Safe at home: prevention of pediatric unintentional injuries.

BACKGROUND: Unintentional injuries are the leading cause of death in children in the United States. Studies have shown that parent adherence to safety guidelines is improved when education is provided in conjunction with safety equipment. METHODS: This study surveyed parents about specific injury prevention behaviors regarding medication and firearm storage and provided education and safety equipment for safe practice of these behaviors. The project took place in a pediatric emergency department (PED) and partnered with the hospital foundation and the school of medicine. Inclusion criteria were families visiting a freestanding PED in a tertiary care center. Participants completed a survey conducted by a medical student approximately 5 min in length. The student then provided each family with a medication lock box (if children ≤ 5 years old lived in the home), firearm cable lock, and education for safe storage of medications and firearms in the home. RESULTS: The medical student researcher spent a total of 20 h in the PED from June to August 2021. 106 families were approached to participate in the study, of which 99 agreed to participate (93.4%). A total of 199 children were reached with ages ranging from less than 1 year old to 18 years old. A total of 73 medication lockboxes and 95 firearm locks were distributed. The majority (79.8%) of survey participants were the mother of the patient and 97.0% of participants lived with the patient > 50% of the time. For medication storage, 12.1% of families store medications locked and 71.7% reported never receiving medication storage education from a healthcare professional. Regarding firearms, 65.2% of participants who reported having at least 1 firearm in the home stored firearms locked and unloaded with various methods of storage. 77.8% of firearm owners reported storing ammunition in a separate location from the firearm. Of all participants surveyed, 82.8% reported never receiving firearm storage education from a healthcare professional. CONCLUSIONS: The pediatric ED is an excellent setting for injury prevention and education. Many families are not storing medications and firearms safely, demonstrating a clear opportunity to increase knowledge in families with young children.

Implementation and Maturity of Clinical Learning Environment Components Across Pediatric Residency Programs.

OBJECTIVE: Pediatric residency programs prioritize clinical learning environment components depending on resource availability, institutional constraints and culture, and accreditation requirements. However, there is limited literature on the landscape of implementation and maturity of clinical learning environment components across programs nationally. METHODS: We used Nordquist's clinical learning environment conceptual framework to craft a survey around the implementation and maturity of learning environment components. We performed a cross-sectional survey of all pediatric program directors enrolled in the Pediatric Resident Burnout-Resiliency Study Consortium. RESULTS: Components with the highest implementation rates were resident retreats, in-person social events, and career development, while components least likely to be implemented were scribes, onsite childcare, and hidden curriculum topics. The most mature components were resident retreats, anonymous systems for reporting patient safety events, and faculty-resident mentoring programs, while the least mature components were use of scribes and formalized mentorship for trainees underrepresented in medicine. Learning environment components included in the Accreditation Council of Graduate Medical Education Program Requirements were significantly more likely to be implemented and mature than nonrequired components. CONCLUSIONS: To our knowledge, this is the first study to use an iterative and expert process to provide extensive and granular data about learning environment components for pediatric residencies.

Important Advances in Pediatric Injury Prevention.

In children, injuries are the leading cause of death, a major source of disability, and the number one cause of death for children after the first year of life. The principles of injury prevention include surveillance, coalitions, communication, interventions, and evaluation. This article discusses a number of common pediatric injuries and their prevention strategies. This review article addresses key components of injury prevention and specifically addresses the following injuries: motor vehicle crashes (with a section on teen driver crashes, sleep-related injury, and death), poisoning, all-terrain vehicle crashes, drowning, and firearm injuries. Injuries are preventable occurrences that can result in devastating sequelae or death. We present an overview of the more common pediatric injuries along with injury-prevention strategies.

Self-Reported Usage of Safety Equipment Provided Through a Community Partnership Approach to Injury Prevention in the Pediatric Emergency Department.

