Letermovir prophylaxis for cytomegalovirus reactivation in allogeneic hematopoietic cell transplant recipients: Single center Canadian data.

BACKGROUND: Cytomegalovirus (CMV) is associated with morbidity and mortality following allogeneic hematopoietic cell transplantation (alloHCT). Letermovir is a novel antiviral agent that prevents CMV reactivation in alloHCT patients, with limited data regarding influence on post-alloHCT outcomes. METHODS: We retrospectively examined 273 alloHCT recipients, 158 in the non-letermovir cohort (NLC), and 115 in the cohort using letermovir prophylaxis (LC). Patients that received letermovir were CMV-seropositive and met criteria for high risk of CMV reactivation. RESULTS: Median start of letermovir was 21 days post-alloHCT, median duration of prophylaxis was 86 days. Letermovir prophylaxis demonstrated a statistically significant reduction in first CMV reactivation (at 200 days post 63.9% in the NLC vs. 35.7% in the LC; p < .001). On univariate analysis at 1 year, overall survival (OS) for NLC was 79.6% and 79.5% for LC (p = .54). Non relapse mortality (NRM) at 1 year for NLC was 12% and 12.3% for LC (p = .69). Cumulative incidence of relapse (CIR) at 1 year was 13.9% for NLC versus 17.1 for the LC (p = .27). On multivariable analysis, there was no significant difference between the two cohorts for OS, NRM, and CIR. CONCLUSIONS: Letermovir prophylaxis started at day +21 post-alloHCT reduced CMV reactivation, with no impact on posttransplant outcomes.

Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter?

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.

Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics.

PURPOSE: To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. METHODS: We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals. RESULTS: Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. CONCLUSIONS: Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

Defining Longer-Term Outcomes in an Ovine Model of Moderate Perinatal Hypoxia-Ischemia.

Hypoxic-ischemic encephalopathy (HIE) is the leading cause of neonatal morbidity and mortality worldwide. Approximately 1 million infants born with HIE each year survive with cerebral palsy and/or serious cognitive disabilities. While infants born with mild and severe HIE frequently result in predictable outcomes, infants born with moderate HIE exhibit variable outcomes that are highly unpredictable. Here, we describe an umbilical cord occlusion (UCO) model of moderate HIE with a 6-day follow-up. Near-term lambs (n = 27) were resuscitated after the induction of 5 min of asystole. Following recovery, lambs were assessed to define neurodevelopmental outcomes. At the end of this period, lambs were euthanized, and brains were harvested for histological analysis. Compared with prior models that typically follow lambs for 3 days, the observation of neurobehavioral outcomes for 6 days enabled identification of animals that recover significant neurological function. Approximately 35% of lambs exhibited severe motor deficits throughout the entirety of the 6-day course and, in the most severely affected lambs, developed spastic diparesis similar to that observed in infants who survive severe neonatal HIE (severe, UCOs). Importantly, and similar to outcomes in human neonates, while initially developing significant acidosis and encephalopathy, the remainder of the lambs in this model recovered normal motor activity and exhibited normal neurodevelopmental outcomes by 6 days of life (improved, UCOi). The UCOs group exhibited gliosis and inflammation in both white and gray matters, oligodendrocyte loss, neuronal loss, and cellular death in the hippocampus and cingulate cortex. While the UCOi group exhibited more cellular death and gliosis in the parasagittal cortex, they demonstrated more preserved white matter markers, along with reduced markers of inflammation and lower cellular death and neuronal loss in Ca3 of the hippocampus compared with UCOs lambs. Our large animal model of moderate HIE with prolonged follow-up will help further define pathophysiologic drivers of brain injury while enabling identification of predictive biomarkers that correlate with disease outcomes and ultimately help support development of therapeutic approaches to this challenging clinical scenario.

Continuous chest compressions with asynchronous ventilations increase carotid blood flow in the perinatal asphyxiated lamb model.

