Relationship between Dysphagia and Home Discharge among Older Patients Receiving Hospital Rehabilitation in Rural Japan: A Retrospective Cohort Study.

Dysphagia refers to swallowing difficulty, which impacts patients' quality of life. Dysphagia influences clinical outcomes, including mortality rates and length of hospital stay of older hospitalized patients. Dysphagia may affect the current and future quality of life of these patients. However, its exact impact remains unclear. We aimed to clarify the impact of dysphagia on discharge to home in older patients in a rural rehabilitation unit. We conducted a secondary analysis using data from a retrospective cohort study including patients aged over 65 years who had been discharged from a community hospital rehabilitation unit in rural Japan. Data from the participants had been previously collected from April 2016 to March 2020. The primary outcome was home discharge. The average participant age was 82.1 (standard deviation, 10.8) years; 34.5% were men. Among medical conditions, brain stroke (44.3%) was the most frequent reason for admission; the most frequent orthopedic condition was femoral fracture (42.9%). The presence of dysphagia (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.20-0.73), polypharmacy (OR = 0.5, 95% CI: 0.32-0.90), and admission for internal medicine diseases (OR = 0.44, 95% CI: 0.26-0.77) were negatively associated with home discharge. High motor domain scores of the Functional Independence Measure were positively associated with home discharge (OR = 1.07, 95% CI: 1.05-1.08). Dysphagia was negatively associated with home discharge as were polypharmacy and admission for internal medicine diseases and conditions. By clarifying effective interventions through interventional studies, including approaches to managing multimorbidity and polypharmacy through interprofessional collaboration, the health conditions of older patients in rural areas may be improved.

Morphine is associated with acute chest syndrome in children hospitalized with sickle cell disease.

OBJECTIVE: To determine if intravenous morphine is associated with acute chest syndrome (ACS) in children with homozygous for hemoglobin S sickle cell disease (SCD) hospitalized with acute pain. METHODS: Health records of patients with homozygous for hemoglobin S SCD aged 2 to 18 years hospitalized with acute pain were reviewed. Patients developed ACS at least 12 hours after emergency department triage; controls did not develop ACS. Survival analyses were performed. RESULTS: There were 38 cases and 45 randomly selected controls. The mean hourly dose of morphine 1, 2, and 3 hours before ACS and cumulative mean morphine dose up to 5 hours before ACS were significantly associated with ACS (P < .05). Adjusted analysis showed that 1 hour before ACS, the mean morphine dose was significantly higher in cases (40 microg/kg) compared with controls (34 microg/kg), and the risk of ACS increased by 23% for each additional 10 microg/kg of morphine received (P = .02). CONCLUSIONS: We recommend close observation for ACS in hospitalized patients with SCD who are receiving morphine.

Should a hospitalized child receive empiric treatment with acyclovir?

BACKGROUND: Herpes simplex encephalitis is associated with substantial morbidity and mortality and may be related to timely diagnosis and treatment. While awaiting the results of testing, hospitalization and empiric treatment with acyclovir is recommended, though the direct and indirect costs associated with this management are substantial. We sought to examine children hospitalized for possible herpes simplex encephalitis, following clinical and laboratory assessment in the emergency department, and empiric treatment with acyclovir, in order to describe the proportion receiving a complete course of treatment; and to identify the clinical variables which are associated with receiving a complete course, as compared with an incomplete course of acyclovir. METHODS: Hospitalized children prescribed acyclovir were included in this case control study. Clinical, laboratory and diagnostic variables were abstracted for children prescribed a complete (≥ 14 days) or an incomplete course (<14 days) of acyclovir. Odds ratios and 95% confidence intervals were calculated. RESULTS: 289 children met eligibility criteria, 30 (10%) received a complete course and 259 (90%) received an incomplete course. A history of mucocutaneous herpes simplex virus infection (p < 0.01), Glasgow Coma Scale ≤ 13 (p = 0.02), focal neurologic findings (p = 0.001) and elevated cerebrospinal fluid white blood cell count (p = 0.05) were associated with a complete course of acyclovir. CONCLUSIONS: Many children did not complete a full course of therapy. Unnecessary testing and treatment is burdensome to families and the health care system. Possible predictive variables include abnormal Glascow Coma Scale, focal neurologic findings and cerebrospinal fluid pleocytosis.

Office-based randomized controlled trial to reduce screen time in preschool children.

OBJECTIVE: To determine if an intervention for preschool-aged children in primary care is effective in reducing screen time, meals in front of the television, and BMI. METHODS: A randomized controlled trial was conducted at a primary care pediatric group practice in Toronto, Canada. Three-year-old children and their parents were randomly assigned to receive a short behavioral counseling intervention on strategies to decrease screen time. The primary outcome 1 year later was parent reported screen time. Secondary outcomes included television in the child's bedroom, number of meals in front of the television, and BMI. RESULTS: In the intention-to-treat analysis at 1 year, there were no significant differences in mean total weekday minutes of screen time (60, interquartile range [IQR]: 35-120 vs 65, IQR: 35-120; P = .68) or mean total weekend day minutes of screen time (80, IQR: 45-130 vs 90, IQR: 60-120; P = .33) between the intervention and control group. Adjusting for baseline BMI, there was a reduction in the number of weekday meals in front of the television (1.6 ± 1.0 vs 1.9 ± 1.2; P = .03) but no differences in BMI or number of televisions in the bedroom. CONCLUSIONS: This pragmatic trial was not effective in reducing screen time or BMI but was effective in reducing meals in front of the screen. Short interventions focused solely on reducing screen time implemented in the primary care practice setting may not be effective in this age group.

Parental factors associated with screen time in pre-school children in primary-care practice: a TARGet Kids! study.