OBJECTIVES: Previous studies have shown that educational programs in conjunction with provision of free or low-cost safety equipment increases the likelihood of parents changing behaviors at home. This project surveyed caregivers in the pediatric emergency department (ED) about safety behaviors before and after provision of education and safety equipment related to medication storage, firearm storage, and drowning. METHODS: A convenience sample of families presenting to the ED for any complaint with a child of any age were approached for participation in this feasibility study. Exclusion criteria included patients presenting for a high acuity problem (Emergency Severity Index 1 or 2) and non-English-speaking caregivers. Enrollment, surveys, and educational intervention were performed by the graduate student investigator from the School of Public Health. Participants were surveyed regarding presence of firearms and medications within the home and their storage practices. Additional questions included relationship to the patient, number and age of children younger than 18 years in the home, and zip code of residence. Educational handouts were reviewed, and participants were provided with a medication lock box, trigger lock, toilet lock, and/or pool watcher tag as indicated by answers given to the survey questions. Process measures were collected for number of products given out, number of children potentially affected by the intervention, and time spent by the investigator. Follow-up calls assessed use of the products provided. RESULTS: The student investigator spent a total of 180 hours and enrolled 357 caregivers accounting for 843 children. Fifty-seven percent of the participants answered the follow-up phone call. Only 9% initially reported that they stored medications in a locked or latched place. Medication lock boxes were given to 316 participants. On follow-up, 88% of those who received a lock box reported using it to store medications and 86% reported satisfaction with the lock box and how it worked. Of the 161 participants who admitted to gun ownership, 45% reported storing their guns locked and unloaded. Of those who reported unsafe manners of gun storage, 96% also reported unsafe manners of medication storage. Although only 161 participants endorsed gun ownership, 236 participants took a gun lock when offered. At follow-up, 66% of participants had used the gun lock and 67% of participants who took the gun lock reported satisfaction with the device. For water safety, 195 toilet latches and 275 drowning prevention lanyards were provided. On follow-up, 48% of those who had received a toilet latch were using it and 62% reported satisfaction with the device. Data were not collected on use of or satisfaction with the drowning prevention lanyards. CONCLUSIONS: Families often report unsafe home storage of medications and firearms, which together account for a large amount of morbidity and mortality in pediatrics. Drowning risk for young children is ubiquitous in the home setting, and low rates of use of home safety devices indicates need for further education and outreach on making the home environment safe. Despite relying on self-reported behaviors and the risk of reporting bias skewing the data, the behaviors reported in the preintervention survey were still very unsafe, suggesting that children may have a much higher risk of injury in the actual home environments. The ED is traditionally thought of as a place to receive care when injuries happen, but any encounter with families should be seen as an opportunity for injury prevention messaging. Partnering with a local school of public health and other community resources can result in the establishment of a low-cost, consistent, and effective injury prevention program in the pediatric ED that reaches a large number of individuals without the added burden of additional tasks that take time away from already busy ED providers and staff.

Utilization of Monitored Beds for Children Admitted With Unintentional Poisonings.

OBJECTIVES: Children with unintentional poisonings (UPs) are frequently admitted to monitored beds (MBs), though most require minimal interventions. We aimed to (1) describe clinical factors and outcomes for children admitted for UPs and (2) identify clinical factors associated with MB placement. METHODS: In this single-center retrospective cohort study, we studied patients younger than 6 years admitted from the emergency department (ED) for UPs over a 5-year period to a quaternary-care children's hospital. Primary outcome was disposition (MB vs non-MB). Secondary outcomes included length of stay, escalation of inpatient care, 7-day readmission, and death. Covariates included age, certainty of ingestion, altered mental status, and ED provider training level. Subanalysis of drug class effect on disposition was also studied. Associations of clinical factors with MB placement were tested with multivariable logistic regression. RESULTS: Of 401 patients screened, 345 subjects met inclusion criteria. Most subjects (308 of 345 [89%]) were admitted to MBs. Children with high certainty of ingestion (adjusted odds ratio [aOR], 4.2; 95% confidence interval [CI], 1.52-11.58), altered mental status (aOR, 5.82; 95% CI, 2.45-13.79), and a fellow (vs faculty) ED provider (aOR, 2.34; 95% CI, 1.04-5.24) were more likely to be admitted to MBs. No escalations of care, readmissions, or deaths occurred. Exposures to cardiac drugs had increased MB placement (aOR, 6.74; 95% CI, 1.93-23.59). CONCLUSIONS: The majority of children admitted for UPs were placed in MBs. Regardless of inpatient placement, no adverse events were observed, suggesting opportunities for optimized resource utilization. Future research may focus on direct costs, inpatient interventions, or prospective outcomes to validate these findings.