BACKGROUND: The neonatal resuscitation program (NRP) recommends interrupted chest compressions (CCs) with ventilation in the severely bradycardic neonate. The conventional 3:1 compression-to-ventilation (C:V) resuscitation provides 90 CCs/min, significantly lower than the intrinsic newborn heart rate (120-160 beats/min). Continuous CC with asynchronous ventilation (CCCaV) may improve the success of return of spontaneous circulation (ROSC). METHODS: Twenty-two near-term fetal lambs were randomized to interrupted 3:1 C:V (90 CCs + 30 breaths/min) or CCCaV (120 CCs + 30 breaths/min). Asphyxiation was induced by cord occlusion. After 5 min of asystole, resuscitation began following NRP guidelines. The first dose of epinephrine was given at 6 min. Invasive arterial blood pressure and left carotid blood flow were continuously measured. Serial arterial blood gases were collected. RESULTS: Baseline characteristics between groups were similar. Rate of and time to ROSC was similar between groups. CCCaV was associated with a higher PaO2 (partial oxygen tension) (22 ± 5.3 vs. 15 ± 3.5 mmHg, p < 0.01), greater left carotid blood flow (7.5 ± 3.1 vs. 4.3 ± 2.6 mL/kg/min, p < 0.01) and oxygen delivery (0.40 ± 0.15 vs. 0.13 ± 0.07 mL O2/kg/min, p < 0.01) compared to 3:1 C:V. CONCLUSIONS: In a perinatal asphyxiated cardiac arrest lamb model, CCCaV showed greater carotid blood flow and cerebral oxygen delivery compared to 3:1 C:V resuscitation. IMPACT: In a perinatal asphyxiated cardiac arrest lamb model, CCCaV improved carotid blood flow and oxygen delivery to the brain compared to the conventional 3:1 C:V resuscitation. Pre-clinical studies assessing neurodevelopmental outcomes and tissue injury comparing continuous uninterrupted chest compressions to the current recommended 3:1 C:V during newborn resuscitation are warranted prior to clinical trials.

Randomized trial of oxygen weaning strategies following chest compressions during neonatal resuscitation.

BACKGROUND: The Neonatal Resuscitation Program (NRP) recommends using 100% O2 during chest compressions and adjusting FiO2 based on SpO2 after return of spontaneous circulation (ROSC). The optimal strategy for adjusting FiO2 is not known. METHODS: Twenty-five near-term lambs asphyxiated by umbilical cord occlusion to cardiac arrest were resuscitated per NRP. Following ROSC, lambs were randomized to gradual decrease versus abrupt wean to 21% O2 followed by FiO2 titration to achieve NRP SpO2 targets. Carotid blood flow and blood gases were monitored. RESULTS: Three minutes after ROSC, PaO2 was 229 ± 32 mmHg in gradual wean group compared to 57 ± 13 following abrupt wean to 21% O2 (p < 0.001). PaO2 remained high in the gradual wean group at 10 min after ROSC (110 ± 10 vs. 67 ± 12, p < 0.01) despite similar FiO2 (~0.3) in both groups. Cerebral O2 delivery (C-DO2) was higher above physiological range following ROSC with gradual wean (p < 0.05). Lower blood oxidized/reduced glutathione ratio (suggesting less oxidative stress) was observed with abrupt wean. CONCLUSION: Weaning FiO2 abruptly to 0.21 with adjustment based on SpO2 prevents surge in PaO2 and C-DO2 and minimizes oxidative stress compared to gradual weaning from 100% O2 following ROSC. Clinical trials with neurodevelopmental outcomes comparing post-ROSC FiO2 weaning strategies are warranted. IMPACT: In a lamb model of perinatal asphyxial cardiac arrest, abrupt weaning of inspired oxygen to 21% prevents excessive oxygen delivery to the brain and oxidative stress compared to gradual weaning from 100% oxygen following return of spontaneous circulation. Clinical studies assessing neurodevelopmental outcomes comparing abrupt and gradual weaning of inspired oxygen after recovery from neonatal asphyxial arrest are warranted.

