Gout in Native Hawaiian Patients in Hawai'i: Clinical Characteristics and Disparities.

OBJECTIVE: The purpose of this study was to investigate differences in clinical characteristics and health care use of Native Hawaiian and White patients with gout. METHODS: We performed a retrospective chart review of Native Hawaiian and White patients with gout treated from 2011 to 2017 within a large health care system in Hawai'i. We compared demographic characteristics, clinical outcomes, and risk factors for gout. We used multivariable logistic regression to identify predictive factors of emergency department visits. RESULTS: We identified 270 Native Hawaiian patients with gout and 239 White patients with gout. The Native Hawaiian patients were younger on average (54.0 vs 64.0 years; P < 0.0001) and had an earlier onset of disease (50.0 vs 57.0 years; P < 0.0001). Native Hawaiian patients with gout had higher mean (7.58 vs 6.87 mg/dL; P < 0.0001) and maximum (10.30 vs 9.50 mg/dL; P < 0.0001) serum urate levels compared to White patients with gout. Native Hawaiian patients with gout also had a greater number of tophi (median 2.00 vs 1.00; P < 0.0001). Native Hawaiians patients with gout were 2.7 times more likely to have frequent (≥1) emergency department visits than White patients with gout. Native Hawaiian patients with gout were less likely to have a therapeutic serum urate ≤6.0 mg/dL and had lower rates of rheumatology specialty care. CONCLUSION: Native Hawaiian patients have a higher disease burden of gout, with earlier disease onset and more tophi. Native Hawaiian patients with gout are more likely to use emergency services for gout and have lower rates of rheumatology specialty care compared to White patients. Future studies are needed to promote culturally appropriate preventive care and management of gout in Native Hawaiians.

Prevalence of invalid ImPACT baseline test results among high school athletes with invalidity and sandbagging indices.

Objective: The comparison of baseline neuropsychological test results with post-concussion neuropsychological test results is a common practice to assess the aftermath of a sport-related concussion. The effectiveness of this approach is compromised when invalid baseline test performances occur. The present study was designed to assess the prevalence of invalid baseline test results of high school athletes, using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Method: A large sample of 8938 high school athletes' baseline test data were examined, including the four ImPACT Composite scores and three sets of embedded invalid indices: five ImPACT Invalidity Indicators, four ImPACT sandbagging red flags, and two ImPACT sandbagging subtest flags. Results: There were 8394 (93.91%) Valid scorers, who failed no Invalidity Indicators; 544 (6.09%) Invalid scorers, who failed at least one Invalidity Indicator, 2718 (30.41%) Red Flag scorers, who had at least one Red Flag score; and 4154 (46.47%) Subtest Flag scorers, who had at least one Subtest Flag score. Of the entire sample, 4485 (54.65%) failed at least one of the invalid indices. Conclusions: As in prior studies of high school athletes, the Invalidity Indicators identified a low portion (6.09%) of the athletes with invalid baseline test results, while other invalidity measures found 30.41% to 46.48% of the athletes producing questionable test results. The high rate of invalid test findings suggested in this research calls for greater efforts to improve the accuracy of baseline test results.

Racial Disparities in Breastmilk Receipt and Extremely Low Gestational Age Neonatal Morbidities in an Asian Pacific Islander Population.