Storage of Medications: A Survey of Families in the Pediatric Emergency Department.

OBJECTIVES: To evaluate caregivers' practice of prescription medication storage, particularly of opioid medications, as well as to provide educational materials to families about the opioid crisis. METHODS: Caregivers of patients in a pediatric emergency department were asked to participate in a survey about medication storage practices and beliefs, focusing on opioid medications. Data were collected through a survey documenting demographic data along with knowledge and behaviors of medication storage. Brief education about the US opioid crisis and safe storage was provided. RESULTS: In total, 233 families participated; 3 families declined; 11.5% of caregivers reported storing prescribed medications in a locked or latched place, although most store them "out of reach." Most believed their child or children's friends could not easily access their medications (81.8%). Families who did not keep their medications in locked or latched places had never thought about it (39.7%). In total, 33% of respondents were unaware of the opioid crisis; 87.4% of caregivers said they would use a medication lock box if given one. CONCLUSIONS: Many caregivers are not aware of the opioid crisis and do not keep opioid medications locked up. Half of the caregivers surveyed stated they "never thought about" locking up medications. Most parents would use a lock box if given to them. This opens the door to further study, education, and interventions.

Social Media Changes in Pediatric Residency Programs During COVID-19 Pandemic.

OBJECTIVE: To describe pediatric residency program's virtual presence and opportunities for the 2021 application cycle. METHODS: A total of 202 pediatric residency programs from the Electronic Residency Application Service (ERAS) were reviewed for departmental and residency Twitter, Instagram, and Facebook accounts. These accounts, residency websites, and the Visiting Student Application Service (VSAS) were reviewed for open house opportunities and virtual subinternships. All data were collected from October 12-15, 2020. RESULTS: A total of 261 social media accounts were identified. 123 (61%) programs had at least one account, with 32 (16%) programs having presence on all 3 platforms. 68 (34%) programs established new accounts after March 1, 2020. Instagram appeared most utilized with 106 (52%) programs having accounts. A total of 115 virtual open house opportunities were offered with most offers on Instagram by 61 (30%) programs. Only 2 virtual subinternships were listed on program websites, 2 on Twitter, 1 on Instagram, and 1 on Facebook. CONCLUSIONS: COVID-19 increased the number of social media accounts used by residency programs. Approximately one-third of all accounts were created after March 1, 2020. However, only 16% of residency programs have a presence on all 3 platforms, allowing for more online growth.

Descriptive Epidemiology of Pediatric Drowning Patients Presenting to a Large Southern US Children's Hospital.

OBJECTIVES: Drowning is the leading cause of death for children ages 1 to 4, and it is among the leading causes of death for children of all ages. National data show disparities in drowning risk for certain racial groups. This study aimed to describe characteristics of patients presenting after a drowning event to guide focused drowning prevention outreach efforts. METHODS: This was a retrospective chart review study designed to analyze the epidemiologic and demographic characteristics of drowning-related injuries and deaths that presented to a large, urban, southern US pediatric hospital from 2016 to 2019. All patients aged 0 to 19 years were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes for drowning or submersion injuries. RESULTS: One hundred sixty-two patients met the inclusion criteria for the study. Submersion injuries were most common in the 1- to 5-year-old age group. Fifty-eight percent of patients were male. The analysis of race showed that 65% of patients were White and 33% of patients were Black. Pools were the setting for 78% of drowning events. Fifty-four percent of patients received cardiopulmonary resuscitation. Sixty-four percent of patients required hospitalization after the injury. CONCLUSIONS: Characteristics of drowning victims may vary significantly from national data, depending on the area involved. This finding highlights the need for assessing local data to better inform local outreach. Further research is necessary to understand why such variance exists. Drowning prevention education, tailored toward pool safety and preschool-age children, should be a focus of injury prevention efforts.

