Disparities in Genetic Testing for Heritable Solid-Tumor Malignancies.

Genetic testing offers providers a potentially life saving tool for identifying and intervening in high-risk individuals. However, disparities in receipt of genetic testing have been consistently demonstrated and undoubtedly have significant implications for the populations not receiving the standard of care. If correctly used, there is the potential for genetic testing to play a role in decreasing health disparities among individuals of different races and ethnicities. However, if genetic testing continues to revolutionize cancer care while being disproportionately distributed, it also has the potential to widen the existing mortality gap between various racial and ethnic populations.

Compelling Voices of Diversity, Equity, and Inclusion in Prelicensure Nursing Students: Application of the Cultural Humility Framework.

BACKGROUND: Diversity, equity, and inclusion are increasingly recognized as core values for guiding nursing education, practice, and research. The conceptual framework of cultural humility has been adapted in a variety of health care settings, fostering a culture of diversity, equity, and inclusion through openness, supportive interaction, self-awareness, self-reflection, and critique. PROBLEM: Nurse educators have the opportunity, but may find it challenging, to teach students about the changing landscape of health care and the populations we serve. APPROACH: This article describes the integration of the cultural humility framework into nursing curricula to teach principles of diversity, equity, and inclusivity. We provide a practical example of a diversity panel, with student and panelist reflections, exploring the intersectionality of experiences in health care and integration of personal accounts and perspectives. CONCLUSION: Dialogue about diversity, equity, and inclusion is essential for preparing future nurses to deliver culturally competent care and promote health equity.

eSIMPLER: A Dynamic, Electronic Health Record-Integrated Checklist for Clinical Decision Support During PICU Daily Rounds.

OBJECTIVES: Design, implement, and evaluate a rounding checklist with deeply embedded, dynamic electronic health record integration. DESIGN: Before-after quality-improvement study. SETTING: Quaternary PICU in an academic, free-standing children's hospital. PATIENTS: All patients in the PICU during daily morning rounds. INTERVENTIONS: Implementation of an updated dynamic checklist (eSIMPLER) providing clinical decision support prompts with display of relevant data automatically pulled from the electronic health record. MEASUREMENTS AND MAIN RESULTS: The prior daily rounding checklist, eSIMPLE, was implemented for 49,709 patient-days (7,779 patients) between October 30, 2011, and October 7, 2018. eSIMPLER was implemented for 5,306 patient-days (971 patients) over 6 months. Checklist completion rates were similar (eSIMPLE: 95% [95% CI, 88-98%] vs eSIMPLER: 98% [95% CI, 92-100%] of patient-days; p = 0.40). eSIMPLER required less time per patient (28 ± 1 vs 47 ± 24 s; p < 0.001). Users reported improved satisfaction with eSIMPLER (p = 0.009). Several checklist-driven process measures-discordance between electronic health record orders for stress ulcer prophylaxis and user-recorded indication for stress ulcer prophylaxis, rate of venous thromboembolism prophylaxis prescribing, and recognition of reduced renal function-improved during the eSIMPLER phase. CONCLUSIONS: eSIMPLER, a dynamic, electronic health record-informed checklist, required less time to complete and improved certain care processes compared with a prior, static checklist with limited electronic health record data. By focusing on the "Five Rights" of clinical decision support, we created a well-accepted clinical decision support tool that was integrated efficiently into daily rounds. Generalizability of eSIMPLER's effectiveness and its impact on patient outcomes need to be examined.

Economic Inequities in the Application of Neuromodulation Devices.

Background  There is a significant upfront cost for the use of neuromodulation devices. The high cost of these devices may lead to disproportionate application in geographical regions with different levels of financial resources. The purpose of this study was to determine if there is geographic based economic inequity in the application of neuromodulation devices in the United States. Methods  Population and average household income data by county from the year 2010 were obtained from publicly available databases on the US Census website. The number of stimulators sold by county in the years 2009 and 2010 were provided by two of the four neuromodulation companies with commercially available products. Pearson correlation and t-test statistics were performed. Results  Of the 3142 U.S. counties analyzed, only 689 placed neuromodulation devices during this period of time. There was a difference in average household income between counties with device implants ($49,663) and counties with no device implants ($41,314), which was statistically significant (p<0.001). Conclusion  Analysis of neuromodulation devices placed in 2009 and 2010 from 50% of neuromodulation companies demonstrated that there was an income disparity between counties in which implantation of devices occurred and counties in which there were no device implantations.

Effects of acute dietary nitrate supplementation on aortic blood pressures and pulse wave characteristics in post-menopausal women.