Access to after-hours primary care: a key determinant of children's medical home status.

BACKGROUND: The medical home (MH) model has been promoted by both the federal and state governments in the United States in recent years. To ascertain American children's MH status, many studies have relied on a large set of survey items, posing a considerable burden on their parents. We aimed to identify individual survey items or domains that best predict MH status for children and use them to develop brief markers of MH status. We also examined whether the identified items differed by status of special health care needs and by racial/ethnic group. METHOD: Using the 9-year data from Medical Expenditure Panel Survey, we examined associations between children's MH status and individual survey items or domains. We randomly split the data into two halves with the first half (training sample, n = 8611) used to identify promising items, and the second half (validation sample, n = 8779) used to calculate all statistical measures. After discovering significant predictors of children's MH status, we incorporated them into several brief markers of MH status. We also conducted stratified analyses by status of special health care needs and by racial/ethnic group. RESULTS: Less than half (48.7%) of the 8779 study children had a MH. The accessibility domain has stronger association with children's MH status (specificity = 0.84, sensitivity = 1, Kappa = 0.83) than other domains. The top two items with the strongest association with MH status asked about after-hours primary care access, including doctors' office hours at night or on the weekend and children's difficulty accessing care after hours. Both belong to the accessibility domain and are one of several reliable markers for children's MH status. While each of the two items did not differ significantly by status of special health care needs, there were considerable disparities across racial/ethnic groups with Latino children lagging behind other children. CONCLUSION: Accessibility, especially the ability to access health care after regular office hours, appears to be the major predictor of having a MH among children. The ongoing efforts to promote the MH model need to target improving accessibility of health care after regular hours for children overall and especially for Latino children.

Factors Influencing Physician Practices' Adoption of Behavioral Health Integration in the United States: A Qualitative Study.

BACKGROUND: Behavioral health integration is uncommon among U.S. physician practices despite recent policy changes that may encourage its adoption. OBJECTIVE: To describe factors influencing physician practices' implementation of behavioral health integration. DESIGN: Semistructured interviews with leaders and clinicians from physician practices that adopted behavioral health integration, supplemented by contextual interviews with experts and vendors in behavioral health integration. SETTING: 30 physician practices, sampled for diversity on specialty, size, affiliation with parent organizations, geographic location, and behavioral health integration model (collaborative or co-located). PARTICIPANTS: 47 physician practice leaders and clinicians, 20 experts, and 5 vendors. MEASUREMENTS: Qualitative analysis (cyclical coding) of interview transcripts. RESULTS: Four overarching factors affecting physician practices' implementation of behavioral health integration were identified. First, practices' motivations for integrating behavioral health care included expanding access to behavioral health services, improving other clinicians' abilities to respond to patients' behavioral health needs, and enhancing practice reputation. Second, practices tailored their implementation of behavioral health integration to local resources, financial incentives, and patient populations. Third, barriers to behavioral health integration included cultural differences and incomplete information flow between behavioral and nonbehavioral health clinicians and billing difficulties. Fourth, practices described the advantages and disadvantages of both fee-for-service and alternative payment models, and few reported positive financial returns. LIMITATION: The practice sample was not nationally representative and excluded practices that did not implement or sustain behavioral health integration, potentially limiting generalizability. CONCLUSION: Practices currently using behavioral health integration face cultural, informational, and financial barriers to implementing and sustaining behavioral health integration. Tailored, context-specific technical support to guide practices' implementation and payment models that improve the business case for practices may enhance the dissemination and long-term sustainability of behavioral health integration. PRIMARY FUNDING SOURCE: American Medical Association and The Commonwealth Fund.

Differences in Physician Income by Gender in a Multiregion Survey.