BACKGROUND: Racial disparities in breastmilk provision and neonatal morbidities of extreme prematurity have been documented in previous studies but are not as well-documented in Asian and Pacific Islander (API) infants. The objectives of this study were to evaluate a predominantly API neonatal intensive care unit (NICU) population for racial disparities in (1) the receipt of breastmilk within 24 h of admission and at discharge and (2) neonatal morbidities among infants ≤ 28 weeks gestational age. METHODS: A retrospective chart review of 2528 infants from 2018 to 2020 born at the largest level 3 NICU in Honolulu, Hawai'i, was conducted. Multivariable logistic regression analysis was performed on NICU outcomes to calculate adjusted odds ratios (aOR) and confidence intervals (CI). RESULTS: Native Hawaiian (NH) (aOR 0.73 [0.54, 0.98]), Pacific Islander (PI) (aOR 0.57 [0.41, 0.79]), and Filipino infants (aOR 0.66 [0.49, 0.89]) were less likely to receive breastmilk at discharge compared to Asian infants. PI infants were also more likely to experience necrotizing enterocolitis (aOR 7.89 [1.07, 58.10]) and intraventricular hemorrhage (aOR 3.86 [1.15, 13.02]) compared to Asian infants. CONCLUSION: In a predominantly API population, disparities in breastmilk receipt and neonatal morbidities exist among NH, PI, and Filipino infants in the NICU. Our findings call for better understanding of the underlying inequities to guide directed efforts, including standardization of care through staff trainings on implicit biases and trauma-informed care, as well as provision of culturally sensitive education and lactation support for these patients.

Heparin Versus Normal Saline: Flushing Effectiveness in Managing Central Venous Catheters in Pediatric Patients With Cancer.

BACKGROUND: There is insufficient evidence of the effects of intermittent flushing with normal saline versus heparin to prevent occlusion or increased alteplase use in pediatric patients with central venous catheters. OBJECTIVES: The primary objective was to evaluate the effectiveness of a new standard flushing practice in the management of central venous access devices in pediatric patients with cancer. A secondary objective was to assess the cost of heparin flushing supplies to patients and financial impact. METHODS: New flushing guidelines included tunneled lines flushed with saline in the push-pause method twice daily in the inpatient setting. The outpatient setting required saline lock while receiving care and heparin lock on discharge. Alteplase usage was monitored for five months in all pediatric patients with cancer who had tunneled central lines. FINDINGS: There was no statistically significant difference in alteplase usage rate pre- to postimplementation. A formal flushing guideline was recommended using saline and lower heparin concentrations for tunneled catheters.

Paediatric resident workflow observations in a community-based hospital.

OBJECTIVE: Residency graduates need to demonstrate competence in prioritising safe patient care through appropriate management of multiple competing tasks and workflow interruptions. This pilot study aimed to characterise and correlate interruptions in paediatric resident workflow at an academically affiliated, community-based hospital. METHODS: One of three trained observers followed a resident physician during a convenience sample of 1-2 hour increments, either in the emergency department or on the wards, and recorded all observed activities and interruptions using an established time-motion tool. All participants completed a baseline Multi-Tasking Ability Test (MTAT) and pre-observation and post-observation surveys. Statistical approach included descriptive statistics, logistic regression, mixed model and ORs. RESULTS: 18 paediatric residents were observed for 57.5 total hours (an average of 3.2 hours/resident) which included 329 interruptions, defined as any external event drawing the resident's attention away from a primary task. Interruptions occurred an average of 5.9 times per resident per hour. Interrupted primary tasks were not resumed during the observation period 11% of the time. A personal/social-related interruption yielded an OR of 0.29 that the resident will return to a primary task within 5 min (p=0.007) when compared with patient-related verbal interruptions by the medical team. The MTAT Score indicated decreased efficiency for interns versus postgraduate year 2 residents (p=0.029). Residents' MTAT Scores did not correlate with their time to return to a primary task following an interruption (p=0.11). CONCLUSIONS: Paediatric resident workflow interruptions in the hospital were observed to occur frequently and should be expected. Personal/social interruptions were most likely to delay prompt return to a primary task. The MTAT Score, although improved between the first 2 years of residency training, did not correlate with efficient return to a primary task. Interruption management and mitigation strategies should be developed as part of a standardised residency task management curriculum.

Osteoporosis treatment rates after hip fracture 2011-2019 in Hawaii: Undertreatment of men after hip fractures.

