Variation in Hospital Practices Regarding Marijuana Use in Pregnancy and Lactation.

Background and Objectives: Evidence is lacking on the safety of marijuana (MJ) exposure on the fetus and neonate, and current guidelines vary across professional organizations. We examined variation in hospital practices regarding use of mother's own milk (MOM) in the setting of perinatal MJ exposure based on hospital location and state MJ legal designation. Methods: We conducted a cross-sectional electronic survey of U.S. perinatal health care workers on hospital policies and clinical practice regarding maternal MJ use from November 2021 to April 2022. We analyzed responses from those working in states with legal recreational MJ (REC), MJ legal for medical use only (MED), and illegal MJ (NON), based on legalization status as of 2021. Results: Two thousand six hundred eighty-three surveys were analyzed from 50 states and the District of Columbia, with 1,392 respondents from REC states, 524 from NON states, and 668 from MED states. Hospital policies and practices showed significant differences between facilities from REC and NON states. REC states were more likely to have policies allowing use of MOM from mothers using MJ after delivery and less likely to routinely include cannabinoids in toxicology testing. Hospital policies also varied within individual hospitals between well baby nurseries and neonatal intensive care units. Conclusions: Hospital practices vary widely surrounding provision of MOM in the presence of maternal MJ use, based on state legalization status and hospital unit of care. Clear guidelines across professional organizations regarding perinatal MJ exposure, regardless of legality, are warranted to improve consistency of care and patient education.

Efficacy of Fosphenytoin as First-Line Antiseizure Medication for Neonatal Seizures Compared to Phenobarbital.

Currently used treatment protocols for neonatal seizures vary among centers with limited evidence to support the choice of a given antiseizure medication. Because of concerns about the potential negative impact of phenobarbital on long-term neurodevelopment outcomes, our unit transitioned to fosphenytoin as the first-line antiseizure medication. A retrospective observational cohort study was conducted to compare the acute and long-term outcomes of fosphenytoin and phenobarbital as first-line antiseizure medication for neonatal seizure treatment. The 2 study groups had similar baseline characteristics for neonatal variables as well as maternal antenatal complications. We did not find any differences in the acute outcomes between the 2 groups. However, significantly fewer infants in the fosphenytoin group had moderate-to-severe neurodevelopmental delay at the 18- and 24-month assessments. In conclusion, although both medications were equally efficacious for acute neonatal seizure control, fosphenytoin had the potential for significantly better neurodevelopmental outcomes at 18-24 months of age.

Effect of Transient and Sustained Acute Kidney Injury on Readmissions in Acute Decompensated Heart Failure.

Although acute kidney injury (AKI) is common in heart failure, yet the impact of the onset, timing, and duration of AKI on short-term outcomes is not well studied. AKI was defined as an increase in serum creatinine SCr of ≥0.3 mg/dl or 1.5 times relative to the admission and further categorized as transient AKI (T-AKI: SCr returning to within 10% of baseline); sustained AKI (S-AKI: those with at least 72 hours of hospital stay and did not meet T-AKI); and unknown duration AKI (U-AKI: those with less than 72 hours stay and did not meet T-AKI). Reference category was no AKI (stable or <0.3 mg/dl change in SCr). The main outcome was 30-day all-cause hospital readmission. Unadjusted and adjusted association between AKI category of interest and main outcome was represented as percent and relative risks with 95% CIs. Statistical significance was set at an alpha of 0.05. From the Cerner Health Facts sample, 14,017 of 22,059 available subjects met the eligibility criteria. Approximately, 19.2% of our sample met the primary outcome. Compared with no AKI (readmission rate of 17.7%; 95% CI 16.4% to 18.9%), the adjusted rate of readmission was highest in patients with S-AKI (22.8%, 95% CI 20.8% to 24.8%; p <0.001), followed by 20.2% (95% CI 17.5% to 22.8%; p = 0.05) in T-AKI patients. Compared with no AKI, the adjusted relative risk of 30-day readmission was 1.29 (95% CI 1.17 to 1.42), 1.14 (95% CI 1.00 to 1.31), and 1.12 (95% CI, 1.01 to 1.26) in S-AKI, T-AKI, and U-AKI, respectively. In conclusion, both sustained AKI and patients with transient elevation still remain at a higher risk of readmission within 30 days. Future studies should focus on examining process-of-care after discharge in patients with different patterns of AKI.

Comparison of antithrombotic agents during urgent percutaneous coronary intervention following thrombolytic therapy: A retrospective cohort study.

