Eutectic Mixture of Lidocaine and Prilocaine Decreases Movement and Propofol Requirements for Pediatric Lumbar Puncture During Deep Sedation: A Randomized, Placebo-Controlled, Double Blind Trial.

Deep sedation/general anesthesia is commonly used in pediatric oncology patients undergoing lumbar puncture (LP). Propofol is often used for sedation, with or without a narcotic. We hypothesized that eutectic mixture of lidocaine and prilocaine (EMLA) would allow for lower cumulative doses of propofol and less movement. We performed a prospective, randomized, double blind, placebo-controlled trial in children undergoing sedation for LP. Standard initial weight-based doses of propofol and fentanyl were administered, with either EMLA cream or a placebo cream applied topically. The primary outcome was the total dose of propofol administered to each patient. We also tracked patient movement and complications. Twenty-seven patients underwent 152 LPs. Patients randomized to EMLA cream (n=75) were significantly more likely to receive a lower dose of propofol (2.94 mg/kg, SE=0.25, vs. 3.22 mg/kg, SE=0.19; P=0.036) and to not require additional propofol doses (probability 0.49, SE=0.08 vs. 0.69, SE=0.06; P=0.001) compared with patients randomized to placebo cream (n=77). In addition, patients with EMLA cream were significantly less likely to demonstrate minor or major movement. EMLA cream results in less movement and less propofol administration in pediatric oncology patients undergoing sedation for LP.

Prioritization of carceral spending in U.S. cities: Development of the Carceral Resource Index (CRI) and the role of race and income inequality.

BACKGROUND: Policing, corrections, and other carceral institutions are under scrutiny for driving health harms, while receiving disproportionate resources at the expense of prevention and other services. Amidst renewed interest in structural determinants of health, roles of race and class in shaping government investment priorities are poorly understood. METHODS: Based on the Social Conflict Model, we assessed relationships between city racial/ economic profiles measured by the Index of Concentration at the Extremes (ICE) and budgetary priorities measured by the novel Carceral Resource Index (CRI), contrasting investments in carceral systems with funding for health and social support across the 50 most populous cities in the United States (U.S.). Bivariate correlations, and unadjusted and adjusted polynomial regression models were used to assess the relationship between budgetary investments and population concentration at extremes in terms of income, racial/ethnic composition, and education, controlling for other demographic characteristics. RESULTS: In our sample, median CRI was -0.59 (IQR -0.64, -0.45), with only seven cities exhibiting positive CRI values. This indicates that most large U.S. cities spend more on carceral systems than on health and supportive services, combined. Adjusted polynomial models showed a convex relationship between the CRI and ICE-Education, and ICE-Race(White vs. Black)+Income, with quadratic terms that were positive and significant at p<0.05. After controlling for age, the strongest prioritization of carceral systems was observed in cities where the proportion of low-income Black residents approached or exceeded that of high-income white residents. CONCLUSIONS: Municipal prioritization of carceral investments over health and social support is pervasive in the U.S and exacerbated by racial and economic disparities. The CRI offers new opportunities to understand the role of government investments as a structural determinant of health and safety. Longitudinal research is warranted to examine the relationship between budget priorities, structural racism, and health outcomes.

Exploring Perceptions of a Fresh Food Prescription Program during COVID-19.

This qualitative study aimed to elicit the perspectives of individuals with food insecurity (FI) who were enrolled in a Fresh Food Prescription (FFRx) delivery program through a collaboration between an academic medical center and multiple community partners in the southeastern United States. Semi-structured interviews and open-ended survey responses explored the experiences of participants enrolled in a FFRx delivery program during the COVID-19 pandemic. The interviews probed the shopping habits, food security, experience, and impact of the program on nutrition, health, and well-being; the surveys explored the perceptions of and satisfaction with the program. A coding scheme was developed inductively, and a thematic analysis was conducted on raw narrative data using Atlas.ti 8.4 to sort and manage the data. The themes included that the program promoted healthy dietary habits, improved access to high-quality foods, improved well-being, enhanced financial well-being, and alleviated logistical barriers to accessing food and cooking. Participants provided suggestions for FFRx improvement. Future studies may facilitate improved clinical-community partnerships to address FI.

Pediatric all-terrain vehicle injuries: does legislation make a dent?

OBJECTIVES: We sought to determine whether North Carolina legislation pertaining to all-terrain vehicles (ATVs) has affected the frequency, distribution, or severity of injury in children. METHODS: This retrospective study reviewed the Wake Forest University Baptist Medical Center Trauma Registry from 2003 to 2008 along with North Carolina Medical Examiner's child fatality data for all children injured on an ATV. Patients were excluded if the accident did not occur in North Carolina, incomplete data, or if the vehicle was not an ATV. We evaluated the use of helmets, the extent of injury, and the mechanism of injury, comparing the patterns before the laws went into effect (2003-2005) with those after the law was enacted (2006-2008). RESULTS: Eighty-eight patients were included for analysis, predominantly white boys with a mean age of 12.1 ± 4.1 years. Children not wearing helmets were 5-fold more likely to have a significant head/neck injury (odds ratio [OR], 5.1; confidence interval [CI], 1.61-15.88; P = 0.01) and 3.7-fold more likely to have a significant chest injury (OR, 3.73; CI, 1.01-13.86; P = 0.05). Passengers were 5-fold more likely to die or require inpatient rehabilitation (OR, 5.0; CI, 1.2-20.8; P = 0.03) and 13.7 times as likely to have a significant injury to their head/neck (OR, 13.7; CI, 3.07-60.93; P = 0.01). CONCLUSIONS: There were no significant changes seen in the children injured without and then with legislation, which may be significant if ATV use indeed is increasing. A child's vehicular position was the most significant predictor of morbidity and mortality. Helmet use was not increased once mandated by law. Further efforts to implement such legislation and educate the public are necessary to make a significant change in injuries.

