Integration of Certified Child Life Specialists to Decrease in Periprocedural Benzodiazepine Use: A Pilot Study.

INTRODUCTION: Periprocedural anxiety is common in pediatric patients and is characterized by tension, anxiety, irritability, and autonomic activation. Periprocedural anxiety increases during certain events including admission to the preoperative area, separation from caregivers, induction of anesthesia, and IV placement. A study of children aged 2-12 showed that perioperative anxiety in children may be influenced by high parental anxiety and low sociability of the child. While these are nonmodifiable variables in the perioperative setting, there are numerous ways to ameliorate both parental and patient anxiety including the use of certified child life specialists (CCLSs) to aid in child comfort. In this study, our objective was to evaluate the integration of CCLS in our perioperative setting on the rate of benzodiazepine use. METHODS: We used a prospectively maintained database to identify patients undergoing outpatient elective surgical and radiologic procedures from July 2022 to September 2023 and January 2023 to September 2023 respectively. CCLSs were used to work with appropriately aged children in order to decrease the use of benzodiazepines and reduce possible adverse events associated with their use. RESULTS: A total of 2175 pediatric patients were seen by CCLS in same day surgery from July 2022 to September 2023. During this period, midazolam use decreased by an average of 11.4% (range 6.2%-19.3%). An even greater effect was seen in the radiologic group with 73% reduction. No adverse events were reported during this period. CONCLUSIONS: CCLSs working with age-appropriate patients in the periprocedural setting is a useful adjunct in easing anxiety in pediatric patients, reducing the need for periprocedural benzodiazepine administration and the risk of exposure to unintended side effects.

Consecutive Immunohistochemical Staining on a Single Slide is Effective in Confirming Melanocytic Derivation.

BACKGROUND: Metastatic melanoma in sentinel lymph nodes is often elusive to detect with morphology alone. Per American Joint Committee on Cancer staging guidelines, a single atypical melanocyte in lymph node qualifies as metastasis, whether identified by morphology or immunohistochemistry, but single cell staining must be convincing. We propose that the use of a second immunohistochemical run performed on a single slide will allow for more confident diagnosis of micrometastases. MATERIALS AND METHODS: We designed a technical study to determine whether a second antibody application on previously stained slides can successfully detect the same population of cells. Melanocytic neoplasms were stained with SOX-10 using Ventana Benchmark Ultra stainers, coverslipped, and examined, followed by coverslip removal and application of MART-1 (Ventana A103). The order of antibody application and chromagen detection kit (AP-RED vs. DAB) was reversed to establish reliability and robustness of the protocol. RESULTS: All melanocytes marked with SOX-10 and MART-1, and produced a range of staining quality that varied based on order of stain application and chromagen kit were used. The optimal combination was red MART-1 applied first followed by brown SOX-10 applied second. CONCLUSIONS: Consecutive staining of melanocytes with SOX-10 and MART-1 may improve diagnostic confidence of melanocyte identification, particularly in detection of single cell, micrometastases in sentinel lymph nodes or in situations where dual immunohistochemical stains may be unavailable.

Implementing a Produce Prescription Program for Hypertensive Patients in Safety Net Clinics.

INTRODUCTION: Although community-clinical linkages can improve chronic disease management, little is known regarding strategies for program implementation. We describe implementation of a unique produce prescription program for patients with hypertension (PRxHTN) involving 3 safety net clinics and 20 farmers' markets (FMs). STRATEGY: Safety net clinics were invited to participate, and provider-leads received assistance in (1) developing a process flow to screen for food insecurity among hypertensive adults for program referral, (2) integrating the program into their electronic health record for scheduling, and (3) counseling patients on PRxHTN/FM use. Research staff met with clinics twice monthly. FM managers were trained on maintaining PRxHTN voucher redemption logs. DISCUSSION: A total of 7 diverse providers screened 266 patients over 3 months; 224 were enrolled. Twelve FM, including one newly established at a clinic through provider-FM manager collaboration, redeemed over $14,500 of the $10 PRxHTN vouchers. We describe several strategies that can be used to prepare for and overcome implementation challenges including organizational and staff selection, facilitative administration, and clinical training and consultation. CONCLUSION: The PRxHTN program offers a flexible implementation process allowing clinics to successfully adapt their workflow to suit their staffing and resources.

Dietary Impact of Produce Prescriptions for Patients With Hypertension.

INTRODUCTION: Little is known regarding the impact of produce prescriptions within the context of hypertension visits at safety net clinics. We evaluated intervention effectiveness on patient usage of farmers markets and dietary change related to fruit and vegetable consumption. METHODS: Health Improvement Partnership - Cuyahoga worked with 3 clinics to integrate, implement, and evaluated a produce prescription for hypertension (PRxHTN) program. PRxHTN involves 3 monthly, nonphysician provider visits, comprising blood pressure measurement, nutrition counseling, and four $10 farmers market produce vouchers, for hypertensive adult patients screening positive for food insecurity. Dietary measures were collected at visits 1 and 3. Voucher use was tracked via farmers market redemption logs. RESULTS: Of the 224 participants from 3 clinics, most were middle-aged (mean age, 62 y), female (72%), and African American (97%) and had a high school education or less (62%). Eighty-six percent visited a farmers market to use their produce vouchers, with one-third reporting it was their first farmers market visit ever. Median number of farmers market visits was 2 (range: 0-6), and median number of vouchers redeemed was 8 (range: 0-12). Among the subsample with follow-up survey data (n = 137), significant improvement in fruit and vegetable consumption was observed as well as a decline in fast food consumption. CONCLUSION: PRxHTN participants visited at least 1 farmers market, reported increases in provider communication related to diet, and exhibited significant changes in dietary behavior. PRxHTN can serve as a strong model for linking safety net clinics with farmers markets to promote community resource use and improve fruit and vegetable consumption among food-insecure patients with hypertension.

