Environmental health literacy for Anishinaabe (Great Lakes Native American) fish consumers: A randomized control trial.

BACKGROUND: Fish consumption comprises an important part of what the Anishinaabe (Great Lakes Native Americans) call "minobimaadiziiwin" which translates roughly to "living in a good way". Industrial activity leading to the accumulation of persistent contaminants in fish disrupts minobimaadiziiwin. Our team of academic and Anishinaabe scientists co-developed a fish consumption advisory for the Anishinaabe using software that can be accessed via mobile phones and/or the internet. OBJECTIVES: The software, Gigiigoo'inaan ("our fish") is designed to improve environmental health literacy using culturally congruent messaging and aesthetics. We tested the following hypotheses: 1) the Gigiigoo'inaan would encourage consumption of fish high in Polyunsaturated Omega-3 fatty acids (PFUA-3) whilst minimizing contaminant intake (methylmercury (MeHg) and Polychorinated Biphenyls (PCBs)); and 2) intervention participants will be more likely than controls to achieve a favorable n-3 PUFA/MeHg consumption ratios. METHODS: We conducted a randomized controlled trial with prospective self-reported fish consumption using automated email surveys. One-month pre and one month post, control and intervention outcome variables were calculated per participant as µg/kg/day of MeHg, µg/kg/day of PCB, g of fish, and mg/day of EPA+DHA. These were modeled using an analysis of covariance (ANCOVA) with a-priori covariates: age, sex, and tribal affiliation. RESULTS: Most participants in both trial arms reported eating relatively elevated amounts of fish yet remained within advisory guidelines for contaminants. EPA+DHA:MeHg ratios were also favorable in most participants. Advisory limits for contaminants were exceeded by relatively few participants in the study. DISCUSSION: Gigiigoo'inaan was previously reported to increase confidence, the current user feedback confirms this. Most participants ate fish but did not exceed the advisory limits, which demonstrates Environmental Health Literacy progress in the region despite a lack of observed behavior change during the trial. A small number of participants exceeded contaminant intake guidelines which matches the pilot work for this study.

Unique Associations of DNA Methylation Regions With 24-Hour Blood Pressure Phenotypes in Black Participants.

BACKGROUND: Epigenetic marks (eg, DNA methylation) may capture the effect of gene-environment interactions. DNA methylation is involved in blood pressure (BP) regulation and hypertension development; however, no studies have evaluated its relationship with 24-hour BP phenotypes (daytime, nighttime, and 24-hour average BPs). METHODS: We examined the association of whole blood DNA methylation with 24-hour BP phenotypes and clinic BPs in a discovery cohort of 281 Blacks participants using reduced representation bisulfite sequencing. We developed a deep and region-specific methylation sequencing method, Bisulfite ULtrapLEx Targeted Sequencing and utilized it to validate our findings in a separate validation cohort (n=117). RESULTS: Analysis of 38 215 DNA methylation regions (MRs), derived from 1 549 368 CpG sites across the genome, identified up to 72 regions that were significantly associated with 24-hour BP phenotypes. No MR was significantly associated with clinic BP. Two to 3 MRs were significantly associated with various 24-hour BP phenotypes after adjustment for age, sex, and body mass index. Together, these MRs explained up to 16.5% of the variance of 24-hour average BP, while age, sex, and BMI explained up to 11.0% of the variance. Analysis of one of the MRs in an independent cohort using Bisulfite ULtrapLEx Targeted Sequencing confirmed its association with 24-hour average BP phenotype. CONCLUSIONS: We identified several MRs that explain a substantial portion of variances in 24-hour BP phenotypes, which might be excellent markers of cumulative effect of factors influencing 24-hour BP levels. The Bisulfite ULtrapLEx Targeted Sequencing workflow has potential to be suitable for clinical testing and population screenings on a large scale.

Does Supply Equal Demand? The Workforce of Direct Patient Care Genetic Counselors in Wisconsin.