BACKGROUND: The optimal antithrombotic regimen for urgent percutaneous coronary interventions (PCI) following thrombolytic therapy for ST segment myocardial infarction (STEMI) is currently unknown. METHODS: We performed a retrospective analysis of all patients referred to our institution from January 2005 to July 2014 who underwent urgent PCI within 24 hr after receiving thrombolytic therapy. The patients were divided into three cohorts based on the anticoagulation strategy during PCI-bivalirudin, heparin alone or heparin plus Glycoprotein IIb/IIIa inhibitor (GPI). The primary end point of major adverse cardiovascular events (MACE) was defined as a composite of inpatient death, myocardial infarction (MI) and stroke. Net adverse clinical events (NACE) were defined as a combination of MACE plus major bleeding complications. Univariable, multivariable and propensity-weighted modeling were used to compare MACE and NACE between the three treatment groups. RESULTS: A total of 695 patients met the inclusion criteria during the study period. In the univariable analysis, there was no significant difference treatment in MACE between the three groups (Bivalirudin: 1.2% vs. Heparin + GPI: 4.4%; Heparin alone: 2.7%, P = 0.11). In the reduced logistic regression model, compared to bivalirudin, the odds of NACE was significantly higher with heparin alone (OR: 3.58, 95% CI: 1.21, 10.54, P = 0.02) or with heparin plus GPI (OR: 9.0, 95% CI: 2.83, 28.64, P <0.001). CONCLUSION: In STEMI patients undergoing PCI within 24 hr after thrombolytic therapy, bivalirudin was associated with a strong trend toward reduced bleeding complications as compared to heparin alone or heparin plus GPI. The optimal antithrombotic regiment for urgent PCI following thrombolytic therapy is currently unknown. Our study demonstrated that use of bivalirudin during PCI following thrombolytic therapy is associated with a trend toward reduced bleeding complications compared to heparin alone or heparin plus GPI. Large randomized trials of adjunctive anticoagulation during PCI in this complex post-thrombolytic population are warranted. © 2017 Wiley Periodicals, Inc.

Ambulatory Morning Report: A Case-Based Method of Teaching EBM Through Experiential Learning.

OBJECTIVES: Evidence-based medicine (EBM) skills are important to daily practice, but residents generally feel unskilled incorporating EBM into practice. The Kolb experiential learning theory, as applied to curricular planning, offers a unique methodology to help learners build an EBM skill set based on clinical experiences. We sought to blend the learner-centered, case-based merits of the morning report with an experientially based EBM curriculum. We describe and evaluate a patient-centered ambulatory morning report combining the User's Guides to the Medical Literature approach to EBM and experiential learning theory in the internal medicine department at Baystate Medical Center. METHODS: The Kolb experiential learning theory postulates that experience transforms knowledge; within that premise we designed a curriculum to build EBM skills incorporating residents' patient encounters. By developing structured clinical questions based on recent clinical problems, residents activate prior knowledge. Residents acquire new knowledge through selection and evaluation of an article that addresses the structured clinical questions. Residents then apply and use new knowledge in future patient encounters. RESULTS: To assess the curriculum, we designed an 18-question EBM test, which addressed applied knowledge and EBM skills based on the User's Guides approach. Of the 66 residents who could participate in the curriculum, 61 (92%) completed the test. There was a modest improvement in EBM knowledge, primarily during the first year of training. CONCLUSIONS: Our experiential curriculum teaches EBM skills essential to clinical practice. The curriculum differs from traditional EBM curricula in that ours blends experiential learning with an EBM skill set; learners use new knowledge in real time.

Integrating Quality Improvement With Graduate Medical Education: Lessons Learned From the AIAMC National Initiatives.

Quality and safety initiatives (QI) are national priorities for health care, yet the role of residents in QI has not always been clear. In academic medical centers, residents and fellows play a critical role in patient care and, as such, their integration into QI presents a unique opportunity to affect change. The Alliance for Independent Academic Medical Centers (AIAMC) began a national campaign in 2007 to harness the potential of infusing graduate medical education (GME) with QI, through their AIAMC National Initiative: Improving Patient Care Through Medical Education. This article describes the National Initiatives (NIs) and the reflections of NI participants, including their reflections on the goals they set for integrating GME with QI, the barriers they encountered along the way, and their advice to others beginning the challenge. These reflections provide some insight into the pathways of promoting organizational change and offer practical insight and inspiring advice for others embarking on the journey.

Cultivating Medical Education Research Mentorship as a Pathway Towards High Quality Medical Education Research.

