTs.

The Impact of Behavioral Health Patients on a Pediatric Emergency Department's Length of Stay and Left Without Being Seen.

OBJECTIVE: Emergency department (ED) boarding of admitted patients negatively impacts ED length of stay (LOS). Behavioral health (BH) patients are often challenging to safely discharge. We examined the association between daily BH census and non-BH LOS and left without being seen (LWBS) rates. METHODS: Retrospective analysis of BH and non-BH patients at a high-volume tertiary care pediatric ED from December 2014 to June 2016 examined the association between BH patients and non-BH LOS and LWBS rates. Behavioral health patients were identified by presence of social work assessment and BH chief complaint and/or final diagnosis. Data were analyzed using 1-sample test of proportions, Student t test, Spearman and Pearson correlations, logistic regression, and odds ratios with 95% confidence intervals. RESULTS: A total of 143,141 patients were seen, 3% (n = 4351) for BH presentations. Median LOS for discharged non-BH patients was 128 minutes compared with 446 minutes for BH patients. Daily LOS and bed hold hours were significantly longer for BH than for non-BH patients (P < 0.0001 for each analysis). After adjusting for ED census, daily BH census was significantly associated with increasing LWBS rates and non-BH LOS. CONCLUSIONS: Behavioral health census and bed hold hours were significantly associated with increased LOS and LWBS rates and with our inability to meet desired LOS and LWBS rates. These associations support the existence of a threshold where the ED has reached capacity and is no longer able to absorb BH patients. Improving BH facility access may help improve overall pediatric ED patient care.

The Effect of COVID-19 Lockdown on PHQ Depression Screening Scores for High School Athletes.

Adolescent behavioral health was in crisis before COVID-19. The shutdown and reopening of in-person learning and extracurricular activities may have worsened this crisis. We examined high school athletes' depression before and during the pandemic. Data were collected as part of a pilot program incorporating Patient Health Questionnaire (PHQ) screenings during high school sports physicals before the COVID-19 lockdown and three timepoints after. Statistical comparisons were made using logistic regression. A total of 927 individual scores were analyzed: 385 from spring 2020; 145 from fall 2020; 163 from fall 2021; and 234 from spring 2022. Fall 2020 students were 3.7 times more likely to have elevated PHQ-2 scores than spring 2020 students (95% CI = 1.8, 7.6). Fall 2021 and spring 2022 scores did not differ significantly from pre-pandemic, although trends of elevated scores persisted (OR = 1.6; 95% CI = 0.7, 3.5, and OR = 1.2; 95% CI = 0.6, 2.4, respectively). A significant difference in PHQ-9 depression severity classification was detected over time (p < 0.01). Elevated PHQ scores were found after the onset of the COVID-19 pandemic. After the initial peak in fall 2020, scores decreased but did not reach pre-pandemic levels.

Reducing Opioid Doses Prescribed From a Pediatric Emergency Department.

BACKGROUND: Opioid overdose and abuse have reached epidemic rates in the United States. Medical prescriptions are a large source of opioid misuse. Our quality improvement initiative aimed to reduce opioid exposure from the pediatric emergency department (ED). Objective was to reduce opioid doses prescribed weekly from our ED by 50% within 4 months. METHODS: Three categories of interventions were implemented in Plan-Do-Study-Act cycles: guidelines and education, electronic medical record optimization, and provider-specific feedback. Primary measures were opioid doses prescribed weekly from the ED and opioid doses per 100 ED visits. Process measures were opioid prescriptions, opioid doses per prescription, and opioid prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection. Balancing measures were phone calls and return visits for poor pain control in patients prescribed opioids and reports of poor pain control in call backs to orthopedic reduction patients. We used statistical process control to examine changes in measures over time. RESULTS: Opioid doses decreased from 153 to 14 per week and from 8 to 0.7 doses per 100 ED visits in 10 months, sustained for 9 months. Opioid prescriptions, opioid doses per prescription, and prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection decreased. Phone calls and return visits in patients prescribed opioids did not increase. There were 2 reports of poor pain control among 152 orthopedic reduction patients called back. CONCLUSIONS: We decreased opioid doses prescribed weekly from the pediatric ED by 91% while minimizing return visits and reports of poor pain control.