Farmers' Market Use Patterns Among Supplemental Nutrition Assistance Program Recipients With High Access to Farmers' Markets.

OBJECTIVE: Evaluate farmers' market (FM) use patterns among Supplemental Nutrition Assistance Program (SNAP) recipients. DESIGN: Cross-sectional survey administered June to August, 2015. SETTING: Cleveland and East Cleveland, OH. PARTICIPANTS: A total of 304 SNAP recipients with children. Participants lived within 1 mile of 1 of 17 FMs. Most were African American (82.6%) and female (88.1%), and had received SNAP for ≥5 years (65.8%). MAIN OUTCOME MEASURES: Patterns of FM shopping, awareness of FM near home and of healthy food incentive program, use of SNAP to buy fruits and vegetables and to buy other foods at FMs, receipt of healthy food incentive program. ANALYSIS: Two-stage cluster analysis to identify segments with similar FM use patterns. Bivariate statistics including chi-square and ANOVA to evaluate main outcomes, with significance at P ≤ .05. RESULTS: A total of 42% reported FM use in the past year. Current FM shoppers (n = 129) were segmented into 4 clusters: single market, public market, multiple market, and high frequency. Clusters differed significantly in awareness of FM near home and the incentive program, use of SNAP to buy fruit and vegetables at FMs, and receipt of incentive. CONCLUSIONS AND IMPLICATIONS: Findings highlight distinct types of FM use and had implications for tailoring outreach to maximize first time and repeat use of FMs among SNAP recipients.

Constraint Induced Aphasia Therapy: Volunteer-led, unconstrained and less intense delivery can be effective.

BACKGROUND: Constraint Induced Aphasia Therapy (CIAT) has been shown to be effective in the treatment of aphasia, but clinicians have expressed concern regarding how far CIAT is practical to implement in clinical practice. OBJECTIVE: To determine whether CIAT delivered in a less-intense, lower dose, reduced constraint and volunteer-led format could produce positive outcomes in people with chronic aphasia. METHODS: Two groups were run, each with two people with chronic aphasia. Treatment involved a standard CIAT card-exchange game, supplemented by a home activity. Spoken language was required for responses but alternative modalities of communication were also permitted. Each group was led by a trained volunteer, lasted 90 minutes and was delivered twice a week for four weeks. RESULTS: Three of the four participants showed significant improvements in target word retrieval following treatment. No significant improvements were observed for untreated stimuli or language tasks. Two participants showed increases in the elaboration of their responses, and the same two showed an increase in the frequency with which they engaged in communication activities. CONCLUSIONS: Clear gains in performance were observed for the majority of people with aphasia who participated in a less intense format, considerably lower dose and less constrained form of CIAT led by trained volunteers. This suggests that this 'clinically realistic' service delivery model for CIAT could be added to the clinical repertoire of speech pathologists.

Exposure to glyphosate- and/or Mn/Zn-ethylene-bis-dithiocarbamate-containing pesticides leads to degeneration of γ-aminobutyric acid and dopamine neurons in Caenorhabditis elegans.

Previous studies demonstrate a positive correlation between pesticide usage and Parkinson's disease (PD), which preferentially targets dopaminergic (DAergic) neurons. In order to examine the potential relationship between two common pesticides and specific neurodegeneration, we chronically (24 h) or acutely (30 min) exposed two Caenorhabditis elegans (C. elegans) strains to varying concentrations (LC(25), LC(50) or LC(75)) of TouchDown(®) (TD) as percent active ingredient (glyphosate), or Mancozeb(®) (MZ) as percent active ingredient (manganese/zinc ethylene-bis-dithiocarbamate). Furthermore, to more precisely model environmental exposure, worms were also exposed to TD for 30 min, followed by 30-min incubation with varying MZ concentrations. Previous data from out lab suggested general neuronal degeneration using the worm strain NW1229 (pan-neuronal//green fluorescent protein (GFP) construct). To determine whether distinct neuronal groups were preferentially affected, we specifically used EG1285 (GABAergic neurons//GFP construct) and BZ555 (DAergic neurons//GFP construct) worms to verify GABAergic and DAergic neurodegeneration, respectively. Results indicated a statistically significant decrease, when compared to controls (CN), in number of green pixels associated with GABAergic neurons in both chronic (*P < 0.05) and acute (*P < 0.05) treatment paradigms. Analysis of the BZ555 worms indicated a statistically significant decrease (*P < 0.05) in number of green pixels associated with DAergic neurons in both treatment paradigms (chronic and acute) when compared to CN. Taken together, our data suggest that exposure to TD and/or MZ promotes neurodegeneration in both GABAergic and DAergic neurons in the model organism C. elegans.