The lack of effective and consistent research mentorship and research mentor training in both undergraduate medical education (UME) and graduate medical education (GME) is a critical constraint on the development of innovative and high quality medical education research. Clinical research mentors are often not familiar with the nuances and context of conducting education research. Clinician-educators, meanwhile, often lack the skills in developing and conducting rigorous research. Mentors who are not prepared to articulate potential scholarship pathways for their mentees risk limiting the mentee's progress in early stages of their career. In fact, the relative paucity of experienced medical education research mentors arguably contributes to the perpetuation of a cycle leading to fewer well-trained researchers in medical education, a lack of high quality medical education research, and relative stagnation in medical education innovation. There is a path forward, however. Integration of doctoral-level educators, structured inter-departmental efforts, and external mentorship provide opportunities for faculty to gain traction in their medical education research efforts. An investment in medical education research mentors will ensure rigorous research for high quality innovation in medical education and patient care.

Site of initial diabetes education does not affect metabolic outcomes in children with T1DM.

OBJECTIVE: To determine the difference in metabolic outcomes at 1 and 2 yr post type 1 diabetes mellitus (T1DM) diagnosis in children depending on the site of initial diabetes education: inpatient, vs. outpatient, vs. mixed locations. PATIENTS AND METHODS: A retrospective chart review was performed for all patients with new onset antibody positive T1DM, aged 1-18 yr old, diagnosed in 2004-2009, and followed for at least 1 yr in a diabetes program at a tertiary academic health care center. Patients were divided into three groups based on the site of initial diabetes education: inpatient, outpatient, and mixed locations. The primary outcome was A1c at 1 and 2 yr. RESULTS: We enrolled 238 children (133 boys), mean (± SD) age 9.9 (± 4.1). A1c levels did not differ among inpatient, outpatient, and mixed location groups at 1 and 2 yr post diagnosis (p = 0.85 and p = 0.69, respectively) and the long-acting insulin doses were similar at 1 and 2 yr (p = 0.18 and p = 0.15, respectively). There was no difference in the number of acute diabetes complications between the groups. At 1 yr, 21.8% of outpatient-educated children were on insulin pump therapy in contrast to 14.7% of inpatient and 2.7% of mixed educated groups (p = 0.04). CONCLUSIONS: Families of children with new onset T1DM can be successfully and safely educated in a clinic setting. An 'education' admission for a medically stable patient is not necessary most of the time, however, clinical judgment and careful assessment of the family's coping and learning capabilities are important when determining the site of education.

Near-infrared spectroscopy assessment of tissue saturation of oxygen in torsed and healthy testes.

OBJECTIVES: The objective was to assess whether testicular torsion is associated with low testicular tissue saturation of oxygen (StO2 ) as measured by transscrotal near-infrared spectroscopy (NIRS) and to compare the differences in NIRS values between testicles of the same patient, both in patients with testicular torsion and in healthy controls. METHODS: This was an observational study of healthy controls and patients with surgically confirmed testicular torsion who were recruited from males under 30 years of age presenting to the emergency department (ED). The hypothesis was that the difference in NIRS values for the control's two testicles would be zero, and that the difference between the torsed and healthy testicles on an individual patient would not be zero. Based on animal data, the study was powered to detect an absolute difference of StO2 of 47%. RESULTS: The mean StO2 for the left control patients' testicles was 73.6% (95% confidence interval [CI] = 68.0% to 79.1%) and the mean StO2 for the right controls' testicles for controls was 73.6% (95% CI = 66.9% to 80.4%; n = 17). The absolute difference in NIRS StO2 for left minus right for each individual was 3.5% (95% CI = 1.8% to 5.4%), which was significantly different (p = 0.0007), and refuted the hypothesis that there was no significant difference in StO2 between left and right testes in healthy patients. In the testicular torsion group, the torsed side had a mean StO2 of 82.8% (95% CI = 68.7% to 96.9%), and the contralateral nontorsed testes had a mean of 85.8% (95% CI = 72.3% to 99.3%). The mean StO2 difference, nontorsed minus torsed was 3.0% (range = -1% to 9%, 95% CI = -2% to 8%; p = 0.174), refuting the hypothesis that torsed testes would demonstrate significantly lower values for StO2 . CONCLUSIONS: While pilot animal investigations support a potential role for transscrotal NIRS for the detection of testicular torsion, this first clinical translation of animal findings reveals that the investigated, transcutaneous, reflectance geometry NIRS device failed to demonstrate symmetric oxygenation of left and right testes in healthy controls and also failed to demonstrate depressed tissue saturation of oxygen values in patients with confirmed testicular torsion. While limited by a small sample size, other problems such as inability to calibrate depth of measurement of StO2 may have led to falsely elevated readings in patients with torsion.

