Nature contact at school: The impact of an outdoor classroom on children's well-being.

Nature contact facilitates healthy child development and a disconnect with nature presents potential health risks. This study was designed to test a nature intervention at an elementary school among children. An experimental crossover design was implemented over six weeks; two teachers taught their respective kindergarten classes the daily language arts lesson in either the control (indoor classroom) or nature treatment (outdoor classroom) conditions. Child well-being measures were compared in the two conditions. Teachers' redirections of child behavior were significantly fewer in the nature condition (t = 2.49, p < 0.05) compared to the control. Also, fewer children were off task in the nature condition on average. There were mixed well-being results; children reported no significance difference in happiness in the two conditions, but teachers reported modest benefit in child well-being in the nature condition. The outdoor classroom is a promising method for increasing nature contact and promoting student well-being.

Successful implementation of a family and patient activated rapid response team in an adult level 1 trauma center.

BACKGROUND: When cardiac arrests occur in hospitalized patients, delays in treatment are associated with lower survival and poorer outcomes. Patients often show a physiological deterioration hours before cardiac or pulmonary arrest. As a result, many hospitals have implemented a rapid response team (RRT) as part of their involvement in the 100,000 Lives Campaign sponsored by the Institute for Healthcare Improvement. METHOD: In conjunction with the University Health System Consortium (UHC) Patient- and Family-Centered Care Implementation Collaborative, Shands Jacksonville Medical Center (SJMC) launched a pilot RRT program in October 2006 followed by campus-wide implementation in July 2007. The program was enhanced to allow patient and family activation of the RRT in October 2007. RESULTS: A review of the first 2 years of data indicates that the SJMC RRT received 25 patient or family activated calls. Forty-eight percent of the calls were initiated by a family member and 52% by the actual patient. Reasons for the calls have varied but the most frequent reason identified by the patient or family member was "something just doesn't feel right" with the patient. Other leading reasons for calls were similar to criteria that are used by staff-initiated calls, such as shortness of breath and pain issues. CONCLUSION: This is one of the first initiations of a family activated component of the RRT in an adult hospital that has led to improvements in outcomes such as reduction in mortality rates and non-ICU codes, without an overload of false positive calls.

Fall-related pediatric brain injuries: the role of race, age, and sex.

BACKGROUND: Falls remain a major cause of childhood morbidity and mortality. To improve effectiveness of our prevention program, we used our electronic injury surveillance database to analyze patient variables and the incidence of fall-related brain injury. METHODS: The database was queried for all injuries treated in the pediatric emergency department for which the word "fall" was listed as part of the chief complaint. Age, sex, and mechanism variables were cross tabulated for analysis with traumatic brain injury (TBI) codes. RESULTS: Between June 2005 and June 2008, the electronic surveillance system reported 39,718 injury-related visits to the pediatric emergency department. Falls were reported in 3,436 patients (2,107 males, 1,329 females). TBI occurred from falls in 171 patients. Although black children had a higher fall rate (69.24%) than white children (23.75%) and non-black, non-white children (7.01%), white children had the highest TBI rate from falls (9.47%). TBI from falls occurred at a lower mean age for females (5.40 +/- 4.45) than males (6.6 +/- 5.15) and for non-whites (5.98 +/- 4.88) than whites (6.21 +/- 4.93). Multiple logistic regression demonstrated a significant influence of age, race, and sex on the likelihood that a fall results in TBI. Females have a higher risk of TBI from falls than males from ages 0 to 11.5. This runs contrary to previous studies suggesting that toddler males are at highest risk for TBI. CONCLUSION: A disproportionate number of infants, toddlers, and adolescents sustain brain injury from falls. Race and sex group differences mandate enhanced focus on environmental safety and risk-taking behaviors.

A multi-method assessment of satisfaction with services in the medical home by parents of children and youth with special health care needs (CYSHCN).

OBJECTIVE: To assess satisfaction of parents of children with special health care needs with treatment by office staff, communication with the pediatrician, involvement in decision-making and coordination of services outside the practice. PATIENTS AND METHODS: We used a mixed-method (qualitative and quantitative) approach to collect parental perceptions of the Medical Home services provided by their pediatricians. Six practices were selected to participate in the study based on geographic and patient demographic characteristics. In total, 262 (75% response rate) families completed surveys, and 28 families of these participated in focus groups. The Family Survey collected information (corroborated and enriched with focus group interviews) on parent and child demographics, severity of the child's condition and the burden on parents. We assessed parental satisfaction with treatment by office staff, communication with the pediatrician, involvement in decision-making, and connection to services outside the practice. Survey responses were analyzed using SAS with all associations considered significant at the P < 0.05 level. Focus groups were recorded, transcribed into EZ-Text and analyzed by a team of three researchers to identify patterns and themes inherent in the data. RESULTS: Families reported in focus group interviews that they experienced significant stress due to the demands of caring for a child with special health care needs. Overall, only a small percentage of families reported being dissatisfied with their treatment by office staff (13-14%), communication with the pediatrician (10%), and involvement in decision-making (15-16%). However, a majority of families (approximately 58%) were dissatisfied with the ability of the pediatrician and his/her office to connect the families with resources outside the pediatric office. Families whose children had more severe conditions, or whose conditions had more of an impact on the families, reported being less satisfied with all aspects of communication and care coordination Families of youth with special health care needs (>12 years of age) were less satisfied than families of younger children with the practice's ability to connect them to resources outside the practice. CONCLUSIONS: Both the focus groups and surveys demonstrated that families of children with special needs are under very significant stress. Pediatricians must become better equipped to identify and communicate more proactively with families of CYSHCN that are experiencing significant parent burden. Pediatricians and their staff also need to improve their knowledge of community resources and proactively make referrals to community services needed by families of CYSHCN.