Using a Resident-Led School Outreach Program to Improve Knowledge of All-Terrain Vehicle Safety.

BACKGROUND: During the past decade, all-terrain vehicle (ATV)-related injuries treated in US emergency departments decreased by 33%, down to approximately 100,000 injuries in 2016. In comparison, the number of children evaluated for ATV injuries in the Children's of Alabama emergency department more than doubled between 2006 and 2016, counter to the national trend. The American Academy of Pediatrics guidelines state that ATV operators should be at least 16 years old; however, children younger than 16 continue to represent almost one-third of all ATV-related injuries nationwide, and nearly all of the injuries to children in Alabama. METHODS: Using surveillance data from the Children's of Alabama hospital electronic medical record database, several Alabama counties near Birmingham were identified as having an increased number of children with ATV-related injuries in 2016. The Safety Tips for ATV Riders (STARs) program, developed in Iowa, was provided to middle school students in these counties by pediatric residents. Surveys were anonymously administered to children before and after the program and included information about demographics, knowledge of safe ATV practices, and the likelihood of using the education afterward. RESULTS: In total, 525 students participated in January 2019; their ages ranged from 11 to 15 years and the proportion of males and females was equivalent. More than 50% of the children reported riding ATVs in the last 12 months, and of these riders, 47% reported never wearing a helmet when riding. Initially, only 20% of the overall participants knew ATVs were not intended for passengers, 20% knew the recommended engine size for their age, and 57% knew that Alabama law prohibits riding on public roads. After education, this increased to 91%, 90%, and 89%, respectively. Before the STARs program, only 6% knew all three correct answers, whereas 80% answered all of the questions correctly on the postprogram survey. After the program, 34% reported they were very likely/likely to use this information in the future. CONCLUSIONS: The STARs program dramatically improved short-term ATV safety knowledge, and many participants reported they were likely to subsequently use the safe practices presented. School-based programs, such as STARs, may help increase ATV safety awareness and change behaviors in high-risk age groups. This training may be successfully provided by various motivated individuals, including medical residents.

Unintentional Opioid Ingestions Presenting to a Pediatric Emergency Department.

OBJECTIVES: The purpose of this study was to describe unintentional opioid exposures in young children, including demographics, medical interventions, and clinical outcomes. METHODS: This was a retrospective, cross-sectional study of children 0 to 6 years of age with possible opioid exposure over a 3-year period (July 2010 to June 2013). Data collected included sex, age, specific drug, whether they were referred to the emergency department (ED) by the Regional Poison Control Center, presence of symptoms, therapeutic interventions, ED disposition, and clinical outcomes for admitted patients. RESULTS: Median age of patients included in the study was 2 years, and 64% of these children were male. The most common drug of exposure was buprenorphine/naloxone. Of the 429 charts screened, 140 patients were reported to be symptomatic and referred to the ED, of which 113 patients actually presented to the ED. An additional 122 patients presented to the ED without Regional Poison Control Center referral. Of the total 235 patients presenting to ED, 76 (32%) received a therapeutic intervention. Of 231 total opioid exposures, 31 exposures were administered naloxone. Three children underwent endotracheal intubation. Sixty-five patients were hospitalized, with a median length of stay of 1 day. Although there were no fatalities, 1 child suffered severe morbidity (anoxic brain injury). CONCLUSIONS: While opioid exposures in young children are a common and potentially life-threatening problem, most children remain asymptomatic. The majority of patients are able to be discharged from the ED after observation, and of those who are admitted, most have favorable outcomes and brief hospital stays. A small number of these patients require considerable medical interventions.

Effect of lock boxes and education on safe storage of medications.