OBJECTIVES: To investigate trends of osteoporosis treatment rates, and factors affecting osteoporosis treatment after hip fracture admission within a single health care system in Hawaii. METHODS: A retrospective chart review was conducted of patients aged 50 years or older and hospitalized for hip fractures between January 1, 2011 and December 31, 2019 at Hawaii Pacific Health, a large health care system in Hawaii. We collected data on basic demographics and osteoporosis medication prescription from electronic medical records. We evaluated trends of osteoporosis treatment rates and performed logistic regression to determine factors associated with osteoporosis treatment. RESULTS: The mean for treatment rates for osteoporosis from 2011 to 2019 was 17.2% (range 8.8%-26.0%). From 2011 to 2019 there was a small increase in treatment rates from 16.3% in 2011 to 24.1% in 2019. Men were less likely to receive osteoporosis treatment after admission for hip fracture. Patients discharged to a facility were more likely to receive osteoporosis treatment. As compared to women, men who had a hip fracture were less likely to receive dual-energy X-ray absorptiometry scan, and osteoporosis medication before hip fracture admission. CONCLUSIONS: The use of osteoporosis medication for secondary prevention after admission for hip fracture in Hawaii from 2011 to 2019 was low. However, there was a small increase in treatment rates from 2011 to 2019. Disparities in treatment of osteoporosis after hip fracture were noted in men. Significant work is needed to increase treatment rates further, and to address the disparity in osteoporosis treatment between men and women.

Complications of operative vaginal delivery and provider volume and experience.

OBJECTIVE: To evaluate associations between operative vaginal delivery complications and provider experience (operative vaginal delivery volume and time since residency). METHODS: We included all operative vaginal deliveries between 2008 and 2014 at a tertiary care teaching hospital, stratified into forceps-assisted and vacuum-assisted deliveries. Complications included severe perineal lacerations (3rd and 4th degree) and neonatal injuries (subgaleal/subdural/cerebral hemorrhage, facial nerve injury, and scalp injury), which were identified by International Classification Diagnosis-9 codes. Providers were categorized by operative vaginal delivery volume (mean annual forceps- or vacuum-assisted deliveries over the study interval) and time since residency. Regression analyses were used to compare complication rates by provider volume and time since residency, adjusting for potential confounders, using 0-1 deliveries per year and <5 years since residency as reference groups. RESULTS: Nine hundred and thirty-four forceps and 1074 vacuums occurred. For forceps-assisted deliveries, severe perineal injury was decreased among providers with >10 forceps per year (aOR 0.50 [95%CI 0.30-0.81]) and at 15-19 years (aOR 0.45 [95% CI 0.22-0.94], and ≥25 years (aOR 0.45 [0.27-0.73]) since residency. There were no associations with neonatal injuries. Among vacuum-assisted deliveries, severe perineal injury decreased at ≥25 years since residency (aOR 0.35 [95%CI 0.17-0.74], with no association with provider volume. Neonatal injury decreased at 5-9 years (aOR 0.53 [95%CI 0.30-0.93]), and 15-19 years since residency (aOR 0.53 [95%CI 0.29-0.97]), due to differences in scalp injuries. Neonatal injuries other than scalp injury were rare. CONCLUSION: Severe perineal lacerations decreased with increasing operative vaginal delivery experience, primarily among forceps-assisted vaginal delivery. Providers >5 years since residency may have lower scalp injury with vacuums, but this cohort was largely underpowered for neonatal injury.

Electrocardiogram Standards for Children and Young Adults Using Z-Scores.

