Implementation of point of care ultrasound to assess umbilical venous catheter position in the neonatal intensive care unit

Point of care ultrasound (POCUS) is an emerging method for assessing umbilical venous catheter (UVC) position. We implemented a training module for neonatal providers geared toward POCUS proficiency in assessing UVC position in our neonatal intensive care unit. Over 14 months, the percentage of providers qualified to use POCUS for UVC placement increased from 0 to 33%. The median time to achieve proficiency was 5 months (interquartile range: 3-14 months). Additionally, we discovered that a minimum of two views were required to correctly assess catheter tip location. The two views in which it was easiest to correctly identify the catheter tip were the subcostal and parasternal short view using the cardiac ultrasound windows, and the phased array ultrasound probe.

Fathers' Visitation of Very Low Birth Weight Infants in the Neonatal Intensive Care Unit during the First Week of Life

OBJECTIVE

The perceived fragility of extremely preterm neonates may deter paternal visitation early during the neonatal intensive care unit (NICU) stay. We retrospectively analyzed the correlation between paternal visitation of very low birth weight (VLBW) infants in our NICU and sociodemographic characteristics.

STUDY DESIGN

We identified inborn VLBW infants admitted to our NICU from 2017 to 2018. The rate of visit days in the first week of life was analyzed using Spearman's correlation and Poisson's regression.

RESULTS

The analysis included 292 infants (median gestational age [GA]: 29 weeks), with fathers present on a median of 3 days of the first week of life. GA was not correlated with visitation (rho = -0.04). On multivariable regression, fathers visited less frequently if they did not live with the mother or if the mother lived 25 to 75 km from the hospital versus < 25 km.

CONCLUSION

Fathers' visitation in our NICU was constrained by socioeconomic factors rather than VLBW infants' characteristics.

Insurance coverage and health care use among children with diabetes

BACKGROUND

Health insurance coverage may be associated with pediatric diabetes mellitus (DM) management. However, it is unknown how continuity of insurance coverage is associated with health care use outcomes in pediatric DM.

METHODS

We used the nationally representative 2016-2019 National Survey of Children's Health to examine how interruption of health insurance coverage may affect health care use among children with DM. Children ages 0-17 years with DM were included in the analysis. Outcomes included emergency department visits, specialist visits, and unmet health care needs in the last 12 months. Insurance coverage was classified as continuous private, continuous public, or discontinuous (including gaps in coverage and year-round lack of coverage).

RESULTS

Based on a sample of 548 children, 56% percent had continuous private insurance coverage, as compared to 32% with continuous public insurance, and 12% with discontinuous coverage. Thirty-five percent of children had visited the ED in the past 12 months, and only 47% had visited any specialist in the past 12 months, including but not limited to a pediatric endocrinologist. An estimated 19% of children had unmet health care needs over the past 12 months. On multivariable analysis, children with coverage gaps were significantly less likely than children with continuous private coverage to have a visited a specialist in the past 12 months (adjusted odds ratio: 0.27; 95% CI: 0.08, 0.88; p = 0.030).

CONCLUSIONS

This study points to a need to establish and maintain specialist follow-up for children with DM, especially those from socioeconomically disadvantaged backgrounds.

Addressing the gate blocking of minority faculty

There have been ongoing efforts to increase the presence of underrepresented minorities in medicine (URMM), including faculty development initiatives, mentoring programs and outreach efforts. However, URMM faculty face unique challenges that are crucial for academic institutions and leaders to recognize in order to improve retention of this group and allow for meaningful advancement in the field. This paper introduces the concept of gate blocking, defined as what happens to minority faculty as a result of the consequences of the minority tax and systems designed to advantage some and disadvantage others. In addition to defining gate blocking, the authors make recommendations to address this concern in academic medicine and promote the advancement and retention of URMM faculty.

Association between asthma and influenza vaccine uptake among US adolescents: a retrospective survey study

OBJECTIVE

Despite longstanding recommendations for children with asthma to receive the influenza vaccine, vaccine uptake in this population remains low. We used the nationally representative National Immunization Survey-Teen to analyze the impact of asthma on adolescent influenza vaccination rates.

METHODS

Adolescents ages 13-17 years with provider-reported data on vaccine coverage were included in the analysis. The primary outcome was being up-to-date on influenza vaccination, defined as receiving the seasonal influenza vaccine in at least one of the past 3 years, and was analyzed using logistic regression. Asthma was defined by parent report of whether the adolescent has ever been told by a health professional that he or she has asthma. Data were collected in 2016-2017 and analyzed in 2020.