Patterns of Stress, Coping and Health-Related Quality of Life in Doctor of Pharmacy Students.

Objective. To examine perceived stress, coping strategies, and health-related quality of life in Doctor of Pharmacy students across the first three years (pre-clinical portion) of the curriculum. Methods. Three instruments, the Perceived Stress Scale, Brief COPE, and Short Form-36, were administered to students three times a year over a five-year period. Median annual scores were compared using Skillings-Mack tests and correlations were assessed using Spearman correlation. Results. One hundred forty-five students (approximately 46% of the school's enrollment) participated. A significant increase in scores on the PSS, increase in students' maladaptive coping behaviors, and worsening mental health-related quality of life were detected in students across the first three years of the pre-clinical curriculum. The PSS scores of first- and second-year pharmacy students had a moderate to large positive correlation with maladaptive coping behaviors (rho = 0.43 and 0.58, respectively) and PSS scores exhibited a large negative correlation with maladaptive coping behaviors in all three years of the pre-clinical curriculum (rho ranged from -0.69 to -0.78). Conclusion. Increasing levels of stress, increasing use of maladaptive coping strategies, and declining mental health-related quality of life among pharmacy students across the first three years of the four-year curriculum were very similar to findings in the cohort of pharmacy students observed in the preceding five years.

Trends in carisoprodol abuse and misuse after regulatory scheduling: a retrospective review of California poison control calls from 2008 to 2015.

BACKGROUND: In January 2012, carisoprodol was classified as a Schedule IV substance under the controlled substances act from a previously non-controlled, non-scheduled classification. Carisoprodol is marketed as a skeletal muscle relaxant and is commonly cited for its abuse potential. OBJECTIVES: We aimed to compare volume of calls involving carisoprodol abuse or misuse to a statewide poison control system before and after the scheduling change. METHODS: Data were extracted from poison control calls coded as "misuse/abuse" involving carisoprodol from four years before (2008 to 2011) and four years after (2012 to 2015) the scheduling change. The volume of calls from pre- and post-scheduling change was compared after adjusting for yearly California census data. RESULTS: The number of calls related to carisoprodol abuse or misuse was significantly decreased in the four years following the change compared to the four years before. CONCLUSION: Scheduling of carisoprodol was temporally related to decreased exposures as reported to California Poison Control Centers. Governmental regulation may impact a drug's potential for abuse.

Validation of the WHI brief physical activity questionnaire among women diagnosed with breast cancer.

OBJECTIVE: To investigate the psychometric properties of the physical activity (PA) measure of the Women's Health Initiative (WHI). METHODS: Women diagnosed with breast cancer and enrolled in the Women's Healthy Eating and Living Study (average age 55 years) wore an accelerometer for 1 week and completed the 7-day Physical Activity Recall (PAR) and brief WHI measure. RESULTS: Both self-reports correlated 0.73 with the accelerometer and had 100% sensitivity for meeting the current PA guideline, but specificity was significantly higher for the PAR. CONCLUSIONS: The WHI measure had comparable validity, sensitivity, and measurement bias compared to the widely accepted PAR.

Effects of a high-fiber, low-fat diet intervention on serum concentrations of reproductive steroid hormones in women with a history of breast cancer.

PURPOSE: Diet intervention trials are testing whether postdiagnosis dietary modification can influence breast cancer recurrence and survival. One possible mechanism is an effect on reproductive steroid hormones. PARTICIPANTS AND METHODS: Serum reproductive steroid hormones were measured at enrollment and 1 year in 291 women with a history of breast cancer who were enrolled onto a randomized, controlled diet intervention trial. Dietary goals for the intervention group were increased fiber, vegetable, and fruit intakes and reduced fat intake. Estradiol, bioavailable estradiol, estrone, estrone sulfate, androstenedione, testosterone, dehydroepiandrosterone sulfate, follicle-stimulating hormone, and sex hormone-binding globulin were measured. RESULTS: The intervention (but not the comparison) group reported a significantly lower intake of energy from fat (21% v 28%), and higher intake of fiber (29 g/d v 22 g/d), at 1-year follow-up (P <.001). Significant weight loss did not occur in either group. A significant difference in the change in bioavailable estradiol concentration from baseline to 1 year in the intervention (-13 pmol/L) versus the comparison (+3 pmol/L) group was observed (P <.05). Change in fiber (but not fat) intake was significantly and independently related to change in serum bioavailable estradiol (P <.01) and total estradiol (P <.05) concentrations. CONCLUSION: Results from this study indicate that a high-fiber, low-fat diet intervention is associated with reduced serum bioavailable estradiol concentration in women diagnosed with breast cancer, the majority of whom did not exhibit weight loss. Increased fiber intake was independently related to the reduction in serum estradiol concentration.

