Voices of Pandemic Care: Perspectives from Pediatric Providers During the First SARS-CoV-2 Surge.

Pediatric providers were called on to care for adult patients well beyond their typical scope of practice during the first surge of the SARS-CoV-2 pandemic. Here, the authors share novel viewpoints and innovations from the perspective of providers, consultants, and families. The authors enumerate several of the challenges encountered, including those faced by leadership in supporting teams, balancing competing responsibilities to children while caring for critically ill adult patients, preserving the model of interdisciplinary care, maintaining communication with families, and finding meaning in work during this unprecedented crisis.

Hypothesizing the body's genius to trigger and self-organize its healing: 25 years using a standardized neurophysics therapy.

We aim for this contribution to operate bi-directionally, both as a "bedside to bench" reverse-translational fractal physiological hypothesis and as a methodological innovation to inform clinical practice. In 25 years using gym equipment therapeutically in non-research settings, the standardized therapy is consistently observed to trigger universal responses of micro to macro waves of system transition dynamics in the human nervous system. These are associated with observably desirable impacts on disorders, injuries, diseases, and athletic performance. Requisite conditions are therapeutic coaching, erect posture, extremely slow movements in mild resistance exercises, and executive control over arousal and attention. To motivate research into the physiological improvements and in validation studies, we integrate from across disciplines to hypothesize explanations for the relationships among the methods, the system dynamics, and evident results. Key hypotheses include: (1) Correctly-directed system efforts may reverse a system's heretofore misdirected efforts, restoring healthier neurophysiology. (2) The enhanced information processing accompanying good posture is an essential initial condition. (3) Behaviors accompanying exercises performed with few degrees of freedom amplify information processing, triggering destabilization and transition dynamics. (4) Executive control over arousal and attention is essential to release system constraints, amplifying and complexifying information. (5) The dynamics create necessary and in many cases evidently sufficient conditions for the body to resolve or improve its own conditions within often short time periods. Literature indicates how the human system possesses material self-awareness. A broad explanation for the nature and effects of the therapy appears rooted in the cascading recursions of the systems' dynamics, which appear to trigger health-fostering self-reorganizing processes when this therapy provides catalytic initial conditions.

Are pediatric critical care medicine fellowships teaching and evaluating communication and professionalism?

OBJECTIVES: To describe the teaching and evaluation modalities used by pediatric critical care medicine training programs in the areas of professionalism and communication. DESIGN: Cross-sectional national survey. SETTING: Pediatric critical care medicine fellowship programs. SUBJECTS: Pediatric critical care medicine program directors. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Survey response rate was 67% of program directors in the United States, representing educators for 73% of current pediatric critical care medicine fellows. Respondents had a median of 4 years experience, with a median of seven fellows and 12 teaching faculty in their program. Faculty role modeling or direct observation with feedback were the most common modalities used to teach communication. However, six of the eight (75%) required elements of communication evaluated were not specifically taught by all programs. Faculty role modeling was the most commonly used technique to teach professionalism in 44% of the content areas evaluated, and didactics was the technique used in 44% of other professionalism content areas. Thirteen of the 16 required elements of professionalism (81%) were not taught by all programs. Evaluations by members of the healthcare team were used for assessment for both competencies. The use of a specific teaching technique was not related to program size, program director experience, or training in medical education. CONCLUSIONS: A wide range of techniques are currently used within pediatric critical care medicine to teach communication and professionalism, but there are a number of required elements that are not specifically taught by fellowship programs. These areas of deficiency represent opportunities for future investigation and improved education in the important competencies of communication and professionalism.

Older persons' reasoning about responsibility for health: variations and predictions.

With many Western societies structured for adults to live longer and take responsibility for their health, it is valuable to investigate how older persons reason about this demand. Using mixed methods, this pilot studied how older persons reason about responsibility for health and their responsibility as a patient. Interviews with a small Swedish sample of 65-84 year olds were analyzed for qualitative characteristics and quantitative complexity in reasoning. Using adult development theory, we predicted at least three different stages of performance in reasoning. Results indicated four different stages: two where there is no actual reasoning about health and responsibility, and two where reasoning does occur, each qualitatively different. Results suggest a long-standing blind spot in health studies, that older people do not comprehend responsibility issues in the same way. There are significant implications for closing this gap between demand to take responsibility and capabilities to do so.

Absence of vaccine-enhanced RSV disease and changes in pulmonary dendritic cells with adenovirus-based RSV vaccine.

The development of a vaccine against respiratory syncytial virus (RSV) has been hampered by the risk for vaccine-enhanced RSV pulmonary disease induced by immunization with formalin-inactivated RSV (FIRSV). This study focuses on the evaluation of vaccine-enhanced pulmonary disease following immunization with AdF.RGD, an integrin-targeted adenovirus vector that expresses the RSV F protein and includes an RGD (Arg-Gly-Asp) motif. Immunization of BALB/c mice with AdF.RGD, resulted in anti-RSV protective immunity and induced increased RSV-specific IFN-γ T cell responses compared to FIRSV. RSV infection 5 wk after immunization with FIRSV induced pulmonary inflammatory responses in the lung, that was not observed with AdF.RGD. Additionally, In the FIRSV-immunized mice following infection with RSV, pulmonary DC increased and Tregs decreased. This suggests that distinct responses of pulmonary DC and Tregs are a features of vaccine-enhanced RSV disease and that immunization with an RGD-modified Ad vaccine does not trigger vaccine-enhanced disease.