BACKGROUND: Recent studies documented a shortage of direct patient care (DPC) genetic counselors in the United States. We aimed to survey genetic counselor members of the Wisconsin Genetic Counselors Association (WIGCA) to determine if the supply and demand was met within the state and where access to services can improve. METHODS: An email invitation was sent to all genetic counselor members of the WIGCA with a link to a confidential online survey. Survey questions addressed the workforce composition, elements that impact services, and professional satisfaction of practicing genetic counselors. RESULTS: The Wisconsin workforce currently has half of the projected need for full-time DPC genetic counselors. One-third of genetic counselors reported changing from direct to non-direct patient care positions. In-person services are concentrated within Milwaukee and Madison. Appointment wait times are decreased when patients meet with a genetic counselor only, and half of the genetic counselors reported moderate to high stress levels. DISCUSSION/CONCLUSION: A shortage of DPC genetic counselors in Wisconsin is confirmed due to the total full-time effort in direct patient care. Data provided here can be used to identify targets for increasing the number of DPC genetic counselors, maximizing time spent on patient care, and improving access.

Twenty-four-hour versus clinic blood pressure levels as predictors of long-term cardiovascular and renal disease outcomes among African Americans.

In Caucasian and Asian populations, evidence suggests that 24-h blood pressures (BP) are more predictive of long-term cardiovascular events than clinic BP. However, few long-term studies have evaluated the predictive value of 24-h BP phenotypes (24-h, daytime, nighttime) among African Americans (AA). The purpose of this study is to evaluate the added value of 24-h BP phenotypes compared to clinic BP in predicting the subsequent fatal and non-fatal cardiovascular/renal disease events in AA subjects. AA subjects (n = 270) were initially studied between 1994 and 2006 and standardized clinic BP measurements were obtained during screening procedures for a 3-day inpatient clinical study during which 24-h BP measurements were obtained. To assess the subsequent incidence of cardiovascular and renal disease events, follow-up information was obtained and confirmed by review of paper and electronic medical records between 2015 and 2017. During a mean follow-up of 14 ± 4 years, 50 subjects had one or more fatal or non-fatal cardiovascular/renal disease events. After adjustment for covariates, clinic systolic and diastolic BP were strongly associated with cardiovascular/renal disease events and all-cause mortality (p < 0.0001). Twenty-four-hour BP phenotypes conferred a small incremental advantage over clinic BP in predicting cardiovascular/renal events, which was limited to making a difference of one predicted event in 250-1,000 predictions depending on the 24-h BP phenotype. Nocturnal BP was no more predictive than the other 24-h BP phenotypes. In AA, 24-h BP monitoring provides limited added value as a predictor of cardiovascular/renal disease events. Larger studies are needed in AA to confirm these findings.

African American Otolaryngologists: Current Trends and Factors Influencing Career Choice.

OBJECTIVES: 1) Identify factors that influence African American physicians to choose a career in otolaryngology; 2) determine the predominant practice setting for African American otolaryngologists who can be role models; and 3) determine if the presence of an African American otolaryngologist in academic setting influences career choice. METHODS: Survey methodology included a 15-item survey to determine trends in practice and factors that influenced choice of specialty. RESULTS: The results were reviewed for trends influencing career choice and practice location and stratified by age group. Most African American otolaryngologists are in academic practice and have subspecialty fellowship training. Enjoying medical student clerkship was the most frequently cited reason why African Americans chose otolaryngology as a career regardless of age. Early exposure was a driving factor in those 30 to 40 years old. Receiving mentorship was less influential in career choice for all age groups, but there was a positive association between those who were mentored in training and those who mentor faculty. CONCLUSION: The findings suggest the continued need for initiatives to increase African Americans in our specialty. Encouraging early exposure, intentional mentoring of students, and development of African American role models who can be mentors may help increase the number of African American otolaryngologist faculty. This can help our specialty achieve racial parity in a percentage that matches the number of African Americans in the United States workforce. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:2336-2342, 2020.

Infants with esophageal atresia and right aortic arch: Characteristics and outcomes from the Midwest Pediatric Surgery Consortium.

