Childhood Educational Outcomes of Children Born with Gastroschisis.

OBJECTIVE: To compare third grade literacy and mathematics test proficiency among children born with gastroschisis vs unaffected controls and identify predictors of academic proficiency among these children. STUDY DESIGN: Infants born with gastroschisis (2000-2005) were identified from the Arkansas Reproductive Health Monitoring System. For each case, 2 controls were selected at random from birth certificates and matched for hospital and month of birth, sex, and race/ethnicity. Data on rehospitalization within the first 6 years and payer data were abstracted from the Arkansas Hospital Inpatient Discharge database. Surviving cases and controls were linked to the Arkansas Department of Education database containing achievement test scores. The primary outcome was proficiency, defined as performance at or above grade level, on third grade achievement tests. Cases and controls who did not attend public schools could not be linked to education records. Multivariable logistic regression models evaluated the association between study characteristics and academic proficiency. RESULTS: The final study cohort included 47 cases and 63 controls. There was no statistically significant difference in the rate of literacy (68% vs 81%; P = .65) or mathematics proficiency (89% vs 87%; P = .15) between cases and controls. On multivariable analysis, a complex gastroschisis (defined as atresia, volvulus, necrosis, or perforation of the bowel) was associated with lower proficiency in literacy (aOR, 0.1; 95% CI, 0.02-0.58; P = .01). No neonatal or maternal characteristics predictive of lower proficiency in mathematics were identified. CONCLUSIONS: Among children born with gastroschisis, the presence of a complex gastroschisis was associated with lower proficiency on third grade literacy achievement tests.

Rapid Recovery After Total Joint Arthroplasty Using General Anesthesia.

BACKGROUND: Multiple papers have purported the superiority of spinal anesthesia used in total joint arthroplasty (TJA). However, there is a paucity of data available for modern general anesthesia (GA) regimens used at high-volume joint replacement centers. METHODS: We retrospectively reviewed a series of 1527 consecutive primary TJAs (644 total hip arthroplasties and 883 total knee arthroplasties) performed over a 3-year span at a single institution that uses a contemporary GA protocol and report on the length of stay, early recovery rates, perioperative complications, and readmissions. RESULTS: From the elective TJAs performed using a modern GA protocol, 96.3% (n = 1471) of patients discharged on postoperative day 1, and 97.2% (n = 1482) of subjects were able to participate with physical therapy on the day of surgery. Only 6 patients (0.4%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 2.4% (n = 36), while the reoperation rate was 1.3% (n = 20). DISCUSSION: Neuraxial anesthesia for TJA is commonly preferred in high-volume institutions utilizing contemporary enhanced recovery pathways. Our data support the notion that the utilization of modern GA techniques that limit narcotics and certain inhalants can be successfully used in short-stay primary total joint arthroplasty. LEVEL OF EVIDENCE: IV- Case series.

After-Hours Calls in a Joint Replacement Practice.

BACKGROUND: Early discharge after joint arthroplasty requires additional resources to manage patients safely after surgery. Patient concerns must be addressed during nonbusiness hours to keep patients out of the emergency department and avoid readmissions. The goal of our study was to determine how type of system is utilized in a busy early discharge joint replacement practice. METHODS: In our total joint program, we have utilized a Google phone number to give patients access to a member of the surgical team after business hours and on weekends. The duration, chief complaint, and resolution of from the phone calls were collected prospectively for 3 months (July 3, 2017-October 3, 2017). RESULTS: Sixty-eight calls were received from 55 patients during the 3-month study period. Three hundred twenty-five cases were performed. The average duration of a call was 3.9 minutes. The average length of time from surgery to call was 17.5 days (range 0-442 days). Suboptimal health literacy was associated with increased calls within the first week after surgery (odds ratio = 4.1, 95% confidence interval = 1.2-14.5, P = .022). A chief complaint of pain was associated with primary versus revision surgery. (odds ratio = 3.23, 95% confidence interval = 1.08-9.86). DISCUSSION: An "after-hours" telephone contact service with a member of the surgical team may help avoid unnecessary emergency department visits. About one phone call was received per day, with an average duration of 3.9 minutes per call. These additional resources are necessary to maintain patient safety and satisfaction in early discharge joint replacement.

Comparative Effectiveness and Maintenance of Diabetes Self-Management Education Interventions for Marshallese Patients With Type 2 Diabetes: A Randomized Controlled Trial.

