Exploring the Breastfeeding Experiences of African American Mothers Through a Critical Race Theory Lens.

Background: Data from the Ohio Department of Health for Hamilton County reveal that the rate of breastfeeding steadily increased for non-Hispanic white babies from 72% initiation in 2006 to 79.8% initiation in 2018. Over the same time period, the rate of breastfeeding initiation increased from 52% to 65.7% for African American babies. Despite positive gains in breastfeeding for the African American community, significant disparities remain. Research Aim/Question(s): Our aim was to gain insight into the breastfeeding experiences of African American women and professionals working primarily with African American women to promote and support breastfeeding. Methods: In this study, a critical race theory approach was used to explore the lived experiences of African American women and health care providers who serve African American communities through the analysis of breakout conference sessions. Breakout sessions were semistructured, with questions developed in a strengths, weaknesses, opportunities, and threats analysis format aimed at obtaining information related to sociocultural factors impacting breastfeeding initiation and duration, with the goal of developing actionable community objectives to address breastfeeding disparities for African American women. Results: Three themes emerged stereotypes and microaggressions, representation, and provider support. Conclusion: Qualitative analysis of the conference proceedings reveals insights that can be developed into an action plan to address breastfeeding disparities in Hamilton County.

Comparison of Polymeric Clips and Endoscopic Staplers for Laparoscopic Appendectomy.

INTRODUCTION: Appendectomy is the most common pediatric surgical procedure. To decrease the cost and environmental impact of single incision pediatric endosurgery (SIPES) appendectomy, we switched from using endoscopic staplers to polymeric clips placed with nondisposable laparoscopic appliers. The aim of this study was to compare the resulting reduction in cost and amount of waste generated per case, as well as to compare the perioperative variables and outcomes in patients in whom clips were used, with those of historical patients in whom staplers were used. MATERIALS AND METHODS: Retrospective chart review of SIPES appendectomies was performed and patients in whom clips were used were compared with patients in whom staplers were used. Demographic, operative, and clinical data were collected. t-Test, Mann-Whitney test, and chi squared test were used to analyze the data as appropriate. The cost to the hospital of the clips and staplers was compared. The disposable waste generated from clips and the staplers was weighed. RESULTS: A total of 246 patients were included: 111 in stapler group and 135 in clip group. There were no statistically significant differences between the groups in operative time, estimated blood loss, length of stay, and complications. There were no complications related to use of clips. In the clip group, staplers were used in 10% because base of appendix was too large, gangrenous, or perforated and could not be clipped. Use of polymeric clips was less expensive and generated less waste. CONCLUSIONS: Use of polymeric clips for appendectomy is safe and effective, and results are comparable with those of stapling. Based on our data, in 90% of appendectomies, the base of appendix is amenable to clipping. This study supports use of clips over staplers to decrease cost and environmental impact.

Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting.

BACKGROUND: The Pediatric Infectious Diseases Society and Infectious Diseases Society of America national childhood community-acquired pneumonia (CAP) guideline encouraged the standard evaluation and treatment of children who were managed as outpatients. Our objectives were to (1) increase adherence to guideline-recommended diagnostics and antibiotic treatment of CAP at 5 pediatric primary care practices (PPCPs) by using quality-improvement methods and (2) evaluate the association between guideline adherence and unscheduled follow-up visits. METHODS: Immunocompetent children >3 months of age with no complex chronic conditions and who were diagnosed with CAP were eligible for inclusion in this stepped-wedge study. Interventions were focused on education, knowledge of colleagues' prescribing practices, and feedback sessions. Statistical process control charts were used to assess changes in recommendations and antibiotic treatment. Unscheduled follow-up visits were compared across time by using generalized estimating equations that were clustered by PPCP. RESULTS: CAP was diagnosed in 1906 children. Guideline recommended therapy and pulse oximetry use increased from a mean baseline of 24.9% to a mean of 68.0% and from 4.3% to 85.0%, respectively, over the study period. Among children >5 years of age, but not among those who were younger, the receipt of guideline recommended antibiotics, as compared with nonguideline therapy, was associated with the increased likelihood of unscheduled follow-up (adjusted odds ratio, 2.12; 95% confidence interval: 1.31-3.43). Chest radiographs and complete blood cell counts were rarely performed at baseline. CONCLUSIONS: Recommendations for limited use of chest radiographs and complete blood cell counts and standardized antibiotic therapy in children is supported at PPCPs. However, the guideline may need to include macrolide monotherapy as appropriate antibiotic therapy for older children.