RESULTS

Of 36,655 adolescents in the analytic sample (mean age 15 years, 49% female), 55% were up-to-date on influenza vaccination, and 21% had been diagnosed with asthma. On bivariate analysis, vaccination was more common among adolescents who had been diagnosed with asthma compared to those who were not (60% vs. 53%, P < 0.001). On multivariable analysis, asthma diagnosis was associated with greater likelihood of being up-to-date on seasonal influenza vaccination (adjusted odds ratio: 1.29; 95% confidence interval: 1.22, 1.36; P < 0.001).

CONCLUSIONS

Seasonal influenza vaccination rates remain low among adolescents. Despite concerns about vaccine effectiveness in children with asthma, this diagnosis was associated with increased likelihood of influenza vaccination, possibly in relation to increased health care use (and exposure to vaccine encouragement) among adolescents with asthma.

Distance from the endocrinology clinic and diabetes control in a rural pediatric population

OBJECTIVE

We analyzed the impact of geographic distance from the clinic on adherence to recommended clinic visits and diabetes control among patients with type 1 diabetes (T1D) seen in a pediatric endocrinology clinic serving a rural region in eastern North Carolina.

METHODS

We retrospectively included patients with T1D age ≤20 years seen in our clinic during 2017. Outcomes were tracked until June 2018. Distance from the clinic was determined according to the zone improvement plan (ZIP) code of patient address. Visit adherence was defined based on the number of attended visits during the study period, aiming for 1 every 3 months. Glycated hemoglobin (HbA1c) was measured at the first and last visits during the review period.

RESULTS

The analysis included 368 patients, of whom 218 (59%) completed at least 1 visit every 3 months. The median HbA1c was 9.1 (interquartile range [IQR]: 8.0, 10.3) at the initial visit, and 9.3 (IQR: 8.0, 11.1) at the final visit. Median distance from the clinic was 56 km (IQR: 35, 86). On multivariable logistic regression, greater distance from the clinic was associated with lower odds of visit adherence (odds ratio per 10 km: 0.93; 95% confidence interval: 0.87, 0.99; p=0.030). Neither distance to the clinic nor clinic visit adherence were associated with HbA1c.

CONCLUSIONS

Patients living further away from the clinic were less likely to adhere to the recommended visit schedule, but distance was not correlated with HbA1c levels. Further work is needed to assist families living far from the clinic with adhering to recommended visits.

Mission matters: Association between a medical school's mission and minority student representation

Increasing enrollment of students who are underrepresented in medicine has been a priority of United States (US) medical schools. The authors sought to compare how increasing minority student representation factors into mission statements, statements of values, and strategic action plans at top research-oriented US medical schools and US medical schools with a social mission. A Web search was performed to locate three documents for each medical school: the mission statement; a statement of values; and a strategic plan. Data were retrieved on the number of underrepresented minority graduates and total graduates from each school in the graduating classes of 2015–2019. The number and percentage of graduates during this period were compared according to schools’ mission statements using rank-sum tests. Other quantitative study data were compared by school mission using Fisher’s exact tests. Five of the schools with a social mission (25%) and none of the schools with a research mission had a mission statement that addressed increasing representation of underrepresented minority students in the medical school (p = 0.047). Schools with a mission statement that addressed this group had a higher proportion of those graduates during 2015–2019 (median 66%; IQR 28%, 68%) compared to schools that did not address this in their mission statement (median 10%; IQR 6%, 13%; p = 0.003). More research is needed to explore the association between US medical school mission statements and the representation of underrepresented students in medical education, especially at research-oriented medical schools.

Communication Between Primary Care Pediatricians and the Pediatric Emergency Department

OBJECTIVES

This study aimed to measure the quality of communication from primary care pediatricians (PCPs) to the pediatric emergency department (ED). We also sought to determine whether the quality of this communication affected patient outcomes.

METHODS

We conducted a retrospective chart review of patients sent from their pediatrician to the pediatric ED during a 4-year period. The quality of communication was classified as no communication, incomplete communication, or complete communication, based on compliance with Joint Commission requirements. Outcome measures included overnight admission, total length of hospital stay, repetition of diagnostic tests, ED revisits, hospital readmissions, and initial follow-up pediatrician visit.

RESULTS

Fifty-five patients were included in the analysis. Communication was complete in 22% of cases, incomplete in 16% of cases, and absent in 62% of cases. Medications and allergies were most often missing. The quality of communication was not associated with any of the prespecified covariates or outcome measures. Chief complaint of respiratory distress and greater severity score were associated with a greater likelihood of hospital admission from the ED.

CONCLUSIONS

Our study demonstrates a lack of documented communication between PCPs and a pediatric ED, albeit with no statistically significant impact on patient outcomes. Practices to increase the quality of PCP-ED communication could include standardizing interfacility referrals, maximizing shared electronic health record use between clinical environments, and increased collaboration between ED physicians and PCPs. Further research to investigate subjective outcomes, such as patient expectations or satisfaction associated with PCP-ED communication, may reveal other consequences of incomplete communication.