PURPOSE: Consumption of nitrate-rich beetroot juice can lower blood pressure in peripheral as well as central arteries and may exert additional hemodynamic benefits (e.g. reduced aortic wave reflections). The specific influence of nitrate supplementation on arterial pressures and aortic wave properties in postmenopausal women, a group that experiences accelerated increases in these variables with age, is unknown. Accordingly, the primary aim of this study was to determine the effect of consuming nitrate-rich beetroot juice on resting brachial and aortic blood pressures (BP) and pulse wave characteristics in a group of healthy postmenopausal women, in comparison to a true (nitrate-free beetroot juice) placebo. METHODS: Brachial (oscillometric cuff) and radial (SphygmoCor) pressures and derived-aortic waveforms were measured during supine rest in thirteen healthy postmenopausal women (63 ±â€¯1 yr) before and 100 min after consumption of 140 ml of either nitrate-rich (9.7 mmol, 0.6 gm NO3-) or nitrate-depleted beetroot juice on randomized visits approximately 10 days apart (cross-over design). Ten young premenopausal women (22 ±â€¯1 yr) served as a reference (non-supplemented) cohort. RESULTS: Brachial and derived-aortic variables showed the expected age-associated differences in these women (all p < 0.05). In post-menopausal women, nitrate supplementation reduced (p < 0.05 vs. placebo visit) brachial systolic BP (BRnitrate -4.9 ±â€¯2.1 mmHg vs BRplacebo +1.1 ± 1.8 mmHg), brachial mean BP (BRnitrate -4.1 ±â€¯1.7 mmHg vs BRplacebo +0.9 ± 1.3 mmHg), aortic systolic BP (BRnitrate -6.3 ±â€¯2.0 mmHg vs BRplacebo +0.5 ± 1.7 mmHg) and aortic mean BP (BRnitrate -4.1 ±â€¯1.7 mmHg vs BRplacebo +0.9 ± 1.3 mmHg), and increased pulse pressure amplification (BRnitrate +4.6 ± 2.0% vs BRplacebo +0.7 ± 2.5%, p = 0.04), but did not alter aortic pulse wave velocity or any other derived-aortic variables (e.g., augmentation pressure or index). CONCLUSIONS: Dietary nitrate supplementation favorably modifies aortic systolic and mean blood pressure under resting conditions in healthy postmenopausal women. Acute supplementation of nitrate does not, however, appear to restore indices of aortic stiffness in this group. Future work should evaluate chronic, long-term effects of this non-pharmacological supplement.

Multidisciplinary Quality Improvement Intervention to Achieve Sustained Improvement in Hand Hygiene Reliability in a Pediatric Intensive Care Unit.

Suboptimal hand hygiene (HH) remains a significant modifiable cause of healthcare-associated infections in the intensive care unit. We report a single-center, quality improvement project aimed at improving adherence to optimal HH among physicians, nurse practitioners, and nursing staff, and to sustain any improvement over time. METHODS: A key driver diagram was developed to identify 5 primary drivers of change: leadership support, education initiatives, patient-family engagement, increased audit frequency, and individual feedback to promote accountability. We examined HH compliance over 3 years in 3 phases (pre-intervention, intervention, and post-intervention). The intervention period involved a multimodal approach designed to influence unit culture as well as individual HH practice. HH screens were installed outside the patient rooms to provide just-in-time reminders and display of regularly updated HH adherence data for provider groups. RESULTS: We recorded 6,563 HH opportunities, providers included nurses (66%), attendings (12%), fellow/resident (16%), and nurse practitioners (NP) (6%). All clinical groups demonstrated HH compliance >90% during the post-intervention period. The improvements in practice were sustained for a year after the intervention. CONCLUSION: Our report highlights modifiable factors that impact HH and may inform quality improvement interventions aimed at improving HH compliance at other centers.

Pediatric Critical Care Medicine Training: 2004-2016.

OBJECTIVES: To describe growth trends in the number of programs, positions, and applicants in pediatric critical care medicine fellowship training as part of the Pediatric Critical Care Medicine Training Study. DESIGN: Descriptive study. SETTINGS: Available archived Match data through the National Resident Matching Program and training data from the Accreditation Council for Graduate Medical Education. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed all data on programs, positions, and applicants through the National Resident Matching Program Specialties Matching Service during the study period of 2004 to 2016. We also analyzed available training data available through the Accreditation Council for Graduate Medical Education for the corresponding study period. During the 12-year study period, there was a statistically significant expansion in programs (38%), positions (82%), and applicants (151%). Correspondingly, the percentage of pediatric critical care medicine programs participating in the Match as a percentage of all Accreditation Council for Graduate Medical Education-accredited programs for that academic year increased 24%. As of 2015, 94% of total first year positions offered for pediatric critical care medicine were through the Match. CONCLUSIONS: For the period 2004 to 2016, there was a substantial increase in positions and applicants applying for training in pediatric critical care medicine. We document an increase in demand (i.e., applicants) that has been matched by an increase in supply (i.e., positions) for pediatric critical care medicine fellowship training. The nearly complete use of the National Resident Matching Program for placing applicants in training positions in pediatric critical care medicine suggests that these data can be used to inform workforce analysis in pediatric critical care medicine.