BACKGROUND: Normative ECG values for children are based on relatively few subjects and are not standardized, resulting in interpersonal variability of interpretation. Recent advances in digital technology allow a more quantitative, reproducible assessment of ECG variables. Our objective was to create the foundation of normative ECG standards in the young utilizing Z-scores. METHODS: One hundred two ECG variables were collected from a retrospective cohort of 27 085 study subjects with no known heart condition, ages 0 to 39 years. The cohort was divided into 16 age groups by sex. Median, interquartile range, and range were calculated for each variable adjusted to body surface area. RESULTS: Normative standards were developed for all 102 ECG variables including heart rate; P, R, and T axis; R-T axis deviation; PR interval, QRS duration, QT, and QTc interval; P, Q, R, S, and T amplitudes in 12 leads; as well as QRS and T wave integrals. Incremental Z-score values between -2.5 and 2.5 were calculated to establish upper and lower limits of normal. Historical ECG interpretative concepts were reassessed and new concepts observed. CONCLUSIONS: Electronically acquired ECG values based on the largest pediatric and young adult cohort ever compiled provide the first detailed, standardized, quantitative foundation of traditional and novel ECG variables. Expression of ECG variables by Z-scores lends an objective and reproducible evaluation without interpreter bias that can lead to more confident establishment of ECG-disease correlations and improved automated ECG readings in high-volume cardiac screening efforts in the young. Graphic Abstract: A graphic abstract is available for this article.

Patient Safety Initiative Using Peer Observations and Feedback Inspire Collegial Workplace Culture.

Following Joint Commission recommendations for standardizing patient handoffs, direct peer observations and feedback were utilized in order to improve patient safety related to transitions of care in the Division of Pediatric Hospital Medicine at Kapi'olani Medical Center for Women & Children. All hospitalist attendings were trained in an evidence-based handoff bundle inclusive of team communication and feedback strategies. For the initial project, each hospitalist performed 12 peer observations and feedback sessions using validated tools for verbal and written handoffs over 6 months. For a subsequent "refresher" project, each hospitalist performed 6 handoff observations. Attendings were surveyed several times before, during, and after completion of the multiple iterations of the project. A qualitative interview was conducted 6 years after the initial handoff project. In total, 204 observations were completed by 17 hospitalists during the initial project. The perceived overall quality of the patient handoff improved significantly across shifts (P < .001 for the quality of each of two critical daily handoffs) as did pediatric hospitalists' confidence in providing peer feedback (P < .001). Downstream effects of this activity led to additional benefits towards the cohesive growth of the division. Themes from post-project qualitative interviews regarding the peer observation and feedback portion of the study included that it was "helpful," "collaborative," and inspired "camaraderie" that led to increased comfort and participation during future opportunities for observation and feedback. Performing direct peer observations with feedback strengthened the workplace culture, promoted growth through collaboration, and allowed acceptance and success of future projects involving peer observations and feedback.

Associations Between Maternal Obesity and Race, with Obstetric Anal Sphincter Injury: A Retrospective Cohort Study.

This retrospective cohort study examined associations between maternal body mass index (BMI), race, and obstetric anal sphincter injury (OASI) (3rd/4th degree perineal lacerations). Obstetric anal sphincter injury may lead to significant maternal morbidity, and a more thorough understanding of risk factors for this complication may guide providers in patient counseling and procedures such as episiotomy or operative vaginal delivery. Vaginal deliveries performed at Kapi'olani Medical Center for Women and Children from 2008-2015 were included. Maternal body mass index at delivery was used and OASIs identified through International Classification of Diseases codes. Demographic/clinical variables were summarized through descriptive statistics. Adjusted odds ratios were calculated using multiple logistic regression. Of the 25,594 deliveries included, 1,198 (4.7%) involved an OASI. OASI prevalence differed by BMI (P < .0001). The prevalence was highest in women with BMI < 30 kg/m2 (5.3%) and then decreased as BMI increased with women with BMI ≥ 50 demonstrating the lowest prevalence (1.7%). Compared to women with BMI < 30 kg/m2, women with BMI > 50 kg/m2 had a lower odds of OASI (OR 0.31 [95%CI 0.11 - 0.83]), which persisted after adjustment (aOR 0.28 [95%CI 0.08-0.96]). OASI also differed by race (P < .0001), with Native Hawaiian and other Pacific Islanders (NHOPI) demonstrating the lowest prevalence (3.0%) and Asians the highest (5.6%). After adjustment, compared to White women, NHOPI women had lower OASI prevalence that met the borderline of statistical significance (aOR 0.79 [95%CI 0.62-1.01]), while Asian women continued to demonstrate increased prevalence (aOR 1.50 [95% CI 1.22-1.85]). We conclude that obese women, including those with BMI ≥ 50 kg/m2, have lower OASI prevalence. Race is also a significant factor, with Asians almost double the prevalence of NHOPIs. These findings contribute to evidence-based, individualized patient counseling on OASI.