BACKGROUND: Previous studies have documented income differences between male and female physicians. However, the implications of these differences are unclear, since previous studies have lacked detailed data on the quantity and composition of work hours. We sought to identify the sources of these income differences using data from a novel survey of physician work and income. OBJECTIVE: To compare differences in income between male and female physicians. DESIGN: We estimated unadjusted income differences between male and female physicians. We then adjusted these differences for total hours worked, composition of work hours, percent of patient care time spent providing procedures, specialty, compensation type, age, years in practice, race, ethnicity, and state and practice random effects. PARTICIPANTS: We surveyed 656 physicians in 30 practices in six states and received 439 responses (67% response rate): 263 from males and 176 from females. MAIN MEASURE: Self-reported annual income. KEY RESULTS: Male physicians had significantly higher annual incomes than female physicians (mean $297,641 vs. $206,751; difference $90,890, 95% CI $27,769 to $154,011) and worked significantly more total hours (mean 2470 vs. 2074; difference 396, 95% CI 250 to 542) and more patient care hours (mean 2203 vs. 1845; difference 358, 95% CI 212 to 505) per year. Male physicians were less likely than female physicians to specialize in primary care (49.1 vs. 70.5%), but more likely to perform procedures with (33.1 vs. 15.5%) or without general anesthesia (84.3 vs. 73.1%). After adjustment, male physicians' incomes were $27,404 (95% CI $3120 to $51,688) greater than female physicians' incomes. CONCLUSIONS: Adjustment for multiple possible confounders, including the number and composition of work hours, can explain approximately 70% of unadjusted income differences between male and female physicians; 30% remains unexplained. Additional study and dedicated efforts might be necessary to identify and address the causes of these unexplained differences.

On the Value of the Umbilical Cord Blood Supply.

BACKGROUND: Several public cord blood banks are struggling financially, and the question remains as to whether additional allocations of funds to them are justified. OBJECTIVES: To estimate the social benefits of public cord blood bank inventory net of cord blood banks' operational costs. METHODS: We used publicly available data from the Health Resources and Service Administration on the number of annual cord blood transplants as well as the patient age distribution in 2010, and the survival estimates between 2008 and 2012 for the several diseases treated by cord blood transplantation. Data on aggregate annual costs to the cord blood industry for recruitment, processing, and storage were obtained from published work. We used estimated increases in life expectancy due to treatment using umbilical cord blood and value for life-years gained to estimate the social benefits of the public cord blood inventory annually. RESULTS: We found that the annual social benefits of between $500 million and $1.5 billion outweigh the current operational annual costs of running cord blood banks of $60 to $70 million by a significant margin. CONCLUSIONS: We estimated that the annual social benefit of having a cord blood system far outweighs its costs, by more than an order of magnitude. Thus, the social benefits of maintaining the US public cord blood banking system at the present time far outweigh the costs of collecting, storing, and distributing cord blood. This suggests that there is a potential justification for government intervention to align social benefits and costs. Nevertheless, simple fixes may produce unintended consequences, and so a careful design for subsidies is needed.

Bupivacaine as an Adjunct to Lidocaine in Mohs Micrographic Surgery: A Prospective Randomized Controlled Trial.

BACKGROUND: In Mohs micrographic surgery (MMS), the standard local anesthetic agent used is lignocaine with adrenaline. However, MMS can be prolonged; thus reinjections of local anesthetics are often required. OBJECTIVE: Is 0.5% bupivacaine with 1:200,000 epinephrine a useful adjunctive treatment when compared with the use of 1% lidocaine with 1:100,000 epinephrine in MMS for the nose? METHODS: Participants undergoing MMS received 2.5 mL of 1% lidocaine with 1:100,000 epinephrine before commencement of Stage 1. At the end of Stage 1, participants were randomized sequentially to either 2.5 mL 0.5% bupivacaine with 1:200,000 epinephrine (Group A) or 2.5 mL of 1% lidocaine with 1:100,000 epinephrine (Group B). Effectiveness of anesthesia was assessed using 30 G needle to 5 points of the wound before further stage or repair. RESULTS: Fifty-one patients were randomized, 26 to Group A, and 25 to Group B. No differences between the 2 groups in size of defect and time lapse between time of injection and time of testing were observed. Seven of 25 were tested positive in Group B. Zero of 26 tested positive in Group A (p = .003, 95% confidence interval: 10%-46%). CONCLUSION: Adjunctive use of 0.5% bupivacaine with 1:200,000 epinephrine is effective in prolonging anesthesia in MMS.