The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment.

BACKGROUND: Controversy remains over the ideal way to transport penetrating trauma victims in an urban environment. Both advance life support (ALS) and basic life support (BLS) transports are used in most urban centers. METHODS: A retrospective cohort study was conducted at an urban Level I trauma center. Victims of penetrating trauma transported by ALS, BLS, or police from January 1, 2008, to November 31, 2013, were identified. Patient survival by mode of transport and by level of care received was analyzed using logistic regression. RESULTS: During the study period, 1,490 penetrating trauma patients were transported by ALS (44.8%), BLS (15.6%), or police (39.6%) personnel. The majority of injuries were gunshot wounds (72.9% for ALS, 66.8% for BLS, 90% for police). Median transport minutes were significantly longer for ALS (16 minutes) than for BLS (14.5 minutes) transports (p = 0.012). After adjusting for transport time and Injury Severity Score (ISS), among victims with an ISS of 0 to 30, there was a 2.4-fold increased odds of death (95% confidence interval [CI], 1.3-4.4) if transported by ALS as compared with BLS. With an ISS of greater than 30, this relationship did not exist (odds ratio, 0.9; 95% CI, 0.3-2.7). When examined by type of care provided, patients with an ISS of 0 to 30 given ALS support were 3.7 times more likely to die than those who received BLS support (95% CI, 2.0-6.8). Among those with an ISS of greater than 30, no relationship was evident (odds ratio, 0.9; 95% CI, 0.3-2.7). CONCLUSION: Among penetrating trauma victims with an ISS of 30 or lower, an increased odds of death was identified for those treated and/or transported by ALS personnel. For those with an ISS of greater than 30, no survival advantage was identified with ALS transport or care. Results suggest that rapid transport may be more important than increased interventions. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Students' health-related quality of life across the preclinical pharmacy curriculum.

OBJECTIVES: To examine health related quality of life (HRQOL), perceived stress, and coping skills in the 3 preclinical years of a doctor of pharmacy (PharmD) curriculum. METHODS: Health-related quality of life, perceived stress, and coping strategies were measured using the Short Form-36, Perceived Stress Scale, and Brief COPE. Average annual scores were compared across curriculum years. RESULTS: Two hundred thirteen students enrolled in the study. Entering students had physical and mental HRQOL scores that were similar to age-adjusted US norms. Mental HRQOL scores were significantly lower and stress significantly higher during the second year of the PharmD curriculum compared to the first year (p < 0.05). Lower mental HRQOL scores were associated with increased stress and use of maladaptive coping skills in all years of the curriculum. CONCLUSION: Increased stress and reduced mental HRQOL were observed across the first 3 years of a PharmD curriculum. Methods to reduce stress and/or use of maladaptive coping skills are needed to improve students' HRQOL throughout the pharmacy curriculum.

Parental artistic drawings of the fetus before and after 3-/4-dimensional ultrasonography.