Improving Health Professions Students' Understanding of Interprofessional Roles Through Participation in a Patient Stabilization Simulation.

Objective. To teach interprofessional communication and teamwork skills to health professions students through a standardized patient simulation on acute patient stabilization and measure the impact on learners' perceptions of interprofessional collaboration.Methods. Medical and pharmacy students in their final year and post-licensure nurses in their initial six-month probationary period worked together to stabilize a simulated acutely ill standardized patient. Perceptions of IPE were assessed pre- and post-simulation using the Student Perceptions of Interprofessional Clinical Education-Revised Instrument, version 2 (SPICE-R2). Medical student participants' scores were compared to those of a concurrently enrolled cohort of medical students who did not participate in the simulation.Results. Eighty learners participated in the simulation and all completed pre and post SPICE-R2 assessments. Learners' perceptions increased significantly in all domains, including understanding of roles in collaborative practice, interprofessional teamwork and team-based practice, and patient outcomes from collaborative practice. Compared to the control cohort, participants' perceptions of team-based practice and the impact on patient outcomes improved significantly, while a statistically similar improvement in scores for understanding of roles and responsibilities was seen. The SPICE-R2 scores increased similarly among students in each profession. Repeat exposure to the simulation continued to improve perceptions but not as robustly as the initial simulation.Conclusion. This simulation changed learners' perceptions of how interprofessional collaboration affects patient care, which supports the incorporation of standardized patient-based interprofessional education even in the late-stage education of health professionals.

Educational priorities of students in the entrustable professional activity era.

BACKGROUND: The Association of American Medical Colleges (AAMC) guidelines on the entrustable professional activities (EPAs) expected of graduating medical students were recently published. Although perceptions of educators, residents and programme directors have been described, the voice of senior medical students is lacking. METHODS: A single-institution cross-sectional study of senior medical students was performed. Student perceptions were collected and compared with: (1) national guidelines (i.e. the 13 newly developed undergraduate EPAs); (2) resident expectations (i.e. through comparison with a recently published survey from >28 000 residents); and (3) institutional objectives. Descriptive statistics were performed. RESULTS: A total of 113 students participated. The top three EPA-based educational priorities were 'recognising a patient requiring urgent/emergent care' (EPA10), 'performing procedures of a physician' (EPA12) and 'collaborating as an interprofessional' (EPA9). Over 80 per cent of students rated 'managing time efficiently' and 'communicating around care transitions' as very important pre-internship skills. Of the institutional objectives, 87 per cent rated 'recognising critically ill patients' and 'knowing when to ask for help' as the most important pre-internship skills. The voice of senior medical students is lacking CONCLUSIONS: Although the emphasis on knowing when to ask for help and communication around care transitions differed somewhat across stakeholders, educational priorities were shared by students, residents, educators and institutional objectives. These preliminary data support national assessments of perceptions and achievements of senior medical students to guide residency readiness in the EPA era.

Choosing a Physician for Your Child.

This Patient Page describes how to find a child health clinician, what you can learn about the clinician at a prenatal visit, and how to decide if a clinic fits your schedule and expectations.

What's in a Name? Impact of marketing different course titles on enrollment for online classes.

PURPOSE: Little is known about the impact of different marketing strategies on enrollment of online courses for health professionals. The authors compared one aspect of marketing, course titles, for online classes about herbs and dietary supplements (HDS). METHOD: The authors marketed two titles-one knowledge-oriented, the other behavior-oriented-for each of seven online HDS classes. The two titles were (1) "Introduction to topic" (Knowledge) and (2) "Talking with patients about topic" (Behavior). The seven classes were two general (introduction and safety) and five specialty (women, children, the elderly, depression, and gastrointestinal) topics. The Area Health Education Center in northwest North Carolina marketed the classes. RESULTS: Altogether, 195 clinicians enrolled in an average of 7.6 classes per enrollee (1,487 total). For every class, enrollment was higher for knowledge-oriented than behavior-oriented titled classes (average of 124 versus 89 enrollees per class, P < .01). Enrollment, combining the two general classes, was also significantly higher for general than specialty classes (266 versus 191 enrollees per class, P < .01). CONCLUSIONS: Differences in titles and levels of generality significantly impacted enrollment rates in these online classes on an unfamiliar topic. Additional marketing research is needed to inform efforts to enroll clinicians into courses on more familiar topics.