Pediatric Weight Errors and Resultant Medication Dosing Errors in the Emergency Department.

BACKGROUND: An accurate weight is critical for dosing medications in children. Weight errors can lead to medication-dosing errors. OBJECTIVES: This study examined the frequency and consequences of weight errors occurring at 1 children's hospital and 2 general hospitals. METHODS: Using an electronic medical record database, 79,000 emergency department encounters of children younger than 5 years were analyzed. Extreme weights were first identified using weight percentiles. Encounters with potential weight errors were further evaluated using a retrospective chart review to determine whether a weight error and medication-dosing error occurred. RESULTS: The percentage of weight errors of total encounters at all 3 institutions was low (0.63% on average), but a large proportion of weight errors led to subsequent medication-dosing errors (34% on average). The children's hospital did not have clinically significantly lower occurrences of weight errors or weight-based medication errors. Common weight errors included the weight in pounds being substituted for the weight in kilograms and decimal placement errors. CONCLUSIONS: Weight errors were uncommon at the 3 emergency departments that we studied, but they led to weight-based medication-dosing errors that had the potential to cause harm.

Effects of Walking on Coronary Heart Disease in Elderly Men with Diabetes.

Previous studies have shown that walking is associated with increased longevity and a reduced risk of cardiovascular and age-related diseases. Whether walking benefits individuals with diabetes who are at high risk of coronary heart disease (CHD) remains to be determined. The objective of this study is to examine the association between walking and risk of CHD among elderly men with and without diabetes. Walking data was assessed in 2732 men aged 71 to 93 years participating in the Honolulu Heart Program from 1991-1993. Study participants were initially without disabilities and free of prevalent CHD. Men were then followed for incident CHD for up to 7 years. For men with diabetes who walked <0.25 miles/day, the age-adjusted incidence of CHD was significantly higher than in men without diabetes (27.1 vs. 12.7/1000 person years, p = 0.026). In contrast when distance walked was >1.5 miles/day, incidence of CHD was similar in men with and without diabetes (12.2 vs. 9.1/1000 person-years, p = 0.46). While risk of CHD declined significantly with increasing walking distance in men with diabetes after age and risk factor adjustment (p = 0.043, p = 0.025), associations in those without diabetes were weaker (p = 0.070, p = 0.10). These findings suggest that among elderly men with diabetes who are capable of physical activity, walking reduces CHD risk to levels similar to when diabetes is absent. Walking is an easy, safe and accessible form of physical activity that may have marked health benefits for elderly men with diabetes.

Discrepancy Between Identification of Early-Term Elective Deliveries by Manual Chart Review and Data Vendor.

Elective delivery from 37 to 39 weeks gestation (early-term deliveries) is a Joint Commission National Quality Measure, and hospitals report on early-term elective delivery rates through Outcome Research Yields Excellence (ORYX) vendors. The objective of this study was to compare early-term elective deliveries, identified through ORYX vendors with those identified through manual chart review, the traditional method of medical record review. We reviewed early-term labor inductions and cesarean deliveries at a single hospital from June 1, 2010 to May 31, 2012. Rates of early-term elective deliveries identified by the data vendor were compared to physician chart review. Overall, the rate of elective deliveries by ORYX was 3% compared to 2% by physician chart review (RR 1.51 [95% CI 1.12-2.03], P < .001). Of the 116 elective early-term deliveries identified by vendor and/or chart review, vendors classified significantly more inductions and cesareans as elective (P < .001) and missed nine elective deliveries. Of the 107 deliveries identified as elective by ORYX, 62 (57.9%) were verified by chart review, including 69.0% of cesareans and 36.1% of inductions. Findings from this study suggest substantial discrepancy between identification of early-term elective deliveries by data vendors and physician chart review, and indicate that vendor-derived data may overestimate the number of electively delivered patients.