Sharing the Power of White Privilege to Catalyze Positive Change in Academic Medicine

White privilege can be often overlooked and poorly understood in academic medicine, by those who wield it, and by those who suffer from its deleterious effects. Dr. Peggy McIntosh, a leader in research on equity and diversity in education, described white privilege as a set of unearned benefits that white people have based on being born white in a culture that favors the white race. White people have privilege because it was given to them by other white people, and it was taken by claiming superiority over people of color, starting before the European colonizations of Africa, Asia, and the Americas, and continuing through the present day. Many white people come from impoverished communities, suffer from socioeconomic disadvantage, and struggle with unemployment. They may also suffer from inadequate housing and limited education. Because they are white, they still benefit from privilege and positive stereotypes associated with light skin color. As our nation reckons with the murders of unarmed Black people by police, recognizing that  many white people have been allies and agents of change forBlack and other minority people, discussing how the power of white privilege can be shared is needed. The authors discuss the power of white privilege and how that power can be shared to promote change in academic medicine.

Decrease in heart rate following the administration of sugammadex in adults

Background and Aims:

Sugammadex is a novel agent for reversal of steroidal neuromuscular blocking agents (NMBAs) with potential advantages over acetylcholinesterase inhibitors. In preclinical trials, there have been rare instances of bradycardia with progression to cardiac arrest. To better define this issue, its incidence and mitigating factors, we prospectively evaluated the incidence of bradycardia after sugammadex administration in adults.

Material and Methods:

Patients ≥ 18 years of age who received sugammadex were included in this prospective, open label trial. After administration, heart rate (HR) was continuously monitored. HR was recorded every minute for 15 minutes and then every five minutes for the next 15 minutes or until patient was transferred out of the operating room. Bradycardia was defined as HR less than 60 beats/minute (bpm) or decrease in HR by ≥ 10 beats per minute (bpm) if the baseline HR was <70 bpm.

Results:

The study cohort included 200 patients. Bradycardia was observed in 13 cases (7%; 95% confidence interval: 4, 11), occurring a median of 4 minutes after sugammadex administration (IQR: 4, 9, range: 2-25). Among patients developing bradycardia, two (15%) had cardiac comorbid conditions. One patient received treatment for bradycardia with ephedrine. No clinically significant blood pressure changes were noted. On bivariate analysis, patients receiving a higher initial sugammadex dose were more likely to develop bradycardia. On multivariable logistic regression, initial sugammadex dose was not associated with the risk of bradycardia.

Conclusion:

The incidence of bradycardia after administration of sugammadex in our study was low and not associated with significant hemodynamic changes.

Ventricular Assist Device Technology and Black-White Disparities on the Heart Transplant Wait List

Introduction:

Heart transplantation is the definitive treatment for end-stage heart failure. Left ventricular assist devices (LVADs) are a continually improving technology that extends life for some candidates on the heart transplant waiting list. Research Questions: Our objective is to compare Black-White differences in LVAD implantation and heart transplant outcomes during a period of technological innovation when the pulsatile flow LVAD was largely replaced by the continuous flow LVAD between 1999-2014.

Design:

We used transplant registry data from the United Network for Organ Sharing (N = 5,550) to identify Black and White patients with heart failure who used an LVAD as a bridge-to-transplant (BTT). Using logistic regression, we compared Black-White differences in access to newer LVAD technology and timing of implantation relative to wait listing for heart transplantation. We used competing-risks event history models to predict transplant outcomes across race, LVAD type, and timing of LVAD implantation.

Results:

Black and White candidates were equally likely to receive newer continuous flow LVADs, but Black candidates received LVADs later in the disease course (i.e. after transplant listing). This later timing of technological intervention contributed to poorer wait list outcomes among black transplant candidates, including lower likelihood of receiving a heart transplant and greater likelihood of being removed from the wait list due to worsening health.

Discussion:

Delayed LVAD implantation is more common among Black patients and is associated with poorer transplant outcomes.

The Impact of Medical Financial Hardship on Children's Health

Objective. To determine whether living in a family with medical financial hardship decreases children's access to health care. Methods. We identified children aged 4 to 17 years from the 2013 to 2018 National Health Interview Surveys. Medical financial hardship was defined as living in a family where one or more family members had problems paying medical bills in the past 12 months. Results. Of 53 483 children in the analysis, 19% were exposed to medical financial hardship. This was adversely associated with children's health status and health care use, especially greater odds of delaying care (odds ratio [OR] = 5.28; 95% confidence interval [CI] = 4.51-6.19) and having unmet health care needs (OR = 4.43; 95% CI = 4.00-4.91). Conclusions. One fifth of children live in families experiencing medical financial hardship, and this exposure is adversely correlated with child health outcomes even controlling for established measures of socioeconomic status, such as family income, health insurance coverage, and need-based program participation.