Same day discharge after thyroidectomy is safe and effective.

Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely. METHODS: This report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits. RESULTS: A total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke. CONCLUSION: Postoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.

Increasing PCP and Hospital Medicine Physician Verbal Communication During Hospital Admissions.

OBJECTIVES: During hospital admission, communication between primary care physicians (PCPs) and hospital medicine (HM) physicians provides an opportunity for collaboration. Two-way communication facilitates collaboration by allowing the receiver to ask and respond to questions. At our institution, most HM-to-PCP communication occurred by telephone call after discharge. Our specific aim was to increase the percentage of patients for whom a telephone conversation occurred between HM and PCPs during hospital admission from 40% to >80%. METHODS: An improvement team that included PCPs and HM physicians redesigned the process for communication with PCPs to emphasize collaboration during hospitalization. Interventions were used to target key drivers of information transparency, PCP and HM provider buy-in, the value of early call initiation, process standardization, accommodating provider availability, and preoccupation with failure. We used improvement-science methods and run charts to measure our progress and attain our goal. RESULTS: The median weekly percentage of patients with a phone call completed during hospitalization increased from 40% to 85% at the satellite campus and 40% to 80% at the main campus. In addition to the standardized use of a telephone operator system to route calls and follow-up on unplaced calls, critical interventions included feedback on PCP call preferences to providers and the provider script for calls. CONCLUSIONS: PCPs and HM physicians applied quality-improvement methodology to ensure reliable HM-PCP communication during hospital admission. Interventions to facilitate communication between providers and learners (who may otherwise have limited interaction), such as the scripting of phone calls and feedback from PCPs to HM physicians, were important for success.

BCL6 Antagonizes NOTCH2 to Maintain Survival of Human Follicular Lymphoma Cells.

Although the BCL6 transcriptional repressor is frequently expressed in human follicular lymphomas (FL), its biological role in this disease remains unknown. Herein, we comprehensively identify the set of gene promoters directly targeted by BCL6 in primary human FLs. We noted that BCL6 binds and represses NOTCH2 and NOTCH pathway genes. Moreover, BCL6 and NOTCH2 pathway gene expression is inversely correlated in FL. Notably, BCL6 upregulation is associated with repression of NOTCH2 and its target genes in primary human and murine germinal center (GC) cells. Repression of NOTCH2 is an essential function of BCL6 in FL and GC B cells because inducible expression of Notch2 abrogated GC formation in mice and killed FL cells. Indeed, BCL6-targeting compounds or gene silencing leads to the induction of NOTCH2 activity and compromises survival of FL cells, whereas NOTCH2 depletion or pathway antagonists rescue FL cells from such effects. Moreover, BCL6 inhibitors induced NOTCH2 expression and suppressed growth of human FL xenografts in vivo and primary human FL specimens ex vivo These studies suggest that established FLs are thus dependent on BCL6 through its suppression of NOTCH2Significance: We show that human FLs are dependent on BCL6, and primary human FLs can be killed using specific BCL6 inhibitors. Integrative genomics and functional studies of BCL6 in primary FL cells point toward a novel mechanism whereby BCL6 repression of NOTCH2 drives the survival and growth of FL cells as well as GC B cells, which are the FL cell of origin. Cancer Discov; 7(5); 506-21. ©2017 AACR.This article is highlighted in the In This Issue feature, p. 443.

Health Care Use and Barriers to Care among Latino Immigrants in a New Migration Area.

Unlike regions with larger Latino populations, the health care infrastructure in Cincinnati does not include linguistically and culturally appropriate services to meet the need of the growing Latino immigrant community. In order to guide development of appropriate health care services, a team of academic and community researchers collaborated on a community-based participatory research project to understand health care use, barriers to health care, perceptions of health care, and health care needs of Latino immigrants. Co-researchers administered 518 surveys and conducted focus groups with 34 Latino immigrants. Participants relied on community clinics for care more often than is seen in nationwide Hispanic samples. Results revealed significant health care barriers, which Latino immigrants attribute to language, lack of quality interpreters, documentation status, and discrimination. Results suggest that the dearth of established social support networks and health care infrastructure in new Latino growth areas exacerbate the health care obstacles experienced by Latino immigrants throughout the country.

Hospital outcomes associated with guideline-recommended antibiotic therapy for pediatric pneumonia.