BACKGROUND: Safe medication storage is a proven barrier to ingestions in the pediatric population, but caregivers are often unaware of the importance of safe storage practices or do not have a safe place to store medications. Caregivers may also not be fully aware that the patterns of opioid use and misuse have recently reached crisis levels. The objectives of this study were to define medication storage practices and knowledge of the opioid crisis of participants and to assess the effectiveness of an emergency department intervention on safe medication storage. METHODS: This was a prospective interventional study of caregivers in an urban pediatric emergency department (ED) on safe medication storage and the opioid crisis. Questions assessed the caregivers' current perceptions and practices related to medication storage and disposal, and opioid crisis awareness. The intervention included verbal instruction about recommended safe storage methods and the opioid crisis, provision of a medication safety handout, and distribution of a medication lock box. A follow-up phone survey conducted 2 weeks later asked participants about use of and satisfaction with the lock box. Frequencies of safe storage behaviors were calculated, and the chi-square statistic was used to compare storage behavior after the intervention. RESULTS: Fifty caregivers of 112 children were enrolled. Only 4% reported they currently stored medications in a locked or latched place. Thirty-eight percent reported their main barrier to storing medications safely was that they did not have a locked or latched storage location. Fifty percent were unaware of the opioid crisis. Ninety-two percent reported they would use a lock box if given one. Twenty-eight participants (56%) responded to the follow-up phone call survey 2 weeks later. At follow up 90% (25/28) reported they placed their medications within the provided lock box (p < 0.00001). Ninety-two percent reported being "very satisfied" with the lock box and how it works. CONCLUSIONS: Despite widespread reporting on this issue, many caregivers remain unaware of safe medication storage practices and the opioid crisis. Providing medication lock boxes removes a commonly reported barrier to safely storing medications and improved reported practices.

Evaluating teen driving knowledge and behaviors following educational outreach.

BACKGROUND: Teen driving educational events are an effective strategy to increase adolescent drivers' awareness of safe driving practices. The objectives of this study were to evaluate changing rates of self-reported driving practices and knowledge of the state Graduated Driver Licensing laws (GDL) by teens over a nine-year period in a single state. METHODS: This was a prospective observational study of high school students ages 14 to 19 years old. Paper surveys were sent to the high schools participating in teen driving educational events (9 schools in 2009 and 4 schools in 2018). Students in those schools completed surveys prior to the events. Students completing the anonymous survey were invited to the event. Questions evaluated awareness of state GDL and safe and risky driving behaviors. Statistical comparisons of survey answers from 2009 to 2018 were analyzed using the z test of proportions (2 tailed, alpha 0.05). RESULTS: A total of 397 students participated in 2018 with ages ranging from 14 to 19 years. Racial distribution was 81% white, 14% black, and there were 57% female participants. Only 69% (n = 273) reported "always" wearing their seatbelt. When asked about high risk behaviors, 78% (n = 309) of adolescents reported they personally "never" text while driving; 97% (385); never drive after drinking, and 87% (n = 344) never ride with someone who has been drinking. Compared to 2009 participants (1304 students, 9 schools from central part of state), the students in 2018 (4 schools scattered across state) reported wearing seatbelts "always" (n = 69% vs 39%; p < 0.001); "never texting while driving" (78% vs 33%; p < 0.001); and "never drinking and driving" (97% vs 88%; p < 0.001). No significant difference in rates of students having taken a driving education class nor driving over speed limit were reported. CONCLUSION: Results are encouraging that participants in 2018 report more use of seatbelts, less texting while driving, less drinking while driving and lower numbers of being in MVC than in 2009. However, rates of high-risk driving behaviors are still concerning.

Child passenger safety education in the emergency department: teen driving, car seats, booster seats, and more.