Impact of bariatric surgery on serum urate targets in people with morbid obesity and diabetes: a prospective longitudinal study.

OBJECTIVES: Weight loss leads to reduced serum urate (SU) in people with obesity. However, the clinical relevance of such reductions in SU is unknown. This study examined the impact of non-surgical weight loss and bariatric surgery on SU targets in people with morbid obesity and diabetes. METHODS: The study was a single-centre, prospective study of 60 people with type 2 diabetes and body mass index ≥35 kg/m(2). Following 6 months of non-surgical weight loss, all participants had laparoscopic sleeve gastrectomy, with a further 1 year of follow-up. Serial SUs were measured throughout the study. RESULTS: Participants experienced mean (SD) weight loss of 5.5 (4.1) kg prior to surgery and 34.3 (11.1) kg following surgery. SU did not change following non-surgical weight loss (0.38 (0.09) mmol/L at baseline and 0.38 (0.10) mmol/L at follow-up), but increased to 0.44 (0.15) mmol/L in the immediate postoperative period and reduced to 0.30 (0.08) mmol/L 1 year after surgery (p<0.05 for both compared with baseline). Baseline SU, cessation of diuretics, female sex and change in creatinine independently predicted change in SU at the final visit. In participants without gout, SU above saturation levels (≥0.41 mmol/L) were present in 19/48 (40%) at baseline and 1/48 (2%) 1 year after surgery (p<0.0001). In participants with gout, SU above therapeutic target levels (≥0.36 mmol/L) were present in 10/12 (83%) at baseline and 4/12 (33%) 1 year after surgery (p=0.031). CONCLUSIONS: Clinically relevant reductions in SU occur following bariatric surgery in people with diabetes and WHO class II or higher obesity.

Response: effectiveness in primary care is paramount, but need not come at the expense of efficiency.

Effective primary care is vital to sustainable provision of primary care for the US population. However, efficiency and effectiveness go hand-in-hand. Effective care is that which enables a health system to optimize the performance of all care providers while eliminating wasteful practices. If high-quality patient care and strengthened patient-provider relationships are to occur outside of isolated pockets of innovation and spread to the populace as a whole, each primary care physician must work within a system that affords the tools, opportunity, and support needed to optimally manage a growing number of patients with mounting health care needs. The expectation that primary care physicians must come into direct contact with each and every patient, no matter the acuity or chief complaint, no longer meets the expectations of patients or those whom we would attract to enter the field of primary care. We can no longer repair the faults in our primary care workforce by simply increasing the number of providers working in exactly the same way primary care physicians have always worked. A modern workforce will require efficient practices to produce the most effective health care for the population.

Do we really need more physicians? Responses to predicted primary care physician shortages.

Predicted primary care shortages have spurred action to increase the number of primary care physicians. However, simply increasing the number of primary care providers is not the only solution to resolving the imbalance between the supply of primary care physicians and the demand for primary care services. In this point-counterpoint, we highlight the limitations of existing primary care shortage predictions and discuss strategies to deliver primary care services without necessarily increasing the number of primary care physicians for a given population. Innovative solutions can be used to reduce or even eliminate projected primary care shortages while changing the prevailing paradigm of primary care.

Recruitment properties and significance of short latency reflexes in neck and eye muscles evoked by brief lateral head accelerations.