BACKGROUND: Recent national guidelines recommend use of narrow-spectrum antibiotic therapy as empiric treatment for children hospitalized with community-acquired pneumonia (CAP). However, clinical outcomes associated with adoption of this recommendation have not been studied. METHODS: This retrospective cohort study included children age 3 months to 18 years, hospitalized with CAP from May 2, 2011 through July 30, 2012. Primary exposure of interest was empiric antibiotic therapy, classified as guideline recommended or not. Primary outcomes were length of stay (LOS), total hospital costs, and inpatient pharmacy costs. Secondary outcomes included broadened antibiotic therapy, emergency department revisits, and readmissions. Multivariable linear regression and Fisher exact test were performed to determine the association of guideline-recommended antibiotic therapy on outcomes. RESULTS: Empiric guideline-recommended therapy was prescribed to 168 (76%) of 220 patients. Median hospital LOS was 1.3 days (interquartile range [IQR]: 0.9-1.9 days), median total cost of index hospitalization was $4097 (IQR: $2657-$6054), and median inpatient pharmacy cost was $91 (IQR: $40-$183). Between patients who did and did not receive guideline-recommended therapy, there were no differences in LOS (adjusted -5.8% change; 95% confidence interval [CI]: -22.1 to 12.8), total costs (adjusted -10.9% change; 95% CI: -27.4 to 9.4), or inpatient pharmacy costs (adjusted 14.8% change; 95% CI: -43.4 to 27.1). Secondary outcomes were rare, with no difference in unadjusted analysis between patients who did and did not receive guideline-recommended therapy. CONCLUSIONS: Use of guideline-recommended antibiotic therapy was not associated with unintended negative consequences; there were no changes in LOS, total costs, or inpatient pharmacy costs.

Quality improvement methods increase appropriate antibiotic prescribing for childhood pneumonia.

OBJECTIVE: In August 2011, the Pediatric Infectious Disease Society and Infectious Disease Society of America published an evidence-based guideline for the management of community-acquired pneumonia (CAP) in children ≥3 months. Our objective was to evaluate if quality improvement (QI) methods could improve appropriate antibiotic prescribing in a setting without a formal antimicrobial stewardship program. METHODS: At a tertiary children's hospital, QI methods were used to rapidly implement the Pediatric Infectious Disease Society/Infectious Disease Society of America guideline recommendations for appropriate first-line antibiotic therapy in children with CAP. QI interventions focused on 4 key drivers and were tested separately in the emergency department and on the hospital medicine resident teams, using multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed weekly to determine the success of prescribing recommended antibiotic therapy. The impact of these interventions on our outcome was tracked over time on run charts. RESULTS: Appropriate first-line antibiotic prescribing for children admitted with the diagnosis of CAP increased in the emergency department from a median baseline of 0% to 100% and on the hospital medicine resident teams from 30% to 100% within 6 months of introducing the guidelines locally at Cincinnati Children's Hospital Medical Center and has been sustained for 3 months. CONCLUSIONS: Our study demonstrates that QI methods can rapidly improve adherence to national guidelines even in settings without a formal antimicrobial stewardship program to encourage judicious antibiotic prescribing for CAP.

Focusing measures for performance-based privileging of physicians on improvement.

BACKGROUND: The Joint Commission requires ongoing professional practice evaluation--or what Cincinnati Children's Medical Center (CCHMC) has termed performance-based privileging (PBP)--for the medical staff reappointment and reprivileging process. BUILDING A SYSTEM: CCHMC is a 475-bed academic medical center affiliated with the University of Cincinnati College of Medicine. Medical staff members are reappointed every two years, with divisions having staggered reappointment dates throughout the two-year cycle. In 2004, CCHMC devised a model in which the 38 divisions retained responsibility for development of measures; collection, maintenance, display, and monitoring of individual provider performance data; and sharing of data with providers, while medical staff services retained responsibility for ensuring compliance with timelines, technical assistance related to measure development, and the collection and display of data. Each clinical division developed a preliminary list of measures. The original PBP process was tested in 2005 and has been revised several times in response to division feedback. DISCUSSION: Members of all 38 clinical divisions have now been reappointed to the medical staff at least twice using measures that have become more robust, meaningful, and outcome oriented. Many measures support organizational or divisional quality imoprovement aims, are evidence based, or build on initiatives sponsored by external bodies and specialty societies. Examples of measures are shared via the PBP intranet, personal consultations, and an annual provider performance improvement conference. Yet, challenges remain, such as the absence of real-time, provider-specific, risk-adjusted data and the difficulty of attributing provider-specific outcomes when most complex and high-risk care is managed by a team.