BACKGROUND: The leading cause of death in children less than 19 years old is motor vehicle crashes (MVC). Non-use or improper use of motor vehicle car seats significantly adds to the morbidity and mortality. Emergency department (ED) encounters provide an opportunity for caregiver education. Our objective was to determine the effect of an educational intervention on knowledge and counseling behaviors of pediatric ED nurses regarding child passenger safety (CPS). METHODS: A pre/post educational intervention study was conducted with nursing staff in an urban ED. Responses to CPS related knowledge and counseling behaviors were collected using surveys administered before and after the intervention. The ED nurse education intervention was a one-hour lecture based on the American Academy of Pediatrics (AAP) CPS guidelines and Alabama state law regarding ages for each car seat type and teen driving risky behaviors. Individual data from pre and post surveys were matched, and nominal variables in pre-post matched pairs were analyzed using McNemar's test. To compare categorical variables within pre or post test data, we used the Chi-square test. RESULTS: Pretests were administered to 83/110 ED nurses; 64 nurses received the educational intervention and posttest. On the pretests, nurses reported "never" or "occasionally" counseling about CPS for the following: 56% car seats, 62% booster seat, 56% teen driving, 32% seat belts. When comparing the pretest CPS knowledge between nurses working 0-1 year vs. ≥ 2 years there was no statistically significant difference. Two CPS knowledge questions did not show significance due to a high correct baseline knowledge rate (> 98%), including baseline knowledge of MVC being the leading cause of death. Of the remaining 7 knowledge questions, 5 questions showed statistically significant improvement in knowledge: age when children can sit in front seat, state GDL law details, seat belt state law for back seat riders, age for booster seat, and rear facing car seat age. All four counseling behavior questions showed increases in intent to counsel families; however, only intent to counsel regarding teen driving reached statistical significance. CONCLUSIONS: Educational efforts improved pediatric ED nursing knowledge regarding CPS. Intent to counsel was also improved following the education.

Characteristics of Pediatric Patients With Retained Bullet Fragments and Need for Follow-Up Blood Lead Monitoring.

OBJECTIVES: Multiple case reports of lead toxicity related to retained bullet fragments in pediatric patients sustaining gunshot wound have been published. The purpose of the present study was to determine whether the demographic and clinical characteristics of gunshot wounds (GSWs) could be classified high/low risk and whether routine blood lead monitoring is necessary in these patients. METHODS: A single-center prospective case series of pediatric GSW patients presenting to the emergency department (ED). The data points that were collected and analyzed included age, sex, race, wound location, disposition, and baseline and follow-up lead levels within 6 months post-injury. RESULTS: Twenty patients were enrolled in the study and the median age was 7.5 years (interquartile range 5.25-10.75); 75% of the patients were African American. A total of 15 patients (75%) had injuries in either a lower or upper extremity, 9 of whom required admission. Almost all of the injuries involving the head, chest, or abdomen required admission. Of the patients, 65% were admitted and 35% were discharged. All of the patients had an initial blood lead level taken, and follow-up lead levels were determined at 6 months post-injury to be <5 µg/dL. Twelve of 20 patients were lost to follow-up. CONCLUSIONS: Pediatric GSW is common in male African Americans and these patients had baseline and follow-up lead levels below the reference level. These patients were difficult to follow up. Based on the available data, follow-up lead monitoring may not be indicated.

Teen Driving Education in a Pediatric Emergency Department: Effectiveness of a Toolkit.