OBJECTIVE: To identify child and parental factors associated with screen time in 3-year-old children. DESIGN: Observational study. SETTING: Participants were recruited from a large primary-care paediatric group practice in Toronto, Canada. SUBJECTS: Healthy 3-year-old children were included. A questionnaire was completed by their parents on screen time. Descriptive statistics and linear regression models were used to assess associations between child screen time and selected factors. Multivariable models included factors from the univariate analysis with P < 0·1. Estimated effects and 95% CI are reported. RESULTS: A total of 157 children were enrolled (91% recruitment). The mean screen time per weekday was 104 min (similar for weekend day). In all, 10% of children had a television (TV) in their bedroom; 59% consumed at least one meal while watching TV; and 81% of parents had household rules about screen time. Controlling for maternal education and age, eating lunch and dinner in front of the screen and mother being employed were associated with an increase in child weekday screen time of 96 (95% CI 30, 192), 42 (95% CI 12, 90) and 36 (95% CI 6, 72) min/d, respectively. Eating lunch in front of the screen and an increase of 1 h of parental screen time were associated with an increase of 78 (95% CI 36, 132) and 12 (95% CI 6, 18) min/d in child weekend screen time. Family rules decreased child weekend screen time by 30 (95% CI 6, 54) min/d. CONCLUSIONS: Interventions that include these important parental factors should be evaluated for their effectiveness in reducing screen time.

Office-based intervention to reduce bottle use among toddlers: TARGet Kids! Pragmatic, randomized trial.

OBJECTIVE: The goal was to determine whether an office-based, educational intervention for parents of 9-month-old children could reduce bottle use and iron depletion at 2 years of age. METHODS: Between January 2006 and 2007, 251 healthy, 9-month-old infants attending a routine health maintenance visit were assigned randomly to intervention or control groups. Parents in the intervention group were introduced to a 1-week protocol to wean their children from the bottle. Iron depletion (ferritin levels of <10 microg/L) and bottle use at 2 years were assessed. RESULTS: A total of 201 children were monitored to 2 years of age (follow-up rate: 81%). Rates of iron depletion (10 [10%] of 102 children vs 13 [13%] of 99 children; P = .42) and milk consumption of >16 oz (16 [16%] of 102 children vs 17 [17%] of 99 children; P = .7) were not significantly different between the 2 groups at 2 years of age. However, children in the intervention group started using a cup 3 months earlier (9 vs 12 months; P = .001), were weaned from the bottle 4 months earlier (12 vs 16 months; P = .004), and were more than one-half as likely to be using a bottle at 2 years of age (15 [15%] of 102 children vs 39 [40%] of 99 children; P = .0004). CONCLUSIONS: This simple intervention administered during a health maintenance visit did not result in a decrease in iron depletion at 2 years of age but did result in a 60% reduction in prolonged bottle use.

Integrating pediatric hospitalists in the academic health science center: practice and perceptions in a Canadian center.

BACKGROUND: The integration of hospitalists in academic settings has been identified as a challenge to the hospitalist movement. The Division of Pediatric Medicine, Hospital for Sick Children, Toronto, was established in 1981, providing a rich resource to examine this field in the academic context and inform academic program development. OBJECTIVES: To explore the characteristics, practice, perceptions, and contributions of pediatric hospital medicine in an academic health science center (AHSC). METHODS: A cross-sectional survey of physicians attending on the pediatric medicine inpatient unit (PMIU) (n = 20). RESULTS: Clinical activity included attending on the PMIU, consultation and comanagement outside the PMIU, and outpatient care of "hospital intense" patients. There was a high level of engagement in research, education, and quality improvement activities. Perceived advantages to a career as a hospitalist included: working in a team; generalist approach to care; stability relative to community practice; intellectually stimulating and rewarding work; and growing area for scholarship. Perceived disadvantages to a career as a hospitalist included: burnout; recognition and respect; and lack of long-term relationships with patients. Themes regarding barriers to establishing a career as a hospitalist in an AHSC were as follows: burnout; time and skills to develop an academic niche; balance between clinical and academic priorities; and system for career advancement. CONCLUSIONS: The contributions of pediatric hospitalists to the academic mission were diverse. Fellowship training, faculty development, and balance between time allocated to direct patient care and academic pursuits should be defined. This will help ensure career development, viability, and realization of excellence in the academic context.

DNA repair gene polymorphisms and genetic predisposition to cutaneous melanoma.

The incidence of cutaneous melanoma is rising rapidly in a number of countries. The key environmental risk factor is exposure to the ultraviolet (UV) component in sunlight. The nucleotide excision repair (NER) pathway deals with the main forms of UV-induced DNA damage. We have investigated the hypothesis that polymorphisms in NER genes constitute genetic susceptibility factors for melanoma. However, not all melanomas arise on sun-exposed sites and so we investigated the hypothesis that genes involved in other pathways for the repair of oxidative DNA damage may also be involved in susceptibility to melanoma. Scotland, with its high incidence of melanoma and stable homogeneous population, was ideal for this case-control study, involving 596 Scottish melanoma patients and 441 population-based controls. Significant associations were found for the NER genes ERCC1 and XPF, with the strongest associations for melanoma cases aged 50 and under [ERCC1 odds ratio (OR) 1.59, P = 0.008; XPF OR 1.69, P = 0.003]. Although an XPD haplotype was associated with melanoma, it did not contain the variant 751 Gln allele, which has been associated with melanoma in some previous studies. No associations were found for the base excision repair and DNA damage response genes investigated. An association was also found for a polymorphism in the promoter of the vitamin D receptor gene, VDR (OR 1.88, P = 0.005). The products of the two NER genes, ERCC1 and XPF, where associations with melanoma were found, act together in a rate-limiting step in the repair pathway.