A stepwise enteral nutrition algorithm for critically ill children helps achieve nutrient delivery goals*.

OBJECTIVES: To evaluate the impact of implementing an enteral nutrition algorithm on achieving optimal enteral nutrition delivery in the PICU. DESIGN: Prospective pre/post implementation audit of enteral nutrition practices. SETTING: One 29-bed medical/surgical PICU in a freestanding, university-affiliated children's hospital. PATIENTS: Consecutive patients admitted to the PICU over two 4-week periods pre and post implementation, with a stay of more than 24 hours who received enteral nutrition. INTERVENTIONS: Based on the results of our previous study, we developed and systematically implemented a stepwise, evidence and consensus-based algorithm for initiating, advancing, and maintaining enteral nutrition in critically ill children. Three months after implementation, we prospectively recorded clinical characteristics, nutrient delivery, enteral nutrition interruptions, parenteral nutrition use, and ability to reach energy goal in eligible children over a 4-week period. Clinical and nutritional variables were compared between the pre and postintervention cohorts. Time to achieving energy goal was analyzed using Kaplan-Meier statistical analysis. MEASUREMENTS AND MAIN RESULTS: Eighty patients were eligible for this study and were compared to a cohort of 80 patients in the preimplementation audit. There were no significant differences in median age, gender, need for mechanical ventilation, time to initiating enteral nutrition, or use of postpyloric feeding between the two cohorts. We recorded a significant decrease in the number of avoidable episodes of enteral nutrition interruption (3 vs 51, p < 0.0001) and the prevalence and duration of parenteral nutrition dependence in patients with avoidable enteral nutrition interruptions in the postintervention cohort. Median time to reach energy goal decreased from 4 days to 1 day (p < 0.0001), with a higher proportion of patients reaching this goal (99% vs 61%, p = 0.01). CONCLUSIONS: The implementation of an enteral nutrition algorithm significantly improved enteral nutrition delivery and decreased reliance on parenteral nutrition in critically ill children. Energy intake goal was reached earlier in a higher proportion of patients.

Perioperative evaluation in Herlyn-Werner-Wunderlich syndrome.

BACKGROUND: Herlyn-Werner-Wunderlich syndrome is defined by uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. We report the presentation, radiographic findings, and outcomes of three patients with Herlyn-Werner-Wunderlich syndrome who underwent surgical management at a tertiary care academic medical center. CASES: Two patients were diagnosed by magnetic resonance imaging and one by ultrasonography. All three underwent successful transvaginal septoplasty and drainage of the hematocolpos and hematometra. One required septoplasty revision with temporary vaginal stent placement. CONCLUSION: Herlyn-Werner-Wunderlich syndrome is a rare condition. The most urgent concern is the obstruction of menstrual effluent. Unlike an isolated transverse vaginal septum, the vaginal septum with Herlyn-Werner-Wunderlich syndrome is parallel to the patent vaginal canal, less pliable, and closer to the cervix. These anatomical differences result in pronounced distortion with significant diagnostic and surgical challenges.

Prescribing generic antiepileptic drugs: Issues and concerns for nurse practitioners.

PURPOSE: To educate prescribing clinicians about bioequivalent standards for therapeutic equivalence of brand and generic antiepileptic drugs (AEDs) as more generic drugs come to market, and to increase awareness of practice and safety issues surrounding the use of these drugs for people with seizures. DATA SOURCES: Information was gathered from a search of the scientific literature as well as the author's clinical experience. CONCLUSIONS: Controversy exists regarding the therapeutic equivalence of brand and generic AEDs, even when bioequivalent standards are satisfied. Generic AEDs have been associated with breakthrough seizures and adverse events that may outweigh cost savings encouraged by third-party payors. Further research is needed comparing brand to generic drugs in a rigorous manner in order to make a consensus statement regarding the safety and equivalency of generic AEDs for all patient populations. IMPLICATIONS FOR PRACTICE: Generic AEDs may be safely prescribed in certain situations if clinicians are aware of ethical, legal, and practice issues surrounding their use. Sufficient time should be spent educating patients, caregivers, and pharmacists about implications of a switch made without the knowledge of the patient and/or prescriber.