Effect of individualized feedback on learning curves in EGD and colonoscopy: a cluster randomized controlled trial.

BACKGROUND AND AIMS: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy. METHODS: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills. RESULTS: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77). CONCLUSIONS: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.).

Intra-articular Steroid Injection as the Etiology of Acute Pancreatitis.

Acute interstitial pancreatitis is typically caused by gallstones and alcohol use. Less common causes include infection and drugs. Patients present with epigastric pain and often require pain medications and hospitalization depending on severity. We present a unique case of drug-induced pancreatitis likely caused by intra-articular corticosteroid injections on two separate occasions in the same patient. In both instances, other etiologies were ruled out. Given the temporal relationship between the intra-articular corticosteroid injection and presentation of pancreatitis, the corticosteroid injection was the likely etiology. This case suggests that intra-articular steroids should be included as an etiology of drug-induced pancreatitis.

Isolated Celiac Artery Vasculitis Presenting as Ileus in a Patient With Ulcerative Colitis.

There is a known association between inflammatory bowel disease (IBD) and vasculitis, which can present with mesenteric ischemia or cutaneous manifestations. Infliximab, an anti-tumor necrosis factor (anti-TNF) used to treat IBD, has been implicated as a potential culprit. We present a unique case of a patient with ulcerative colitis who developed isolated celiac artery vasculitis presenting with abdominal pain and ileus after decreasing his dosage of azathioprine. Vasculitis resolved with steroids and increasing azathioprine dosage, while continuing anti-TNF therapy, suggesting that anti-TNF agents are not the only cause of vasculitis in patients with IBD or that thiopurines may be protective.

Twenty-five years of child and family homelessness: where are we now?

Family homelessness emerged as a major social and public health problem in the United States during the 1980s. We reviewed the literature, including journal articles, news stories, and government reports, that described conditions associated with family homelessness, the scope of the problem, and the health and mental health of homeless children and families. Much of this literature was published during the 1980s and 1990s. This raises questions about its continued applicability for the public health community. We concluded that descriptions of the economic conditions and public policies associated with family homelessness are still relevant; however, the homeless family population has changed over time. Family homelessness has become more prevalent and pervasive among poor and low-income families. We provide public health recommendations for these homeless families.

Cooking, healthy eating, fitness and fun (CHEFFs): qualitative evaluation of a nutrition education program for children living at urban family homeless shelters.

OBJECTIVES: We assessed the feasibility of a 15-week nutrition education, physical activity, and media literacy program for children living in urban family homeless shelters. METHODS: We developed a qualitative monitoring tool to evaluate program process and impact at 2 shelter sites in the Bronx, New York, from 2009 to 2012. Facilitators recorded indications of participants' understanding of intended messages and demonstrations of changes in attitudes and behaviors. Comments, insights, and actions were recorded as they occurred. Facilitators also documented barriers to delivery of content and activities as intended. We used content analysis to examine data for patterns and identify themes. RESULTS: A total of 162 children participated at the 2 shelter sites. Analysis of qualitative data yielded 3 themes: (1) children's knowledge and understanding of content, (2) children's shift in attitudes or intentions, and (3) interpretations through children's life experience. Food insecurity as well as shelter food service and policies were important influences on children's choices, hunger, and sense of well-being. CONCLUSIONS: Children's experiences highlighted the need to advocate for shelter policies that adequately provide for children's nutritional and physical activity requirements and foster academic development.

Experiences of Mothers Participating in a Mother-Child Video Therapy Program.

INTRODUCTION: Responsive and sensitive parenting promotes the development of self-regulation and lowers stress in children, which in turn is associated with greater educational and economic achievement and better physical and emotional health later in life. Dyadic parent-child video-feedback programs can help parents learn effective parenting skills, yet these programs are estimated to retain only about half of eligible participants. Programs vary widely, and little is known about what is valued by parents who do complete these programs. The purpose of this qualitative study was to understand the goals, experiences, and outcomes important to mothers who completed a video-feedback program. METHODS: Transcripts of exit interviews of participants in a video-feedback program (N = 31) were analyzed using qualitative description methodology. Trustworthiness was achieved through deep engagement with the material, following an iterative process in analyzing transcripts, and member checks to confirm results. RESULTS: Mothers enrolled in the program to better understand their child, help their child learn, and to develop closer connections with their child. Elements of the program that helped mothers achieve these goals were (1) positive feedback and support by the therapist, (2) dedicated one-on-one time spent with their infant, (3) help with concrete needs, and (4) learning from watching videotaped play sessions. As a result, mothers reported greater confidence as caregivers, use of more responsive and sensitive parenting strategies, and improvements in their children's behaviors and their own mental health. DISCUSSION: Incorporating elements of the program found to be most useful in this study into video-feedback programs may make video-feedback programs more attractive to parents and increase retention. Midwives and women's health care providers may incorporate elements of the program into their clinical practice and advocacy, with special attention to elements most valued by parents themselves.