OBJECTIVE: Marshallese adults experience high rates of type 2 diabetes. Previous diabetes self-management education (DSME) interventions among Marshallese were unsuccessful. This study compared the extent to which two DSME interventions improved glycemic control, measured on the basis of change in glycated hemoglobin (HbA1c). RESEARCH DESIGN AND METHODS: A two-arm randomized controlled trial compared a standard-model DSME (standard DSME) with a culturally adapted family-model DSME (adapted DSME). Marshallese adults with type 2 diabetes (n = 221) received either standard DSME in a community setting (n = 111) or adapted DSME in a home setting (n = 110). Outcome measures were assessed at baseline, immediately after the intervention, and at 6 and 12 months after the intervention and were examined with adjusted linear mixed-effects regression models. RESULTS: Participants in the adapted DSME arm showed significantly greater declines in mean HbA1c immediately (-0.61% [95% CI -1.19, -0.03]; P = 0.038) and 12 months (-0.77% [95% CI -1.38, -0.17]; P = 0.013) after the intervention than those in the standard DSME arm. Within the adapted DSME arm, participants had significant reductions in mean HbA1c from baseline to immediately after the intervention (-1.18% [95% CI -1.55, -0.81]), to 6 months (-0.67% [95% CI -1.06, -0.28]), and to 12 months (-0.87% [95% CI -1.28, -0.46]) (P < 0.001 for all). Participants in the standard DSME arm had significant reductions in mean HbA1c from baseline to immediately after the intervention (-0.55% [95% CI -0.93, -0.17]; P = 0.005). CONCLUSIONS: Participants receiving the adapted DSME showed significantly greater reductions in mean HbA1c immediately after and 12 months after the intervention than the reductions among those receiving standard DSME. This study adds to the body of research that shows the potential effectiveness of culturally adapted DSME that includes participants' family members.

Effects of the Affordable Care Act on Vascular Patient Amputation Rates in Arkansas.

BACKGROUND: The Patient Protection and Affordable Care Act was signed into law in 2010 and enacted in 2013 which improved insurance coverage across America due to increasing Medicaid eligibility as well as changes to individual insurance markets. In Arkansas, this was implemented by a Medicaid expansion waiver which allowed patients to purchase insurance with funds provided by the government to subsidize premiums through the marketplace. The goal of this study was to determine the effects of the Affordable Care Act (ACA) on Arkansas patients with peripheral arterial disease. METHODS: A pre-post research design using the Arkansas Hospital Discharge Dataset was used to study the impact of the ACA on limb amputation, distal bypass, discharge disposition, and total costs for patients diagnosed with peripheral arterial disease/atherosclerosis. The data were obtained for the years 2007 through 2009 (pre-ACA), 2011 through 2013 (post-ACA), and 2014 through 2015 (post-Arkansas expansion). Bivariate analysis, analysis of variance, and regression analyses were performed to analyze the data. RESULTS: A total of 10,923 patients were identified. Uninsured patients ("self-pay") decreased from 7% pre-ACA to 3.4% post-Arkansas expansion (P < 0.0001). There was a decrease in adjusted health-care costs after the Arkansas expansion (P < 0.0001). There was no change in mortality or transfer to rehabilitation facilities, but there was an increase in discharge to skilled nursing facilities along with a decrease in patients being discharged home (P < 0.0001). Regression analysis showed private insurance to be associated with a 49% reduction in the odds of an amputation (P < 0.0001). The Arkansas expansion was associated with a 26% reduction in the odds of an amputation when compared with that before the ACA implementation (P < 0.005). Having private insurance was associated with a 26% increase in the odds of having a bypass when compared with uninsured patients (P < 0.05). CONCLUSIONS: Patients with private insurance have a decreased chance of amputation and increased odds of having a bypass when compared with patients who were of the self-pay category. The increase in private insurance coverage in our patient population could improve the rate of amputation in the vascular population in Arkansas by increasing early interventions for peripheral vascular disease.

Recreational Drug and Psychosocial Profile in Chronic Hepatitis C Patients Seeking Antiviral Therapy.