Restricted episiotomy use and maternal and neonatal injuries: a retrospective cohort study.

PURPOSE: There is relatively little information on episiotomies in the context of restricted episiotomy use. This study sought to examine maternal and neonatal injuries with restricted episiotomy use. METHODS: We performed a retrospective database analysis of vaginal deliveries at a tertiary care maternity hospital from June 2010 to June 2015. Maternal injuries (third- or fourth-degree lacerations) and neonatal injuries (birth trauma) were identified through the International Classification of Diseases, Ninth Revision, codes. Vaginal deliveries were classified as spontaneous, vacuum-assisted, or forceps-assisted. The associations between episiotomy and maternal and neonatal injuries were examined with stratification by parity, type of vaginal delivery, and type of episiotomy (midline or mediolateral). Adjusted-odds' ratios were calculated for maternal and neonatal injuries using a multiple logistic regression model to adjust for potential confounders. RESULTS: 22,800 deliveries occurred during the study interval involving 23,016 neonates. The episiotomy rate was 6.7 % overall and 22.9 % in operative vaginal deliveries. Episiotomies, both midline and mediolateral, were associated with increased risks of maternal and neonatal injuries regardless of parity (p < 0.0001). Upon stratification by the type of delivery, the association with maternal injury remained only for spontaneous vaginal deliveries (p < 0.0001). Adjusted-odds' ratios demonstrated a continued association between episiotomy and maternal [aOR 1.67 (1.39-2.05)] and neonatal injuries [aOR 1.43 (1.17-1.73)]. CONCLUSION: Episiotomy continues to be associated with increased third- and fourth-degree lacerations with restricted use, particularly in spontaneous vaginal deliveries.

Surgical site infection: comparing surgeon versus patient self-report.

BACKGROUND: To compare the rate of surgical site infection (SSI) using surgeon versus patient report. MATERIALS AND METHODS: A prospective observational study of surgical patients in four hospitals within one private health-care system was performed. Surgeon report consisted of contacting the surgeon or staff 30 d after procedure to identify infections. Patient report consisted of telephone contact with the patient and confirmation of infections by a trained surgical clinical reviewer. RESULTS: Between February 2011 and June 2012, there were 2853 surgical procedures that met inclusion criteria. Surgeon-reported SSI rate was significantly lower (2.4%, P value < 0.01) compared with patient self-report (4.3%). The rate was lower across most infection subtypes (1.3% versus 3.0% superficial, 0.3% versus 0.5% organ/space) except deep incisional, most procedure types (2.3% versus 4.4% general surgery) except plastics, most patient characteristics (except body mass index < 18.5), and all hospitals. There were disagreements in 3.4% of cases; 74 cases reported by patients but not surgeons and 21 cases vice versa. Disagreements were more likely in superficial infections (59.8% versus 1.0%), C-sections (22.7% versus 17.7%), hospital A (22.7% versus 17.7%), age < 65 y (74.2% versus 68.3%), and body mass index ≥ 30 (54.2% versus 39.9%). CONCLUSIONS: Patient report is a more sensitive method of detection of SSI compared with surgeon report, resulting in nearly twice the SSI rate. Fair and consistent ways of identifying SSIs are essential for comparing hospitals and surgeons, locally and nationally.

The Electrocardiogram Is a Poor Diagnostic Tool to Detect Left Ventricular Hypertrophy in Children: A Comparison with Echocardiographic Assessment of Left Ventricular Mass.