Persistence of Emotional Distress in Unaccompanied Migrant Children and Adolescents Primarily From the Northern Triangle of Central America.

Importance: In the US, unaccompanied migrant children and adolescents (hereinafter referred to as children) are predominantly from Central America's Northern Triangle. While unaccompanied migrant children are at high risk for psychiatric sequelae due to complex traumatic exposures, longitudinal investigations of psychiatric distress after resettlement are lacking. Objective: To identify factors associated with emotional distress and longitudinal changes in emotional distress among unaccompanied migrant children in the US. Design, Setting, and Participants: For this retrospective cohort study, the 15-item Refugee Health Screener (RHS-15) was administered between January 1, 2015, and December 31, 2019, to unaccompanied migrant children as part of their medical care to detect emotional distress. Follow-up RHS-15 results were included if they were completed before February 29, 2020. Median follow-up interval was 203 days (IQR, 113-375 days). The study was conducted in a federally qualified health center that provides medical, mental health, and legal services. Unaccompanied migrant children who completed the initial RHS-15 were eligible for analysis. Data were analyzed from April 18, 2022, to April 23, 2023. Exposures: Traumatic events before migration, during migration, during detention, and after resettlement in the US. Main Outcomes and Measures: Emotional distress, including symptoms of posttraumatic stress disorder, anxiety, and depressive symptoms, as indicated by the RHS-15 (ie, score ≥12 on items 1-14 or ≥5 on item 15). Results: In total, 176 unaccompanied migrant children completed an initial RHS-15. They were primarily from Central America's Northern Triangle (153 [86.9%]), were mostly male (126 [71.6%]), and had a mean (SD) age of 16.9 (2.1) years. Of the 176 unaccompanied migrant children, 101 (57.4%) had screen results above the positive cutoff. Girls were more likely to have positive screen results than boys (odds ratio, 2.48 [95% CI, 1.15-5.34]; P = .02). Follow-up scores were available for 68 unaccompanied migrant children (38.6%). On the follow-up RHS-15, most scored above the positive cutoff (44 [64.7%]). Three-quarters of unaccompanied migrant children who scored above the positive cutoff initially continued to have positive scores at follow-up (30 of 40), and half of those with negative screen scores initially had positive scores at follow-up (14 of 28). Female vs male unaccompanied migrant children (unstandardized ß = 5.14 [95% CI, 0.23-10.06]; P = .04) and initial total score (unstandardized ß = 0.41 [95% CI, 0.18-0.64]; P = .001) were independently associated with increased follow-up RHS-15 total score. Conclusions and Relevance: The findings suggest that unaccompanied migrant children are at high risk for emotional distress, including symptoms of depression, anxiety, and posttraumatic stress. The persistence of emotional distress suggests that unaccompanied migrant children would benefit from ongoing psychosocial and material support after resettlement.

Evaluation of a Mother-Infant Dyadic Video-Feedback Intervention in a Community Health Center in South Bronx, New York City.

OBJECTIVE: This study evaluates a video-feedback program's effectiveness in promoting responsive and sensitive parenting for families in care in a community health center located in the South Bronx, New York City. METHODS: Change in measures of parent responsiveness/sensitivity (Global Rating Scale), depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder 7), and parenting stress (Parenting Stress Index-Short Form) were analyzed for mother-infant dyads (N=34) completing a six-session videofeedback program between 2014 and 2016. RESULTS: Participants were primarily mothers of color (30% African American; 63% Hispanic) with young infants (mean age 8 months). At program completion, mothers demonstrated a significant improvement of 19% in maternal responsiveness and fewer depressive and anxious symptoms. CONCLUSION: Cost-effectiveness studies are needed to compare parenting interventions by setting (community health center, home, or mental health facility) for acceptability and effectiveness to determine best practice models for communities challenged by poverty, trauma, and health disparities.

Pseudomonas aeruginosa: An Uncommon Cause of Antibiotic-Associated Diarrhea in an Immunocompetent Ambulatory Adult.