PURPOSE: Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF. METHODS: A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up. RESULTS: In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54-2.65) vs. 2.57 kg (2.00-3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32-37) vs. 37 weeks (35-39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p < 0.0001). The most common cardiac lesions in the RAA group were ventricular septal defect (7), tetralogy of Fallot (7) and vascular ring (5). Seventeen infants with RAA underwent successful EA repair, 12 (71%) via right thoracotomy and 5 (29%) through left thoracotomy. Anastomotic strictures trended toward a difference in RAA patients undergoing right thoracotomy for primary repair of their EA/TEF compared to left thoracotomy (50% vs. 0%, p = 0.1). Side of thoracotomy in RAA patients undergoing EA/TEF repair was not significantly associated with mortality, anastomotic leak, recurrent laryngeal nerve injury, recurrent fistula, or esophageal dehiscence (all p > 0.29). CONCLUSION: RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach. LEVEL OF EVIDENCE: Level III.

The effect of losing federal coverage through the Affordable Care Act on ear tube placements at an urban children's hospital.

PURPOSE: 15-31% of the population in a large Mid-western city is between 100 and 400% of the Federal Poverty Level, thus qualifying for health care coverage under the Affordable Care Act (ACA). Coverage for their children would potentially be available under Children's Health Insurance Program (CHIP) or Medicaid programs. Loss of funding for these programs could be devastating for this community. METHODS: We retrospectively reviewed 1162 charts of pediatric patients with tympanostomy tube (TT) placement pre-ACA from November 2012 to December 2013 and 1606 charts post-ACA from January 2014 to July 2015. We filtered demographics by health insurance (Medicaid/CHIP/Other), residential zip codes, identified race/ethnicity within those zip codes as well as gender and age of patients getting TT during these periods. RESULTS: Bivariate analysis of these demographics between the two periods showed statistical significance (p = 0.0098) between White Hispanic/Latino children receiving ear tubes (pre-ACA = 3.8%, post-ACA = 6.4%). However, there was no statistical significance for insurance enrollment (Medicaid or non-Medicaid) and other races (White-not Hispanic/Latino (nHL), African American, Other/Unknown/Refused) with respect to TT placement. Using pre-ACA period and White nHL females as arbitrary reference, a multivariate logistic regression showed that patients requiring TT surgery were equally likely to be covered on Medicaid either before or after ACA. CONCLUSION: We demonstrated that the pre and post ACA Medicaid coverage for TT surgery did not change. Underserved children did not obtain other forms of insurance during this time. This demonstrates a potentially catastrophic loss of coverage for children should Medicaid/CHIP benefits be lost to sole coverage under the ACA.

Diversity in Otolaryngology Residency Programs: A Survey of Otolaryngology Program Directors.

Objective As the population of the United States becomes increasingly racially and ethnically diverse, it is important that the medical profession reflect these changes. Otolaryngology has previously been identified as one of the surgical subspecialties with the smallest presence of those underrepresented in medicine. In the context of this study, the term underrepresented in medicine is defined as blacks, Latinos, Native American, and Native Hawaiians. The purpose of this study was to describe the current state of otolaryngology residency programs in terms of diversity of resident and faculty cohort, explore general interviewing practices, and investigate recruitment of underrepresented in medicine applicants. Study Design Survey via electronic questionnaire. Setting Academic otolaryngology residency programs. Subjects and Methods A 14-item survey was distributed to 105 program directors asking them to consider their program's past 15 years of existence. Results With a response rate of roughly 30%, we found that over one-third of responding programs had matriculated 1 or fewer underrepresented in medicine residents. There was a statistically significant association between the number of underrepresented in medicine faculty and the number of underrepresented in medicine residents matriculated ( P = .02). Conclusion The authors stress the importance of underrepresented in medicine faculty mentorship. Although not statistically significant in this study, increasing the number of underrepresented in medicine applicants interviewed, as well as recommending outreach programs, may help to improve underrepresented minority matriculation into residency programs as demonstrated in the literature.

Relationship between perioperative blood transfusion and surgical site infections in pediatric general and thoracic surgical patients.