Factors associated with utilization of healthcare resources among epilepsy patients.

PURPOSE: To determine those variables associated with utilization of healthcare resources in epilepsy patients. METHODS: We interviewed 256 epilepsy patients. Target variables included the number of clinic visits, ER visits and in-patient admissions over the past year and AEDs currently being used. Predictor variables were age, race/ethnicity, marital status, education, income, insurance, seizure frequency and QOLIE-10 results. We used univariate analysis to determine those factors associated with the target variables and multivariate analysis to ascertain those independently significant. RESULTS: On univariate analysis, higher seizure frequency and poorer QOLIE-10 scores were associated with the number of clinic visits, ER visits and in-patient admissions. Increased seizure frequency and male gender were associated with higher use of AEDs. Using ordinal logistic regression, QOLIE-10 scores was the only variable associated with the number of clinic visits. Both seizure frequency and QOLIE-10 scores were independently associated with the number of in-patient admissions while seizure frequency and male gender remained independently associated with AED use. Using binary logistic regression, QOLIE-10 scores and seizure frequency were independently associated with the number of ER visits. CONCLUSION: Seizure frequency and quality of life are major factors associated with utilization of healthcare resources in epilepsy patients.

Neonatal gut barrier and multiple organ failure: role of endotoxin and proinflammatory cytokines in sepsis and necrotizing enterocolitis.

BACKGROUND/PURPOSE: Failure of the gut barrier and endotoxemia have been implicated in sepsis and multiple organ failure (MOF) syndromes in adults. The contributions of endotoxin (ETX) and proinflammatory cytokines (CKs) to the pathophysiology of disease and the outcomes of infants in the neonatal intensive care unit (NICU) are not clear. We measured ETX and CK concentrations in infants who presented with clinical signs of sepsis and/or necrotizing enterocolitis (NEC) to study their impact on MOF and outcomes. METHODS: Blood samples from infants with signs of NEC and/or sepsis were collected for culture and determination of complete blood cell counts and concentrations of CKs (interleukin [IL]-1beta, tumor necrosis factor [TNF] alpha, and IL-6) and ETX at the onset of illness. Infants with signs of sepsis but without those of NEC were classified by blood culture results into a confirmed sepsis group (ie, positive culture) or a control group (ie, negative culture). Endotoxin concentrations were determined by chromogenic Limulus amebocyte lysate assay, and CK levels were quantitated by enzyme-linked immunoassay. Data are expressed as mean +/- SD and as odds ratios (ORs) with 95% confidence intervals (CIs). P values lower than .05 were considered to be significant. RESULTS: There was no demographic or clinical difference among the NEC (n = 27), sepsis (n = 44), and control (n = 56) groups, except that fewer (P = .02) infants in the NEC group (11%) had received maternal milk feedings as compared with infants in the sepsis group (23%) and those in the control group (39%). Endotoxin concentrations were higher (P < .0001) in the NEC group (3.30 +/- 2.11) as compared with the sepsis group (0.67 +/- .86) and the control group (0.09 +/- 0.24). Generalized linear regression analysis using formula feeding, mechanical ventilation, and gram-negative bacteremia as covariates demonstrated that NEC increased ETX concentrations independently (r = .80; P < .0001). Endotoxemia correlated with higher concentrations of all 3 CKs (P < .0001). There was an inverse association between ETX and both platelet count (r = -0.30; P = .0003) and absolute neutrophil count (r = -0.29; P = .0009). Infants who died of MOF had higher concentrations of ETX (2.83 +/- 3.04 vs 0.67 +/- 1.04 EU/mL; P < .0001), IL-1beta (509 +/- 493 vs 106 +/- 223 pg/mL; P < .0001), IL-6 (416 +/- 308 vs 99 +/- 165 pg/mL; P < .0001), and TNF-alpha (503 +/- 449 vs 126 +/- 237 pg/mL; P < .0001) as compared with those without MOF. Eighty-six percent of the infants with MOF died. Multivariate logistic regression analysis demonstrated that higher ETX concentrations (OR = 2.47; 95% CI = 1.39-4.40; P = .002) and lower gestational age (OR = 1.41; 95% CI = 1.12-1.77; P = .003) predicted mortality. CONCLUSIONS: Neonatal endotoxemia and release of proinflammatory CKs are important contributors to MOF and mortality in the NICU. Endotoxemia was most severe at the onset of illness among the infants with NEC, suggesting that gut barrier failure plays an important role in adverse outcomes in the NICU.