OBJECTIVES: In the United States, the leading cause of death for adolescents aged 16 to 24 years is motor vehicle crashes, with Alabama ranked as the second-worst state in the nation for teen driving deaths. We sought to determine the efficacy of teenage driving education within the setting of the pediatric emergency department and to assess the driving habits of teenagers and their parents and their understanding of the Alabama Graduated Driver's License (GDL) law. METHODS: Surveys were administered to noncritically ill teenagers aged 13 to 19 years and their parents who presented to the children's emergency department. Participation was voluntary and anonymous. Presurveys were administered to assess driving habits and knowledge. Intervention was then given in the form of a "safe driving toolkit," followed by postsurveys to measure educational outcomes. Pre- and postsurvey data were then analyzed and compared using Epistat. RESULTS: A total of 41 parents, 2 grandparents, and 45 teenagers were enrolled in this study. An additional 47 teenagers answered a single curfew question at a teen driving event. Of all of the participants, 63% had never heard of the Alabama GDL law, and of that 63%, 37% had been enrolled in a driver's education course. A χ2 analysis revealed no significant difference between parents and teenagers having taken a driver's education course. Of the participants, 22% responded that they knew the specifics of the Alabama GDL law, with only 1 correct on all 3 counts. The most common item missed was the curfew for teenagers, with 4 believing it to be 8 pm, 14 believing it to be 9 pm, 23 believing it to be 10 pm, and 7 believing it to be 11 pm. Sixty-nine percent of the respondents correctly answered that there was to be no cellular telephone use while driving for teenagers with a GDL. More than 97.2% of participants, both parents and teens, reported learning new information from this study. CONCLUSIONS: The majority of participants enrolled were not aware of the Alabama GDL law, which has been in place since 2002. More than 97% of those surveyed were given new information during the education session. There is a strong need for further public education regarding the law and safe driving habits. Sixty-one percent of respondents believe that the teen curfew is earlier than the present curfew. The authors believe that this shows support for revising the curfew in the present law to an earlier time. Nighttime driving restrictions starting at 10 pm or earlier have been shown to result in greater reductions in motor vehicle crashes involving teenagers. Our study affirmed that teen driving education within the pediatric emergency department setting is efficacious.

Evolution of Minimally Invasive Coronary Artery Bypass Grafting: Learning Curve.

OBJECTIVE: Minimally invasive coronary surgery approach for coronary artery bypass grafting is a safe and reproducible procedure for multivessel revascularization. This study reviewed a single surgeon's experience with minimally invasive coronary surgery coronary artery bypass grafting, including operative time, number of bypasses, and conversion to sternotomy. METHODS: A prospective database of consecutive minimally invasive coronary surgery coronary artery bypass grafting procedures from 2005 to 2013 was reviewed. A small anterolateral left thoracotomy allowed left internal mammary artery harvest, proximal anastomoses on the ascending aorta, and distal coronary anastomoses. Early cases were compared with the later cases, focusing on grafting strategies that led to a standardized approach with Propensity Score Matching analysis. RESULTS: Seven hundred consecutive cases were divided into early (1-200) and late (201-700) groups. In the late group, the number of triple-vessel disease patients trended higher (50% vs. 57%, P = 0.0674) and the number of bypasses increased (2.3 ± 0.8 vs. 2.7 ± 1.0, P < 0.0001). Conversion to sternotomy significantly decreased between the groups (6% vs. 0.6%, P < 0.0001). There was no difference in rate of postoperative complications between the groups except for prolonged intubation (10% vs. 5%, P = 0.0236) and shortened length of stay (5.9 ± 6.7 vs. 5.5 ± 6.0, P = 0.0268). Propensity score matching analysis (n = 177) was significant for total bypass performed and time per bypass (P < 0.05). The late group was further divided into subgroups of one hundred each (subgroup 1 through 5). Operative times differed significantly (subgroup 1: 249 ± 71.2, subgroup 2: 259 ± 85.8, subgroup 3: 244 ± 71.0, subgroup 4: 270 ± 58.4, and subgroup 5: 246 ± 47.9, P < 0.005). CONCLUSIONS: As experience with minimally invasive coronary surgery coronary artery bypass grafting increased, the ideal sequence of steps to optimize surgical outcome was defined. The number of bypassed vessels increased and the operative time and conversion to sternotomy decreased.

Risky Teen Driving in a Rural Southern State.

OBJECTIVE: Alabama is one of the five US states with the highest teen driving mortality. We recruited teen drivers to participate in a questionnaire regarding high-risk driving behaviors. METHODS: Teens were recruited from a large county school system to participate in a voluntary anonymous survey. Questions were taken in part from the National Youth Risk Behavior Survey. Descriptive statistics and odds ratios with 95% confidence intervals were calculated. RESULTS: A total of 1023 teen drivers participated (46% boys, 47% African American, 39% white, 6% Latino, and 7% other). In all, 526 students (52%) reported inconsistent seat belt use. Half of the teens surveyed reported using a cellular telephone while driving within the past 30 days (51%); 10% admitted to driving after drinking alcoholic beverages in the past 30 days, with 23% saying they had ridden with a driver who had been drinking. CONCLUSIONS: High-risk teen driving behaviors were reported by many of the participants in our study. The majority of teens surveyed do not routinely wear seatbelts. Common misperceptions still exist regarding seatbelts and should be a focus of future education. Future research should focus on parental behaviors and correcting misperceptions of young drivers.