BACKGROUND: Recently, perioperative transfusions were demonstrated to be associated with higher rate of surgical site infections (SSIs) in neonates. We sought to examine whether a similar relationship exists between perioperative blood transfusions and SSI among non-neonatal pediatric general surgical patients. METHODS: We conducted an IRB-approved retrospective study reviewing non-neonatal patients (age greater than 28days and less than 18years) who underwent a general or thoracic surgical procedure in 2012, 2013, 2014, in the American College of Surgeons National Safety and Quality Improvement Project-Pediatric (ACS-NSQIP-P) Participant User Files. We used Chi-square analyses to perform a bivariate analysis comparing proportions of SSI's between patients who received blood transfusion to those who did not. Multiple logistic regression analyses compared the odds of SSIs in transfused versus nontransfused patients controlling for organ failure, steroid use, nutritional status, current infection, American Society of Anesthesiologists (ASA) Physical Status classification, and wound classification. RESULTS: There were 55,133 patients with 1779 patients who received blood transfusion (≥25ml/kg body weight) during or within 72h of surgery. Bivariate analysis showed at least twice the rate of infection in transfused patients compared to nontransfused patients (p<0.01): superficial SSI 3.5% vs 1.5%; deep SSI 0.8% vs 0.2%, organ space SSI 3.8% vs 1.6%; deep dehiscence 2% vs 0.3%. Total wound infections and dehiscence for transfused patients were 10.5% vs 3.8% in nontransfused patients (p<0.01). Multiple regression analysis showed that nutritional issue, current infection, and wounds not classified as "clean" have statistically significant correlation with SSI. Although there was significant interaction between ASA and transfusion (p<0.0001), we found statistically significant associations between transfusions and SSI for ASA class 1-2 (OR=5.51, 95% CI 3.47-7.52), ASA class 3 (OR=2.06, 95% CI 1.63-2.61), and ASA class 4-5 (OR=1.67, 95% CI 1.15-2.42). CONCLUSION: In non-newborn pediatric general and thoracic surgery patients, transfusions were associated with higher risk of SSI or wound dehiscence. Although there was a significant interaction between ASA and transfusion, OR for SSI was stronger for lower ASA classes. TYPE OF STUDY: Retrospective Review. LEVEL OF EVIDENCE: II.

Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium.

PURPOSE: Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. METHODS: The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers. RESULTS: 292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. CONCLUSION: Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. STUDY TYPE: Treatment study. LEVEL OF EVIDENCE: III.

Utilizing stricture indices to predict dilation of strictures after esophageal atresia repair.

BACKGROUND: Anastomotic stricture is the most common postoperative complication in infants undergoing repair of esophageal atresia with or without tracheoesophageal fistula (EA/TEF). Stricture indices (SIs) are used to predict infants at risk for stricture requiring dilation. We sought to determine the most accurate SI and optimal timing for predicting anastomotic dilation. MATERIALS AND METHODS: A retrospective study of infants undergoing repair of EA/TEF between 2008 and 2013 was performed. Esophagrams were used to calculate four SIs (upper pouch esophageal anastomotic stricture index [U-EASI], lower pouch esophageal anastomotic stricture index [L-EASI], lateral SI, and anterior/posterior SI). The best performing SI was identified. Logistic regression analysis was performed to determine if a first or second esophagram SI threshold was associated with dilation. A receiver operating characteristic curve measured the accuracy of the model using SIs to predict dilation. RESULTS: Of 45 EA/TEF infants included, 20 (44%) had postoperative strictures requiring dilation. As the best performing SI, logistic regression analysis showed that U-EASI as a continuous variable was predictive of dilation (P = 0.03) but was not significant at U-EASI ≤ 0.37. However, U-EASI ≤ 0.37 was associated with needing earlier dilation. On second esophagram (median, 38 days), U-EASI of ≤0.39 was significantly associated with dilation (OR: 7.8, 95% CI: 1.05-57.58, P = 0.04). The area under the receiver operating characteristic curve of the U-EASI model controlling for days to esophagram demonstrated improved predictive ability from first (AUC 0.73) to second esophagram (AUC 0.81). CONCLUSIONS: Calculation of the SI utilizing a U-EASI ≤ 0.39 on the delayed esophagram is associated with future anastomotic dilation. A multi-institutional study is necessary to confirm the predictive ability of the U-EASI.