OBJECTIVE: The purpose of this study was to assess the impact of 3-/4-dimensional ultrasonography (3D/4DUS) on parental impressions of their fetus using preexamination and postexamination parental drawings. METHODS: One hundred one parents (32 male and 69 female) were asked to draw pictures of their fetus immediately before and after undergoing 3D/4DUS. A drawing assessment instrument was used to evaluate the fetal anatomy by 4 reviewers. Overall descriptive quality and a comparison of before and after images were assessed. RESULTS: Reviewers judged the drawings as significantly different in 23% to 56% of cases, slightly different in 41% to 64%, and having no significant difference in 2% to 22%; some difference was identified in at least 78%. Reviewers familiar with ultrasonography were able to correctly predict which picture was drawn first in 78%. Differences identified were related to extremity positioning, personalized uterine environment, and artistic nature. No significant difference in the overall total scoring for anatomic differentiation before and after 3D/4DUS was found. A trend in drawing less anatomic structures after 3D/4DUS was discovered. Significantly fewer people drew hair after 3D/4DUS (P<.01) even when they had drawn hair before the 3D/4DUS. Similar significant differences were seen for the lower extremities (P<.01), with less detail being presented after the 3D/4DUS. CONCLUSIONS: Differences were seen between drawings made before and after 3D/4DUS by parents. Drawings after 3D/4DUS emphasized structures seen during the 3D/4DUS examination and were more reality based, whereas drawings before 3D/4DUS were more iconographic and based on preconceived anatomic knowledge.

Diet and biomarkers of oxidative damage in women previously treated for breast cancer.

This study sought to evaluate the relationship between dietary intake of fat, polyunsaturated fat, saturated fat, arachidonic acid, and selected dietary antioxidants and levels of oxidative damage as measured by urinary levels of 8-hydroxy-2'-deoxyguanosine (8-OHdG) and 8-epi-prostaglandin F2alpha (8-iso-PGF2alpha) in women previously treated for breast cancer. Two hundred two study subjects participating in the Women's Healthy Eating and Living (WHEL) study were included in this ancillary study. Dietary intakes and concentrations of urinary 8-OHdG and 8-iso-PGF2alpha were measured at baseline and 12 mo in the 179 women included in the analytical cohort. Study subjects demonstrated a significant reduction in dietary total, polyunsaturated, and saturated fat intake and a significant increase in vitamins E and C and beta-carotene intake from baseline to 12 mo. Linear mixed-models analysis using baseline and Year 1 data indicated that vitamin E intake was inversely associated with both 8-OHdG and 8-iso-PGF2alpha. 8-Iso-PGF2alpha is increased with increased body mass index (BMI) and polyunsaturated fatty acid (PUFA) intake, indicating an increase in lipid peroxidation with greater BMI and higher PUFA intake. 8-OHdG was inversely related to age but positively related to arachidonic acid, indicating an increase in DNA damage with higher intake of arachidonic acid (meat). The results of this nested case-controlled study provide potential mechanisms by which a high fruit and vegetable, low-fat diet might reduce the recurrence rate of or early-stage breast cancer.

Telephone counseling intervention increases intakes of micronutrient- and phytochemical-rich vegetables, fruit and fiber in breast cancer survivors.

Although a large body of evidence suggests that diet may play an important role in cancer prevention, randomized controlled trials reported to date have not achieved sufficient increases in protective micronutrients and phytochemicals to adequately test the hypothesis that diet can reduce cancer risk. The Women's Healthy Eating and Living (WHEL) Study, a randomized controlled trial of the role diet modification may play in future breast cancer events, introduced an innovative theory-based telephone counseling intervention to teach participants to consume a high fiber, low fat diet emphasizing vegetables and fruits rich in carotenoids and other potentially protective phytochemicals. This report examines the baseline to 12-mo changes in dietary intakes of 2970 participants, assessed through 24-h recalls and validated with plasma carotenoid concentrations. At 12 mo, the intervention group reported a significantly increased daily vegetable intake (+vegetable juice) of 7.1 servings (+82%) and fruit intake of 3.9 servings (+18%). Fiber intake increased from 3.04 to 4.16 g/(MJ. d), whereas energy from fat decreased significantly from 28.6 to 23.7%. Plasma carotenoid concentrations increased significantly, i.e., alpha-carotene (+223%); beta-carotene (+87%); lutein (+29%); and lycopene (+17%). In the comparison group, dietary intake and plasma carotenoid concentrations were essentially identical to those of the intervention group at baseline and were unchanged at 12 mo. The WHEL Study showed that a telephone counseling intervention can achieve major increases in micronutrient- and phytochemical-rich vegetables, fruit and fiber intakes, enabling an investigation of the potential cancer preventive effects of these food components.