Pediatric Residents' Perceptions of Potential Professionalism Violations on Social Media: A US National Survey.

BACKGROUND: The ubiquitous use of social media by physicians poses professionalism challenges. Regulatory bodies have disseminated guidelines related to physicians' use of social media. OBJECTIVE: This study had 2 objectives: (1) to understand what pediatric residents view as appropriate social media postings, and (2) to recognize the degree to which these residents are exposed to postings that violate social media professionalism guidelines. METHODS: We distributed an electronic survey to pediatric residents across the United States. The survey consisted of 5 postings from a hypothetical resident's personal Facebook page. The vignettes highlighted common scenarios that challenge published social media professionalism guidelines. We asked 2 questions for each vignette regarding (1) the resident's opinion of the posting's appropriateness, and (2) their frequency of viewing similar posts. We also elicited demographic data (age, sex, postgraduate year level), frequency of Facebook use, awareness of their institutional policies, and prior social media training. RESULTS: Of 1628 respondents, 1498 (92.01%) of the pediatric residents acknowledged having a Facebook account, of whom 888/1628 (54.55%) reported daily use and 346/1628 (21.25%) reported using Facebook a few times a week. Residents frequently viewed posts that violated professionalism standards, including use of derogatory remarks about patients (1756/3256, 53.93%) and, much less frequently, about attending physicians (114/1628, 7.00%). The majority of the residents properly identified these postings as inappropriate. Residents had frequently viewed a post similar to one showing physicians drinking alcoholic beverages while in professional attire or scrubs and were neutral on this post's appropriateness. Residents also reported a lack of knowledge about institutional policies on social media (651/1628, or 40.00%, were unaware of a policy; 204/1628, or 12.53%, said that no policy existed). A total of 372/1628 respondents (22.85%) stated that they had never received any structured training on social media professionalism. CONCLUSIONS: Today's residents, like others of their generation, use social media sites to converse with peers without considering the implications for the profession. The frequent use of social media by learners needs to change the emphasis educators and regulatory bodies place on social media guidelines and teaching professionalism in the digital age.

Teen driving behaviors in a rural southern state.

OBJECTIVES: Motor vehicle crashes are the leading cause of death for teenagers. Alabama ranks fourth in the United States for teen crash fatalities. We sought to describe risky driving behaviors among teens in the rural areas of the state's most populous county. METHODS: A questionnaire was adapted from the Youth Risk Behavior Surveillance System. Each of the schools in Jefferson County, Alabama, participated in 2009 and 2010. Surveys were anonymous and data were entered into an Excel spreadsheet. Inclusion criteria were age 15 years and older. RESULTS: A total of 1399 surveys met inclusion criteria. A total of 52% of respondents were boys; 64% were white, 29% were African American, and 3% were Hispanic. Respondents were 15 (38%), 16 (36%), 17 (21%), and 18 (5%) years old. When asked about behaviors during driving in the last 30 days, 41% reported texting and 11% reported driving after drinking. Teens reported being a passenger in a car with the driver texting (67%) or after the driver had been drinking (27%) in the last 30 days. Overall, 58% reported not wearing a seatbelt; 13% reported driving after using drugs; 60% reported routinely exceeding the speed limit; 80% reported having discussed safe driving with a parent, but only 16% with their doctor; 25% had signed a safe driving contract; and 63% had taken a driving class. CONCLUSIONS: Many risky behaviors were identified for both teen drivers and passengers. A concerning number of teens are not receiving safe driving educational messages from parents, doctors, or driver's education classes. Some interventions have been instituted; however, more outreach efforts should be made to focus on strengthening driving laws and educating parents and teens.