Screening the modern girl: intermediality in the adaptation of "Flaming Youth".

In the early 1920s, the film industry seized on the furor over the modern girls' demands for sexual liberty and fulfillment inside and outside of marriage to introduce not only new subject matter, but new modes of addressing its diverse audience. Social upheaval in this period coincided with the media industries' movement toward unprecedented speed of adaptation and cooperation, making possible a powerful new intermediality. The film industry used this to generate layered meanings beyond the confines of the film text, encouraging bold viewers to see through the camouflage with which it sought to appease more traditionalist audience members. With Flaming Youth, through a smokescreen of melodramatic conventions and moral lessons, it delivered a strikingly modern conception of sexuality and marriage to the big screen.

Outcomes following thoracoabdominal resection of neuroblastoma.

OBJECTIVE: To evaluate the intraoperative and postoperative care of children following thoracoabdominal resection of neuroblastoma. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit (PICU) of major pediatric cancer center. PATIENTS: Eighty-eight patients undergoing thoracoabdominal resection of neuroblastoma over a 6-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical data were collected, including: length of PICU stay (LOS-P), duration of mechanical ventilation (MVD), mean arterial blood pressure, central venous pressure (CVP), fluid management, pressor use, and mortality. Twenty-one patients required inotropic/vasopressors support pressors following surgery. Patients who received pressors had longer operative times (p < .05) and received less intraoperative fluid (p < .05), but had the same estimated blood loss and urine output as nonpressor (NP) patients. Among the patients who received pressors, the MVD was 57 hrs, compared with 24 hrs in the NP group (p < .01). The LOS-P was 118 hours in the pressors group, vs. 69 hrs in the NP group (p < .01). The mean arterial blood pressure was lower and the CVP was higher in the pressors group compared with the NP group, and pressors patients received significantly more fluid postoperatively (p < .01). When pressors were initiated at a low CVP (<8), MVD was 39 hrs compared with 71 hrs when pressors were started at a higher CVP (p = .08). LOS-P was only slightly shorter in the low CVP group, 112 hrs vs. 123 hours (p = NS). The PICU mortality rate was 0%. CONCLUSIONS: Patients who received pressors had longer operative times and received less intraoperative fluid. Subsequently, they required more postoperative fluid, which is likely the result of hemodynamic instability leading to longer MVD and LOS-P. A prospective study evaluating operative fluid management and optimal time for initiation of pressors, in addition to the role of catecholamines and cytokines in this unique postoperative patient population is indicated.

Trends in characteristics and country of origin among foreign-trained nurses in the United States, 1990 and 2000.

OBJECTIVES: We describe long-term trends in the characteristics of foreign-trained new entrants to the registered nurse (RN) workforce in the United States. METHODS: Using the 1990 and 2000 US Census 5% Public Use Microdata Sample files, we compared trends in characteristics of US- and foreign-trained new entrants to the RN labor force (n=40827) and identified trends in the country of origin of the foreign-trained new entrants. RESULTS: Foreign-trained RNs grew as a percentage of new entrants to the RN workforce, from 8.8% in 1990 to 15.2% in 2000. Compared with US-trained RNs, foreign-trained RNs were 3 times as likely to work in nursing homes and were more likely to have earned a bachelor's degree. In 2000, 21% of foreign-trained RNs originated from low-income countries, a doubling of the rate since 1990. CONCLUSIONS: Foreign-trained RNs now account for a substantial and growing proportion of the US RN workforce. Our findings suggest foreign-trained RNs entering the United States are not of lower quality than US-trained RNs. However, growth in the proportion of RNs from low-income countries may have negative consequences in those countries.

Access to health care for migrants returning to Mexico.

Continued migration from Mexico over the past several decades has created a large population of elderly Mexicans in the U.S. There is no system in Mexico for those Mexicans who would like to retire there to obtain health insurance during their retirement years. Using a nationally representative dataset of Mexican elders, we explore the current state of health insurance status for Mexican elders with a history of migration to the U.S. We find a robust negative association between years spent in the U.S. and the probability of being insured. Coordination between the U.S. and Mexico on policy options to insure Mexicans migrants may prove beneficial to the social security systems in both countries as well as to migrants themselves.

Self-medication and health insurance coverage in Mexico.

Self-medication is a common practice in many developing countries but little is known about its determinants. This study analyzes the factors that are associated with the use of self-medication in Mexico using the Mexican Health and Aging Study, a new nationally representative survey on adults aged 50 and over. We find that self-medication is related to socioeconomic status and the lack of access to professional healthcare. Our empirical results suggest that lack of government-sponsored health insurance coverage increases the propensity to self-medicate. A 10% increase in the proportion of adults with health insurance coverage could decrease the use of pharmacy consultations by .8% for public sector workers and by 1.7% for private sector workers. Increasing health insurance coverage could reduce the demand for self-medication by making healthcare more affordable and by changing the population perceptions about the benefits of modern medicine.