Pepsin as a biomarker for laryngopharyngeal reflux in children with laryngomalacia.

OBJECTIVES/HYPOTHESIS: Laryngomalacia is a common cause of newborn stridor. Laryngopharyngeal reflux (LPR) has been associated with laryngomalacia. Although pepsin, a component of LPR, has been associated with inflammatory diseases of the aerodigestive tract, its presence in the airways of laryngomalacia patients is unknown. STUDY DESIGN: Prospective case-control study comparing patients under age 3 years with laryngomalacia to children without laryngomalacia. METHODS: Children less than 3 years old undergoing supraglottoplasty for laryngomalacia or surgery unrelated to the airway, without a history of laryngomalacia, reflux, or respiratory disease, were offered enrollment. Supraglottic lavage samples (3 mL) were obtained from all subjects. Two-millimeter arytenoid biopsies were collected from laryngomalacia patients. Pepsin Western blot and enzyme-linked immunosorbent assay were performed. RESULTS: Ten laryngomalacia and five control subjects were enrolled. Pepsin was detected in lavages of laryngomalacia patients (8/10) but absent in controls (0/5; P = .007). Pepsin was observed more frequently in lavages (8/10) than biopsies (4/10; P = .046) of laryngomalacia subjects. Higher median pepsin concentration was observed in laryngomalacia than control lavages (P = .025). CONCLUSIONS: Pepsin in supraglottic specimens demonstrated an association with laryngomalacia, supporting a role for refluxed pepsin in laryngomalacia. These data corroborate previous work implicating pepsin in inflammatory diseases of the upper airways. Further studies are warranted to investigate the contribution of pepsin to the pathophysiology of laryngomalacia. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:2413-2417, 2017.

Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula.

BACKGROUND/PURPOSE: Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly lacking contemporary data detailing patient demographics, medical/surgical management and outcomes. Substantial variation in the care of infants with EA/TEF may affect both short- and long-term outcomes. The purpose of this study was to characterize the demographics, management strategies and outcomes in a contemporary multi-institutional cohort of infants diagnosed with EA/TEF to identify potential areas for standardization of care. METHODS: A multi-institutional retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals between 2009 and 2014 was performed. Over the 5year period, 396 cases were identified in the 11 centers (7±5 per center per year). All infants with a diagnosis of EA/TEF made within 30days of life who had surgical repair of their defect defined as esophageal reconstruction with or without ligation of TEF within the first six months of life were included. Demographic, operative, and outcome data were collected and analyzed to detect associations between variables. RESULTS: Prenatal suspicion or diagnosis of EA/TEF was present in 53 (13%). The most common anatomy was proximal EA with distal TEF (n=335; 85%) followed by pure EA (n=27; 7%). Clinically significant congenital heart disease (CHD) was present in 137 (35%). Mortality was 7.5% and significantly associated with CHD (p<0.0001). Postoperative morbidity occurred in 62% of the population, including 165 (42%) cases with anastomotic stricture requiring intervention, anastomotic leak in 89 (23%), vocal cord paresis/paralysis in 26 (7%), recurrent fistula in 19 (5%), and anastomotic dehiscence in 9 (2%). Substantial variation in practice across our institutions existed: bronchoscopy prior to repair was performed in 64% of cases (range: 0%-100%); proximal pouch contrast study in 21% (0%-69%); use of interposing material between the esophageal and tracheal suture lines in 38% (0%-69%); perioperative antibiotics ≥24h in 69% (36%-97%); and transanastomotic tubes in 73% (21%-100%). CONCLUSION: Contemporary treatment of EA/TEF is characterized by substantial variation in perioperative management and considerable postoperative morbidity and mortality. Future studies are planned to establish best practices and clinical care guidelines for infants with EA/TEF. LEVEL OF EVIDENCE: Type of study: Treatment study. Level IV.