Short lateral head accelerations were applied to investigate the recruitment properties of the reflexes underlying the earliest ocular and cervical electromyographic reflex responses to these disturbances. Components of both reflexes are vestibular dependent and have been termed "ocular vestibular evoked myogenic potentials" and "cervical vestibular evoked myogenic potentials", respectively. Previous investigations using a unilateral vestibular stimulus have indicated that some but not all these vestibular-dependent reflexes show a simple power law relationship to stimulus intensity. In particular, crossed otolith-ocular reflexes showed evidence of an inflection separating two types of behaviour. The present stimulus acts bilaterally, and only the earliest crossed otolith-ocular reflex, previously shown to have a strictly unilateral origin, showed evidence of an inflection. Reflex changes in ocular torsion could, in principle, correct for the changes associated with translation for an elevated eye, but our findings indicated that the responses were consistent with previous reports of tilt-type reflexes. For the neck, both vestibular and segmental (muscle spindle) reflexes were evoked and followed power law relationships, without any clear separation in sensitivity. Our findings are consistent with previous evidence of "tilt-like" reflexes evoked by lateral acceleration and suggest that the departure from a power law occurs as a consequence of a unilateral crossed pathway. For the neck, responses to transients are likely to always consist of both vestibular and non-vestibular (segmental) components. Most of the translation-evoked ocular and cervical reflexes appear to follow power law relationship to stimulus amplitude over a physiological range.

Preteen Suicide Risk Screening in the Pediatric Outpatient Setting: A Clinical Pathway.

We are in a youth mental health crisis with unprecedented and staggeringly high rates of suicidal ideations and suicide behaviors in preteens. In the United States 14.5% of children aged 9-10 have experienced suicidal thoughts and behaviors, including 1.3% with a suicide attempt. American Academy of Pediatrics guidelines call for universal suicide risk screening of youth aged 12+ years during preventative healthcare visits, and screening in preteens aged 8-11 years when clinically indicated. However, what constitutes a clinical indication at 8-11 years can be difficult to systematically detect and pediatric practitioners may not be equipped with necessary age-specific assessment tools. This is compounded by the lack of emphasis on preteen suicide risk screening (and focus on adolescents), which leaves practitioners without age-appropriate resources to make clinical determinations for at-risk preteens. The objective of this project was thus to develop an evidence-informed suicide risk screening pathway for pediatric practitioners to implement with preteen patients in outpatient settings. Suicide risk assessment in younger children (<8 years) is also briefly addressed. We convened a group of researchers and practitioners with expertise in preadolescent suicide, pediatric medicine, behavioral health screening integration with primary care, and child development. They reviewed the empirical literature and existing practice guidelines to iterate on a multi-informant clinical suicide risk screening pathway for preteens that includes both caregivers and preteens in the screening process. We also developed tools and accompanying guidelines for a preteen suicide risk screening workflow and risk determination to aid practitioners in deciding who, when, and how to screen. Finally, we provide scripts for introducing suicide risk screening to caregivers and preteens and to discuss screening findings.

Direct Umbilical Vein Injection of Epinephrine with Cut-Cord Milking in an Ovine Model of Neonatal Resuscitation.

BACKGROUND: An umbilical venous catheter (UVC) is the preferred route of epinephrine administration during neonatal resuscitation but requires specialized equipment, expertise, and time. HYPOTHESIS: Direct injection of epinephrine into the umbilical vein (UV) followed by milking a ~20 cm segment of cut umbilical cord to flush the epinephrine (DUV + UCM) will lead to a quicker administration and earlier return of spontaneous circulation (ROSC) compared with epinephrine given through a UVC. DESIGN: Eighteen near-term asphyxiated lambs were randomized to receive a low-UVC or DUV + UCM of epinephrine at 0.02 or 0.03 mg/kg doses. OUTCOME MEASURES: A total of 16/18 lambs achieved ROSC with a similar mean (±SEM) time to ROSC [DUV + UCM vs. low-UVC (4.67 ± 0.67 vs. 3.99 ± 0.58 min); p = 0.46]. Two out of ten lambs in the DUV + UCM group required UVC placement for additional epinephrine. The administration of the first dose of epinephrine was similar (DUV + UCM-2.97 ± 0.48 vs. UVC-4.23 ± 0.58 min; p = 0.12). Both methods yielded similar epinephrine concentrations (peak concentrations of 253 ± 63 and 328 ± 80 ng/mL for DUV + UCM and UVC EPI, respectively). CONCLUSIONS: DUV + UCM resulted in a ROSC success of 78% following the first epinephrine dose and showed similar epinephrine concentrations to UVC. Clinical studies evaluating DUV + UCM as an alternate route for epinephrine while intravenous access is being established are warranted.