USMLE step 1 scores as a significant predictor of future board passage in pediatrics.

PURPOSE: To explore the relationship(s) between USMLE, In-Training Exam, and American Board of Pediatrics (ABP) board-certifying exam scores within a Pediatric residency-training program. METHODS: Data were abstracted from records of graduating residents from the Pediatric residency program at the University of Florida College of Medicine Jacksonville from 1999 to 2005. Seventy (70) residents were identified and their files reviewed for the following information: USMLE Step 1 and 2 scores, in-training exam results and eventual board scores as reported by the ABP. Correlation and regression analyses were performed and compared across all tests. RESULTS: The correlation coefficients between the three types of tests were all statistically significant. Using logistic regression, however, only USMLE Step 1 scores (compared to Step 2) had a statistically significant association with board performance. Interestingly, none of the three in-training exam scores had any additional impact on predicting board performance given one's USMLE Step 1 score. USMLE Step 1 scores greater than 220 were associated with nearly a 95 per cent passage rate on the board-certifying exam. CONCLUSIONS: The data suggests that performance on USMLE Step 1 is an important predictor of a resident's chances of passing the pediatric boards. This information, which is available when a resident initiates training, can be used to identify those at risk of not passing the boards. While Step 1 scores should not be used as a sole determinant in the recruiting process, individual learning plans can be developed and implemented early in training to maximize one's ability to pass the certifying exam.

Portal venous gas and surgical outcome of neonatal necrotizing enterocolitis.

PURPOSE: The prognostic significance of portal venous gas (PVG) in neonatal necrotizing enterocolitis (NEC) for operative intervention (OP), neonatal complications, and mortality remains uncertain. The authors designed a long-term prospective study to describe the natural history of PVG related to these outcomes and to test the hypothesis that PVG does not mandate OP. METHODS: All infants admitted to a single center between October 1991 and February 2003 were evaluated weekly to identify all cases of NEC (defined as Bell stage II or higher). Demographic, radiological, surgical, and outcome data were abstracted prospectively. Radiographic studies were performed at the onset of illness and at subsequent 6- to 8-hour intervals or as clinically indicated. A single pediatric radiologist reviewed all radiographs. Values are expressed as mean +/- SD. Odds ratios and relative risk ratios are reported with 95% CIs. The level of significance was P < or = .05. RESULTS: After the exclusion of 24 infants with lethal diseases, major congenital or chromosomal anomalies, or recurrent episodes of NEC, 194 of 5891 infants developed NEC. The overall incidence of NEC was 3.7%. In 194 infants with NEC, the incidence of PVG was 33% (n = 64). Gestational age (30.8 +/- 4 vs 29.3 +/- 4.2 weeks; P = .02) but not birth weight (1609 +/- 761 vs 1434 +/- 810 g; P = NS) was greater in infants with PVG compared with infants without PVG (n = 130). Sixty-six (34%) infants with NEC underwent OP. Operative intervention occurred more frequently in infants with PVG compared with infants without PVG (OR, 2.5; CI, 1.37-4.76; P = .003)--only 48% of infants with PVG underwent OP. Among the variables, gestational age, severe NEC (Bell stage III), severe intramural gas (in all 4 abdominal quadrants), and the presence of PVG, severe NEC was most highly associated with OP (OR, 77.47; CI, 10.36-580.16; P < .0001). Bell stage III NEC was present in 98% of infants who underwent OP compared with 40% of infants without OP ( P < .0001). Of all infants with NEC, 37 (19%) died. Mortality was higher among infants who underwent OP (33% vs 12%; P < .0003). A multivariate regression model identified Bell stage III (OR, 3.74; CI, 1.20-11.62; P = .02), but neither PVG nor OP, to be significantly associated with mortality. Of interest is that survival in infants with PVG was greater (but not significantly so) than in infants without PVG in both OP (74% vs 59%) and non-OP (91% vs 87%) groups. Furthermore, 30 of 64 (47%) infants with PVG survived without OP, and of all 33 infants with PVG who did not undergo OP, 30 (91%) infants survived. CONCLUSIONS: Decision for OP should be based on the severity of NEC and not on the presence of PVG alone because nearly half of infants with PVG survive without OP. Overall, the presence of PVG does not increase the risk of mortality among infants with NEC. Severe NEC, but not OP, is associated with higher mortality.