BACKGROUND AND AIMS: Practitioners treating hepatitis C (HCV) provide healthcare to a special population with high rates of substance abuse and psychiatric disorders. We investigated the psychosocial profile in HCV patients and tested what variables affect commencement of antiviral therapy. MATERIAL AND METHODS: Recreational drug use (RDU), marijuana (THC), alcohol use, and psychiatric history were initially investigated with a questionnaire prior to history and physical. Following an educational intervention, we reinterrogated patients for RDU and THC use, and revision of initial statement was documented. Variables affecting commencement of antiviral therapy were analysed with logistic regression. RESULTS: Out of 153 patients, 140 (92%) answered the questionnaire. Intervention increased total yield by 6%, however, 39% (11/28) of those initially denying use revised their statement. Drug screening identified 9 more patients with RDU/THC use. Half of patients consuming alcohol were heavy drinkers, and psychiatric disease was identified in 54%. Only 73 (48%) of 139 patients eligible for antivirals received treatment. Multivariable analysis revealed that younger patients (OR = 1.04, 95% CI 1.01-1.08), and those testing positive on drug screen (OR = 0.41, 95% CI 0.19-0.92) were less likely to be treated. Denial by insurance and loss to follow-up were the most common reasons for not starting antiviral treatment. CONCLUSION: Substance abuse is highly prevalent among HCV patients, and it is difficult to tell prior from current users. Integral care of HCV patients should include a diligent screen for substance abuse and rehabilitation referral, aiming to increase the pool of patients eligible for antiviral therapy. This can only be achieved through a multidisciplinary approach.

The Chewing Lice (Insecta, Phthiraptera) Fauna of the Swainson's Warbler, Limnothlypis swainsonii (Aves, Parulidae).

We examined Swainson's warblers (Limnothlypis swainsonii (Audubon, 1834), Aves: Parulidae) for lice fauna during 2 yr at three study sites in Arkansas, USA. A total of 66 individuals were examined; eight birds (10.6%) were parasitized with 16 lice of two new species belonging to two genera Myrsidea Waterson, 1915 (Amblycera: Menoponidae) and Brueelia Kéler, 1936 (Ischnocera: Philopteridae). Parasitological parameter data are given on the prevalence of lice on Swainson's warblers. Species descriptions and illustrations are provided for Myrsidea bensoni sp. nov. and Brueelia limnothlypiae sp. nov.; including a key for females of the genus Myrsidea that parasitize Parulidae (Passeriformes).

Predictors of outcome after acetaminophen poisoning in children and adolescents.

OBJECTIVE: Shortened courses of N-acetylcysteine may be acceptable in patients with acetaminophen poisoning who are at low risk for toxicity. The goal of this study was to determine which clinical findings best identified patients at lowest risk for acetaminophen-related hepatotoxicity after an acute overdose. STUDY DESIGN: This was a retrospective analysis, throughout 10 years, of hospital admissions for acute acetaminophen poisoning, with inclusion criteria being an acetaminophen concentration above the possible toxicity line by nomogram, arrival within 24 hours, and an initial prothrombin time (PT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) measured within 24 hours of ingestion. Clinical parameters capable of identifying patients most and least likely to have hepatotoxicity were evaluated by using sensitivity and specificity testing. RESULTS: Of 95 patient charts identified, 41 met all inclusion criteria, with 16 patients having hepatotoxicity. PT, AST, and ALT within the first 24 hours postingestion did not identify all patients who had hepatotoxicity. The best predictor of a low risk of toxicity was the presence of normal values for the PT, AST, or ALT within 48 hours of ingestion. CONCLUSIONS: These data suggest that all patients with an acute acetaminophen overdose should be observed and treated for at least 48 hours postingestion.

Assessing the outcome of pediatric intensive care.

To describe the short-term outcome of pediatric intensive care by quantifying overall functional morbidity and cognitive impairment, I developed the Pediatric Overall Performance Category (POPC) and the Pediatric Cerebral Performance Category (PCPC) scales, respectively. A total of 1469 subjects (1539 admissions) were admitted to the pediatric intensive care unit of Arkansas Children's Hospital from July 1989 through December 1990. Patients were assigned baseline POPC and PCPC scores derived from historical information and discharge scores at the time of discharge from the hospital (or from the pediatric intensive care unit for patients with multiple hospitalizations). Delta scores were calculated as the difference between the discharge scores and the baseline scores. The changes in POPC and PCPC scores were associated with several measures of morbidity (length of stay in the pediatric intensive care unit, total hospital charges, and discharge care needs) and with severity of illness (pediatric risk of mortality score) or severity of injury (pediatric trauma score) (p less than 0.0001). Interrater reliability was excellent (r = 0.88 to 0.96; p less than 0.001). The POPC and PCPC scales are apparently reliable and valid tools for assessing the outcome of pediatric intensive care.