Pseudomonas aeruginosa is an opportunistic Gram-negative pathogen known to cause enterocolitis in children, amongst other types of infections. Pseudomonas aeruginosa has been widely reported as a cause of antibiotic-associated diarrhea in adult immunocompromised hosts. We present an 81-year-old previously healthy female as the first reported case of Pseudomonas aeruginosa antibiotic-associated diarrhea in an immunocompetent host in the United States.

Gastric Outlet Obstruction as the Initial Presentation of Upper Tract Urothelial Carcinoma.

GOO is often the first sign of advanced upper gastrointestinal neoplasms. The most common neoplasms associated with GOO include gastric, pancreatic, and biliary tract cancers. Urinary tract urothelial carcinoma has been a rarely documented cause of GOO.

A Prospective Multicenter Study Evaluating Endoscopy Competence Among Gastroenterology Trainees in the Era of the Next Accreditation System.

PURPOSE: The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy. METHOD: During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis. RESULTS: Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills. CONCLUSIONS: This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.

From Clinic to Classroom: A Community Health Center-Based Program to Assist Families in Accessing Pre-K in New York City.

Medical homes are an underused resource to promote enrollment in high-quality early education in urban areas. This report summarizes a newly implemented, unique, and replicable community health center-based outreach program designed to help families apply to and enroll in Pre-K programs in the South Bronx region of New York City.

A Qualitative Study of Women's Recall of Content and Skills Developed in Group Prenatal and Well-Baby Care 2 Years Later.

INTRODUCTION: Group prenatal and well-baby care is a system of health care visits that occur in a group setting. Each individual session lasts approximately 2 hours, allowing more time for education and support than can occur in an individual visit. Compared with individual care, research suggests that group care is associated with similar or better short-term outcomes, but no studies have yet examined potential long-term benefits beyond one year postpartum. The purpose of this qualitative descriptive study was to elicit women's recall about content covered in group prenatal and well-baby care and whether they were or were not continuing to use skills discussed during group prenatal and well-baby care 2 or more years after their group ended. METHODS: Eligible women participated in group prenatal and/or well-baby care between 2008 and 2012, were aged at least 18 years, and were English-speaking. Of the 127 eligible women, 32 were reached and 17 agreed to participate. Women were interviewed on average 3 years after group prenatal or well-baby care ended using a semistructured interview guide. Transcripts were reviewed and coded by each team member. Final codes and themes were identified using an iterative review process among the research team. RESULTS: Three themes were identified: sustained change, transferable skills, and group as a safe haven. All women were still using strategies discussed during group and had made sustained improvements in nutrition, stress management, and/or in the quality of their interactions with their children, partner, or families. The group environment was described as a safe haven: a respectful, nonjudgmental space that allowed women to share and support each other while learning new skills. DISCUSSION: This is the first study to document that group prenatal and well-baby care is associated with long-term benefits in areas not yet reported in the literature: nutrition, family communication, and parenting.

The role of law enforcement agencies in out-of-hospital emergency care.

BACKGROUND: A key component of out-of-hospital emergency care is the rapid response of trained providers with appropriate medical equipment. In some communities, law enforcement agents function as first responders to accomplish this goal. The purpose of this national survey was to assess the proportion of law enforcement agencies that provide medical care to determine the extent of care they provide, to identify how many use AEDs, and to assess the attitudes of agency leaders regarding their roles as medical first responders. METHODS: Eight hundred agencies were selected at random from a national database of 43,000 agencies available through the National Public Safety Bureau (Stevens Pt, WI). These agencies were sent a 19-question survey either by US mail or telephone. RESULTS: Four-hundred and fifty-four (57%) surveys were returned, and 420 (53%) were available for use after exclusion criteria were applied. Eighty percent of law enforcement agencies respond routinely to medical emergencies and 39% of these reported they deploy AEDs. Thirty-one percent of all law enforcement agencies are equipped with AEDs, a ten-fold increase from 2.6% reported in a previous national study in 1997. Funding issues were the most common reasons cited for not using AEDs. Approximately 75% of respondents agreed that law enforcement agencies should provide initial emergency medical care and indicated that officers in their agency would be willing to receive additional training to accomplish this. CONCLUSION: Based on this survey, law enforcement agents often serve as medical first responders. Nearly three quarters of responding agencies felt this role was appropriate. AEDs are now deployed much more frequently than indicated by a previous national study, but still less than one-third of law enforcement agencies carry AEDs as part of their standard response equipment.