A predictive model for SIVH risk in preterm infants and targeted indomethacin therapy for prevention.

Prophylactic indomethacin may decrease Severe Intraventricular Hemorrhage (SIVH). Our goal was to develop a predictive model for SIVH using parameters available by six hours of age. De-identified data for preterm infants born ≤ 34 weeks gestational age was abstracted from Vermont Oxford Network database. Using clinical variables available by 6 hrs of age the model was developed, and validated. Statistical methods were used to evaluate the ability of the model to discriminate infants with and without SIVH and, to compare observed and predicted risk. The model achieved excellent discrimination as indicated by ROC curve of 0·85. A good agreement was noted between observed and predicted risk (HLtest: p = 0·22). Application of the model to patients receiving indomethacin suggests a benefit at the highest risk levels. We have developed a valid predictive model for predicting SIVH as well as shown that exposure to indomethacin decreases the incidence of SIVH overall.

Distinguishing benign from malignant mesothelial cells in effusions by Glut-1, EMA, and Desmin expression: an evidence-based approach.

Distinguishing malignant mesothelioma (MM) from reactive mesothelial hyperplasia (RM) may be difficult in effusions. This study tested the hypothesis that immunocytochemistry (IC) in effusion cell blocks (CB) can distinguish MM from RM and that the results may be applied to individual specimens. External validation of a risk score (RS) model associating sensitivity and specificity was applied to an external set of MM and RM specimens from a separate institution. Forty three effusion cytology CBs of 25 confirmed malignant mesotheliomas were compared to CBs of 23 benign mesothelial effusions without inflammation and 13 reactive mesothelial proliferations associated with inflammation. Glut-1, EMA, and Desmin expression were evaluated by immunocytochemistry on CBs. Each antibody was compared using ROC values, where the area under the curve (AUC) was 0.90, 0.82, and 0.84 for Glut-1, EMA, and Desmin, respectively. Logistic regression (LR) analysis was applied to a combination of Glut-1 and EMA. A combined ROC curve was modeled for Glut-1 and EMA (AUC = 0.93). A RS = 2 × (Glut-1%) + 1 × (EMA%) was created from this ROC curve. When applied to an external set of MM and RM, the RS resulted in an ROC with AUC = 0.91. In conclusion, a RS derived from a LR of Glut-1 and EMA IC greatly improves the distinction between MM from RM cells in individual effusions. The study illustrates principles of evidence-based pathology concerning internal and external test performance in the differential diagnosis of MM versus RM.

Vitamin D and retinopathy in adults with diabetes mellitus.

OBJECTIVE To explore a hypothesized association between vitamin D inadequacy and diabetic retinopathy. METHODS This cross-sectional study analyzed data from individuals aged 40 years and older with diabetes mellitus who participated in the interview and medical examination components of the Third National Health and Nutrition Examination Survey conducted from October 1, 1988, through September 30, 1994. The relationship between diabetic retinopathy and serum 25-hydroxyvitamin D concentration was evaluated using regression analysis in the presence of demographic and clinical covariates, such as age, race, obesity, and persistent hyperglycemia. RESULTS On the basis of the 1790 adults with diabetes who met the study's inclusion criteria, the percentage of individuals with vitamin D deficiency increased with severity of retinopathy: no retinopathy, 27.9%; mild, 28.2%; moderate to severe, 43.2%; and proliferative, 64.6% (P = .01). Regression analysis of retinopathy severity vs serum 25-hydroxyvitamin D concentration did not demonstrate a statistically significant relationship between the two variables (P = .07). CONCLUSIONS This study found an association between severity of diabetic retinopathy and prevalence of vitamin D deficiency, but the findings were inconclusive about the existence of a relationship between retinopathy severity and serum 25-hydroxyvitamin D concentration. Given previous research indicating possible anti-inflammatory and antiangiogenic properties of vitamin D, the connection between vitamin D and diabetic retinopathy warrants further study.

Condom availability program in an inner city public school: effect on the rates of gonorrhea and chlamydia infection.