OBJECTIVE: The electrocardiogram (ECG) is used to detect left ventricular hypertrophy (LVH) in children and young adults, and it is considered an important screening tool for the most common causes of sudden cardiac arrest in the United States. However, the reliability and accuracy of the ECG in the detection of LVH are poorly understood. This study's objective was to assess the reliability and accuracy of ECG parameters predicting LVH in comparison with echocardiographic two-dimensional left ventricular mass (2D-LVM) assessment. DESIGN: Two hundred fifty patients met study criteria with complete 2D-LVM measurements, temporally matched ECGs and no confounding structural heart defects. The echocardiographic diagnosis of LVH was made by 2D-LVM z-score > 2. The electrocardiographic diagnosis of LVH was fulfilled if specific Q, R, or S wave voltages exceeded the normal limits for the respective age groups established by the Davignon, Macfarlane and Rijnbeek datasets, or fulfilled the LVH criteria set forth by adult indices (Sokolow-Lyon, Cornell, Gubner, Romhilt-Estes). RESULTS: None of the ECG parameters showed significant correlation with 2D-LVM z-scores. In the detection of LVH, the most commonly used R in V6 voltages showed the following results: sensitivity 13-29%, specificity 77-96%, positive predictive value (PPV) 29-50%, and negative predictive value (NPV) 77%. The overall accuracy ranged 65-75%. The accuracy of adult indices for LVH ranged from 49% to 78%. CONCLUSIONS: The ECG's prediction of LVH is unreliable with dismal sensitivity, variable specificity, poor PPV, and barely acceptable NPV. With such overall poor reliability, the use of current ECG standards in screening for LVH warrants reassessment.

Induction rates and delivery outcomes after a policy limiting elective inductions.

The purpose of this study was to assess induction rates, maternal, and neonatal outcomes following adoption of a policy prohibiting elective inductions at less than 39 weeks gestation and inductions between 39 and 41 weeks with an unfavorable cervix. A retrospective cohort study of all deliveries greater than or equal to 37 weeks gestation was conducted 1 year prior to through 1 year after implementation of the induction policy. Induction rates before and after the policy were calculated as the primary outcome while maternal and neonatal conditions were assessed as secondary outcomes. Elective inductions (p = 0.016), elective inductions less than 39 weeks gestation (p = 0.020), and elective inductions 39-40 weeks and 6 days gestation with an unfavorable cervix (p = 0.031) decreased significantly following adoption of the policy. Maternal and neonatal outcomes, including rates of cesarean deliveries, postpartum hemorrhage, chorioamnionitis, and neonatal intensive care unit admissions remained unchanged, though this study was not adequately powered to detect differences in these outcomes. An institutional induction policy was associated with a reduction in elective inductions prior to 39 weeks and up to 40 weeks and 6 days with an unfavorable cervix. These reductions were not accompanied by change in maternal or neonatal outcomes at our institution.

Linking patient-centered medical home and asthma measures reduces hospital readmission rates.

OBJECTIVE: We sought to achieve 100% compliance with all 3 Children's Asthma Care (CAC; CAC-1, CAC-2, CAC-3) measures and track attendance at follow-up appointments with the patient-centered medical home. The impact of these measures on readmission and emergency department utilization rates was evaluated. METHODS: This quality improvement study evaluated compliance with CAC measures in pediatric patients aged 2 to 18 years old hospitalized with a primary diagnosis of asthma from January 1, 2008, through June 30, 2012. A multidisciplinary Asthma Task Force was assembled to develop interventions. Attendance at the follow-up appointment was tracked monthly from January 1, 2009. Readmission and emergency department utilization rates were compared between the preimplementation period (January 1, 2006, through December 31, 2007) and the postimplementation period (January 1, 2008, through June 30, 2012). RESULTS: The preimplementation period included 231 subjects and the postimplementation period included 532 subjects. Compliance with CAC-3 was 95% from October 1, 2009, through June 30, 2012. Compliance with the postdischarge follow-up appointment was 69% from January 1, 2009 through September 30, 2009, increasing significantly to 90% from October 1, 2009, through June 30, 2012 (P < .001). Postimplementation readmission rates significantly decreased in the 91- to 180-day postdischarge interval (odds ratio: 0.29; 95% confidence interval: 0.11-0.78). CONCLUSIONS: In children hospitalized with asthma, compliance with the asthma core measures and the postdischarge follow-up appointment with the primary care provider was associated with reduced readmission rates at 91 to 180 days after discharge. We attribute our results to a comprehensive set of interventions designed by our multidisciplinary Asthma Task Force.