A mobile medical care approach targeting underserved populations in post-Hurricane Katrina Mississippi.

On August 29, 2005, Hurricane Katrina devastated the Gulf Coast Mississippi region, damaging health care infrastructure and adversely affecting the health of populations left behind. Operation Assist, a project of the Children's Health Fund and the Columbia University Mailman School of Public Health, operated mobile medical units to provide health services to underserved populations in the affected areas. Data collected from all patient encounters from September 5-20, 2005 demonstrate that in addition to common respiratory illnesses, skin conditions, and minor injuries, a high proportion of visits were for vaccine administration and chronic medical problems including hypertension, diabetes, and asthma. Mobile medical units staffed by primary care clinicians experienced in dealing with the clinical and social needs of the underserved and comfortable working in a resource-poor environment can make a positive contribution to post-disaster care.

The health of homeless children revisited.

To the extent that representative data are available for specific health conditions (eg, under-immunization, asthma prevalence), the authors' data suggest that the gap between the health status of homeless children and housed children in minority, low-income families is narrowing. Studies of the health status of homeless children allow a window into the health status of medically underserved children whose needs may not be readily documented because of their lack of access to the health care system. Although prevalence rates of most of the health conditions discussed in this article exceeded national norms, they were generally consistent with rates characteristic of health disparities based on race-ethnicity and income. It must be emphasized that in most instances, children were seen for their first pediatric visit within weeks of entering the homeless shelter system. The health conditions identified were often present before the child and family became homeless. The high prevalence of asthma among homeless children should therefore be a matter of concern to health providers and payors, because the authors' data strongly suggest that this is not confined to children in homeless shelters as a special population. Similarly, childhood obesity predates homelessness (or at least the episode of homelessness during which health care was provided) and as such the authors' data may indicate the extent of this problem more generally among medically underserved children in the communities of origin. These conditions seem to be exacerbated by the specific conditions associated with homeless shelter life. Asthma care, assuming it was previously available, is disrupted when housing is lost, and shelter conditions may have multiple asthma triggers. Nutrition often suffers as a result of inadequate access to nutritious food and cooking facilities in shelters, as indicated by the high rate of iron-deficiency anemia among very young children. It is clear that homeless children in shelters require enhanced access to primary and specialist care. Shelter placement necessarily disrupts prior health care relationships (if any), while simultaneously placing additional stress on the child's physical and emotional well being. A medical home model is strongly recommended to allow for continuous, culturally competent care. Developmental and mental health problems are also more prevalent among homeless children. These conditions may jeopardize life successes. The overcrowding associated with homeless shelters and the housing conditions that frequently precede episodes of homelessness are associated with the higher prevalence of otitis media found among young children. This in turn is associated with developmental delay. Also contributing to the developmental risk associated with homelessness is exposure to DV, which is also frequently an antecedent of homelessness. Developmental surveillance for young, homeless children, monitoring of school attendance and academic performance, and assessment of mental status for homeless adolescents are recommended to facilitate early identification of problems and delivery of necessary interventions. For young children, providers of health care to the homeless should be well networked into the Early Intervention and Preschool Special Education programs in their locality. Given the multiplicity of needs for homeless families, which of course includes help finding affordable housing, health care providers serving this population should also develop linkages with community agencies, including those that can help parents develop the skills necessary for economic self-sufficiency and long-term ability to sustain independent housing.

Nonadjunctive Use of Continuous Glucose Monitors for Insulin Dosing: Is It Safe?

With the increasing accuracy of continuous glucose monitors (CGM) have come calls for the Food and Drug Administration (FDA) to label these devices as safe for nonadjunctive dosing of insulin. However, there is evidence that these devices are subject to sporadic, unpredictable, large errors. A text analysis of reports to the FDA MAUDE database since 2015 reveals over 25 000 complaints of CGM sensor inaccuracy, with instances directly leading to serious outcomes. These new data were not considered at a recent FDA Advisory Panel meeting that voted to approve Dexcom G5 relabeling for nonadjunctive use. Social media is another source of surveillance data providing evidence of large CGM inaccuracies in real-world use. We need to improve safety procedures, not remove them. CGMs offer unique information and alerts for managing diabetes, but the issue is not whether they are better than other approaches to monitoring glucose, but how they can be best used in conjunction with devices that offer the confirmatory readings needed for patient safety.