PURPOSE: Sexual activity and sexually transmitted infection (STI) rates are high in adolescents. In this study, we sought to determine whether the initiation of a school-based condom availability program was associated with a decrease in STI rates. METHODS: We compared the rates of STIs in 15-19-yr-olds reported to the Massachusetts Department of Public Health for the 3 years before and after a condom availability program was introduced in Holyoke, MA, as compared with a similar city, Springfield, MA, which did not have such a program. RESULTS: Holyoke males, aged 15-19 years, showed a 47% decrease in the rates of gonorrhea and chlamydia infection combined over the 3 years after the implementation of the condom availability program, whereas similar aged males in Springfield had a 23% increase in the rates of gonorrhea and chlamydia infection. The difference in regression slopes in this period was significant (p < .01). Females, aged 15-19 years, from either Holyoke or Springfield, showed moderate, variable changes in rates of STIs after 2005; there was no significant difference in the regression slopes of STIs between Holyoke and Springfield. CONCLUSIONS: Initiating a condom availability program in a city's high school was associated with a decrease in STI rates for 15-19-yr-old males but not females.

High flow nasal cannulae therapy in infants with bronchiolitis.

OBJECTIVES: To determine whether the introduction of heated humidified high-flow nasal cannulae (HFNC) therapy was associated with decreased rates of intubation for infants <24 months old with bronchiolitis admitted to a pediatric intensive care unit (PICU). STUDY DESIGN: A retrospective chart review of infants with bronchiolitis admitted before and in the season after introduction of HFNC. RESULTS: In the season after the introduction of HFNC, only 9% of infants admitted to the PICU with bronchiolitis required intubation, compared with 23% in the prior season (P=.043). This 68% decrease in need for intubation persisted in a logistic regression model controlling for age, weight, and RSV status. HFNC therapy resulted in a greater decrease in respiratory rate compared with other forms of respiratory support, and those infants with the greatest decrease in respiratory rate were least likely to be intubated. In addition, median PICU length of stay for children with bronchiolitis decreased from 6 to 4 days after the introduction of HFNC. DISCUSSION: We hypothesize that HFNC decreases rates of intubation in infants with bronchiolitis by decreasing the respiratory rate and work of breathing by providing a comfortable and well-tolerated means of noninvasive ventilatory support.

The abnormal measures of iron homeostasis in pediatric obesity are associated with the inflammation of obesity.

Objectives. To determine if the low iron state described in obese children is associated with the chronic inflammatory state seen in obesity. Study Design. Obese children age from 2 to 19 years seen at a weight management clinic were studied prospectively. Data were collected on age, gender, BMI, BMI z-score, serum iron, ferritin, transferrin saturation, free erythrocyte protoporphyrin, high sensitivity creactive protein (hs-crp), and hemoglobin concentration. Results. 107 subjects were studied. Hs-crp levels correlated positively with BMI (P < .001) and BMI z-score (P = .005) and negatively with serum iron (P = .002). 11.2% of subjects had low serum iron. Median serum iron was significantly lower for subjects with American Heart Association high risk hs-crp values (>3 mg/L) compared to those with low risk hs-crp (<1 mg/L), (65 mcg/dL versus 96 mcg/dL, P = .016). After adjusting for age, gender, and BMI z-score, serum iron was still negatively associated with hs-crp (P = .048). Conclusions. We conclude that the chronic inflammation of obesity results in the low iron state previously reported in obese children, similar to what is seen in other inflammatory diseases.

Emesis predicts bacteremia in immunocompromised children with central venous catheters and fever.

BACKGROUND: The objective of this study was to determine whether vomiting at presentation of a febrile illness in immunocompromised children with central venous catheters (CVCs) predicts bacteremia. METHODS: A chart review was conducted of children who were admitted to the hospital with a diagnosis of cancer or aplastic anemia, fever, and a CVC. Data were collected on the presence or absence of vomiting, catheter type, presence or absence of severe neutropenia, C-reactive protein (Crp) value, and culture results. RESULTS: There were 143 admissions for fever among 48 children. Among 35 admissions with emesis, 19 included bacteremia; whereas, among 107 admissions without emesis, 19 included bacteremia (P < .001). There was a 5-fold greater risk of bacteremia in children with children without vomiting (odds ratio, 5.50; 95% confidence interval, 2.20-13.67). Gram-negative organisms were more likely to be associated with vomiting than Gram-positive organisms (P = .008). Children with severe neutropenia did not have a significantly higher rate of bacteremia than children who had neutrophil counts >500 cells/mm(3). Other factors that were associated with higher rates of bacteremia were underlying diagnosis and catheter type. CONCLUSIONS: Immunocompromised children with a CVC and a fever who presented with vomiting were more likely to have bacteremia than similar children who presented without vomiting. Gram-negative organisms were more likely to be associated with emesis than Gram-positive organisms. The absence of severe neutropenia was not associated with a decreased likelihood of bacteremia. These findings may be useful in identifying children who are at high risk for bacteremia and in determining initial, empiric therapy.