Relationship between perioperative blood transfusion and surgical site infections in the newborn population: An ACS-NSQIP-Pediatrics analysis.

BACKGROUND: Adult data suggest that perioperative transfusion may have deleterious effects through immunomodulation. Limited data regarding the effect of transfusions exist in the pediatric population. We hypothesized that perioperative transfusions may be associated with surgical site infections (SSI) in newborns. METHODS: The 2012 and 2013 American College of Surgeons National Safety and Quality Improvement Project-Pediatric (ACS-NSQIP-P) Participant User Files were queried to include all neonates that underwent surgical procedures. SSI rates in infants who had a perioperative blood transfusion were compared to those who were not transfused using a Fisher's Exact Test. Logistic regression analysis compared the odds of SSIs in transfused patients versus nontransfused patients. p Values <0.05 were statistically significant. RESULTS: The study population included 6499 patients, of which 1109 (17.1%) had transfusions. Transfused patients had increased SSIs. In the multivariate analysis, patients with nutritional issues (OR=1.58, 95%CI 1.24-2.00), current infection (OR=1.98, 95%CI 1.52-2.57), and perioperative transfusion (OR=2.08, 95%CI 1.59-2.72) were associated with increased risk of SSI after controlling for all other variables. CONCLUSIONS: Perioperative transfusions are associated with increased risk of SSIs. Further work to determine possible mechanisms of this association may be warranted.

Travel distances by Wisconsin Medicaid enrollees who visit emergency departments for dental care.

OBJECTIVES: Prior studies document increased numbers of nontraumatic dental condition (NTDC) visits to U.S. emergency departments (EDs). However, the influence of travel distance on ED use for NTDCs, particularly for Medicaid enrollees has hitherto received little attention. The authors examined the effect of travel distance on Wisconsin Medicaid enrollees' NTDC visits to EDs after adjustment for covariates. METHODS: NTDC-related visits claims data for Wisconsin Medicaid (2001-2009) was analyzed. For each enrollee, travel distance to the nearest of 130 EDs in Wisconsin was determined. The number of NTDC visits per person-year was aggregated by ZIP+4 of residence. Negative binomial regression adjusting for the expected number of visits based on race, sex, age of the residents and calendar year was used to evaluate the effect of travel distance, urbanicity, and dentist-population ratio on rate of visits. RESULTS: Enrollees residing in rural counties, entire dental health professional shortage areas, areas with dentist population ratios >20,000: 1 and non-Hispanic Whites travelled the furthest, compared to nearest mean ED distance of 2.9 miles. Enrollees residing 3 miles away or further had significantly lower rates of NTDC visits to EDs. CONCLUSIONS: This study demonstrates that distance is a barrier to making NTDC-related visits to EDs. Rates of NTDC visits decreased as travel distance to the nearest ED increased for Medicaid enrollees.

Medical Student Views of the Affordable Care Act.

INTRODUCTION: With new insurance coverage under the Affordable Care Act (ACA) beginning in 2014 and the ever-changing practice of medicine, it is important to understand medical students' recent perspectives on health policy and reform. OBJECTIVE: This study describes the opinions, perceptions, and comprehension of the ACA and health care reform by a cross-section of medical students in Wisconsin. METHODS: A total of 578 students (35%) completed an original survey developed from previous surveys. RESULTS: Of those sampled, one-half identified as liberal or very liberal and 20% as conservative or very conservative. Respondents were split equally in their opinions of whether the United States or other nations had the highest quality care. One-half felt that faculty physicians and the media influenced their opinion of the ACA, while two-thirds felt that coursework and peers had no influence on their views. The vast majority sampled thought everyone is entitled to adequate medical care regardless of ability to pay and that physicians have a major responsibility to help reduce health care costs. A majority of liberal students and a minority of conservative students, supported the ACA. Personal and family experience as a patient influenced most liberals to support and most conservatives to oppose the ACA. One-half felt that medical school spent adequate time on health care policy education.