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons.

BACKGROUND: Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. METHODS: The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). RESULTS: Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). CONCLUSIONS: Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

Testing an Intervention to Improve Health Care Worker Well-Being During the COVID-19 Pandemic: A Cluster Randomized Clinical Trial.

Importance: Stress First Aid is an evidence-informed peer-to-peer support intervention to mitigate the effect of the COVID-19 pandemic on the well-being of health care workers (HCWs). Objective: To evaluate the effectiveness of a tailored peer-to-peer support intervention compared with usual care to support HCWs' well-being at hospitals and federally qualified health centers (FQHCs) during the COVID-19 pandemic. Design, Setting, and Participants: This cluster randomized clinical trial comprised 3 cohorts of HCWs who were enrolled from March 2021 through July 2022 at 28 hospitals and FQHCs in the US. Participating sites were matched as pairs by type, size, and COVID-19 burden and then randomized to the intervention arm or usual care arm (any programs already in place to support HCW well-being). The HCWs were surveyed before and after peer-to-peer support intervention implementation. Intention-to-treat (ITT) analysis was used to evaluate the intervention's effect on outcomes, including general psychological distress and posttraumatic stress disorder (PTSD). Intervention: The peer-to-peer support intervention was delivered to HCWs by site champions who received training and subsequently trained the HCWs at their site. Recipients of the intervention were taught to respond to their own and their peers' stress reactions. Main Outcomes and Measures: Primary outcomes were general psychological distress and PTSD. General psychological distress was measured with the Kessler 6 instrument, and PTSD was measured with the PTSD Checklist. Results: A total of 28 hospitals and FQHCs with 2077 HCWs participated. Both preintervention and postintervention surveys were completed by 2077 HCWs, for an overall response rate of 28% (41% at FQHCs and 26% at hospitals). A total of 862 individuals (696 females [80.7%]) were from sites that were randomly assigned to the intervention arm; the baseline mean (SD) psychological distress score was 5.86 (5.70) and the baseline mean (SD) PTSD score was 16.11 (16.07). A total of 1215 individuals (947 females [78.2%]) were from sites assigned to the usual care arm; the baseline mean (SD) psychological distress score was 5.98 (5.62) and the baseline mean (SD) PTSD score was 16.40 (16.43). Adherence to the intervention was 70% for FQHCs and 32% for hospitals. The ITT analyses revealed no overall treatment effect for psychological distress score (0.238 [95% CI, -0.310 to 0.785] points) or PTSD symptom score (0.189 [95% CI, -1.068 to 1.446] points). Post hoc analyses examined the heterogeneity of treatment effect by age group with consistent age effects observed across primary outcomes (psychological distress and PTSD). Among HCWs in FQHCs, there were significant and clinically meaningful treatment effects for HCWs 30 years or younger: a more than 4-point reduction for psychological distress (-4.552 [95% CI, -8.067 to -1.037]) and a nearly 7-point reduction for PTSD symptom scores (-6.771 [95% CI, -13.224 to -0.318]). Conclusions and Relevance: This trial found that this peer-to-peer support intervention did not improve well-being outcomes for HCWs overall but had a protective effect against general psychological distress and PTSD in HCWs aged 30 years or younger in FQHCs, which had higher intervention adherence. Incorporating this peer-to-peer support intervention into medical training, with ongoing support over time, may yield beneficial results in both standard care and during public health crises. Trial Registration: ClinicalTrials.gov Identifier: NCT04723576.