The impact of healing touch on pediatric oncology patients.

HYPOTHESES: Healing Touch (HT) is an energy therapy that has been shown to lower stress, pain, and fatigue in adult oncology patients. This study evaluated the feasibility of administering HT in pediatric oncology inpatient and outpatient units at Kapi'olani Medical Center for Women and Children. STUDY DESIGN: This study was a 1-year randomized prospective study consisting of 2 study arms. The HT arm was considered the treatment group, and reading/play activity was designated as the control group. Participants were randomly assigned to each arm on enrollment in the study. METHODS: They were recruited by the pediatric oncology social worker. Interested participants were asked to provide informed consent and were randomized to either the HT arm or the reading/play activity arm of the study. They received their designated intervention for 30 minutes at each inpatient or outpatient encounter. Participants, parents, and care providers were asked to complete preintervention and postintervention assessments. RESULTS: In all, 15 participants, aged 3 to 18 years old, were approached about the study between July 2009 and June 2010. A total of 9 participants enrolled (recruitment rate of 60%); 6 patients were randomized to receive HT sessions, and 3 patients received reading/play activities; 2 participants dropped out of the study because of prolonged hospitalizations and complicated treatments. An additional participant expired while in the study because of disease progression. Those in the HT group showed significant decreases in the scores for pain, stress, and fatigue for participants, parents, and caregivers. Furthermore, parents' perception of their children's pain decreased significantly for the HT group when compared with the group receiving reading/play activity. CONCLUSION: This study demonstrates the feasibility of using energy therapy in the pediatric oncology patient population. There also seems to be an interest in this treatment modality for this patient population. Furthermore, these findings suggest that HT has a positive impact on pain, stress, and fatigue related to oncology treatment.

Clinical and pathologic features of young endometrial cancer patients with loss of mismatch repair expression.

OBJECTIVE: This study examines premenopausal and early menopause patients in a unique population with endometrial cancer and loss of mismatch repair (MMR) gene expression. The purpose is to compare clinical and pathologic differences in patients with loss of expression (LOE) to those with normal expression (NE). METHODS: Endometrial cancer patients under age 60 in-between 1998 and 2008 were identified from a single tumor registry. Clinical and pathologic data were abstracted from records. Staining for expression of MSH6, MSH2, MLH1, and PMS2 were performed on archived tissue blocks. Statistical analysis was performed. RESULTS: 158 patients were analyzed; 58% Asian, 34% Pacific Islander, and 8% Caucasian. 31 demonstrated LOE of at least one MMR gene; 127 retained NE. 50% Caucasian, 21.9% Asian, and 12.5% Pacific Island populations had LOE of one or more MMR genes. LOE was found to have a higher incidence of Grade III (p=0.0013) and stage 3-4 tumors (p=0.0079), mean depth of myometrial invasion (p=0.0019), lymphovascular space invasion (p=0.0020), nodal metastases (p=0.0157), and a lower incidence of Grade I (p=0.0020) and stage 1A tumors (p=0.0085). LOE had a significantly lower mean BMI (p=0.0001). 35% of patients in the NE vs zero in the LOE group had a BMI greater than 40. CONCLUSION: Younger patients with LOE endometrial cancer appear to represent a clinically significant subgroup of patients without features characteristically found in classic type 1 endometrial cancer generally demonstrating lower BMI and tumors associated with poor prognostic characteristics. It is unclear if the distinctive ethnicity found in Hawaii has a significant impact on outcome. Further investigation is necessary to identify appropriate treatment strategies.