Prematurity and breastfeeding initiation: A sibling analysis

AIM

Studies suggest breastfeeding initiation is less common for premature infants. This association may be confounded by socio-economic characteristics that correlate with the risk of premature birth. We compared premature and term-born children to determine whether prematurity independently predicted likelihood of breastfeeding continuation and duration.

METHODS

Data were obtained from women ages 15-44 years reporting at least two live pregnancies on the 2011-2017 National Survey of Family Growth. Participants completed a pregnancy and breastfeeding history. Breastfeeding initiation was defined as breastfeeding for at least 1 week, and duration of exclusive breastfeeding was recorded in months. Sibling fixed effects regression models were used to evaluate the impact of prematurity.

RESULTS

Among families with some children who were breastfed and others who were not (n = 2848 children), preterm birth was not associated with breastfeeding initiation (odds ratio = 1.11; P = .468). Among children who were ever breastfed, exclusive breastfeeding lasted 5% fewer months among children born preterm, compared with term-born siblings (incidence rate ratio = 0.95; P = .060).

CONCLUSION

Using sibling-group analysis to control for confounding, we found no independent association between prematurity and likelihood of breastfeeding initiation. This suggests interventions supporting breastfeeding for premature infants may need to address external barriers to breastfeeding not specifically preterm birth.

Correction to: Influence of Cystic Fibrosis‑Related Diabetes on Mental Health in Adults: A Single‑Center Study

The original version of this article unfortunately contained a mistake in one of the co-author name Prof. Don Hayes Jr. During production process, "Jr." was missed to add after the author name. The author name is corrected with this correction. The original article has been corrected.

Rural Employment of Health Care Workers: A Longitudinal Cohort Study

PURPOSE

Preserving and increasing the health care workforce in rural areas has become imperative due to the shortage of health care workers serving rural populations. However, limited data are available on long-term patterns of employment in rural settings among health care workers.

METHODS

We analyzed the National Longitudinal Survey of Youth, which enrolled a nationally representative sample of adolescents in 1979 and tracked their career outcomes through 2016. Using the US Census Bureau occupation codes, we identified participants who worked in health care occupations, and we classified their employment in rural versus urban areas.

FINDINGS

Of the 1,007 respondents (including 109 doctoral health professionals), 70% worked only in urban locations, 13% worked only in rural locations, and 17% worked in both rural and urban locations during their health care career. Rural upbringing, White race, and female gender were associated with rural employment. Among nondoctoral health professionals, lower educational attainment was associated with increased likelihood of working only in rural settings.

CONCLUSION

Our study indicates the rural workforce is split between workers who are only employed in rural settings, and those who are intermittently employed in rural and urban settings. Therefore, retention of health care workers in rural settings and recruitment of workers from urban settings to practice in rural areas are important strategies for addressing the rural health care worker shortage. Rural upbringing, previously described as predictive of physician practice in rural locations, appears the strongest predictor of rural employment for both doctoral health professionals and nondoctoral health professionals.

Characteristics of Medical School Applicants: A Single-Institution Study

BACKGROUND AND OBJECTIVES

Medical schools aim to admit talented learners who are honest, patient centered, and caring, in addition to possessing the required cognitive skills. The Association of American Medical Colleges (AAMC) describes core competencies for entering medical students in three categories: science, preprofessional, and thinking and reasoning. The authors sought to determine desired characteristics of medical school applicants at a rural, community-based medical school in light of the published core competencies.

METHODS

This qualitative study involved an analysis of data from discussion groups, all from a convenience sample of participants. The authors led the discussion groups, and large sticky note pads and pens were provided to scribe responses. Group members were given the prompt, "What do you see as traits or characteristics of your ideal doctor?" We used a content analysis approach to analyze the data.

RESULTS

The total number of responses across groups was 243, representing 15 unique characteristics. The 15 characteristics, listed in decreasing order of frequency, included good communicator, knowledgeable, dedicated, compassionate, respectful, community oriented, well rounded, patient, team player, available, leader, positive attitude, equal treatment, prevention focused, and urgency when needed for patient care. Of the top characteristics with 20 or more responses, alignment with AAMC competencies was noted, but less so with being community oriented as defined by study participants.

CONCLUSIONS

This study demonstrates that there are unique characteristics that a rural community and its medical school consider when admitting applicants to their medical program. Further research is needed to explore the need for additional competencies for rural medical schools to consider for entering medical students.

Documentation of drug abuse in the family or household of children admitted to the hospital for non-accidental trauma

BACKGROUND

Drug abuse in the family is known to increase the risk of child abuse, but its impact on outcomes of hospitalizations for non-accidental trauma (NAT) has not been characterized.

OBJECTIVE

We aimed to identify how frequently drug abuse in the household was documented among children with known or suspected NAT, and to correlate drug abuse in the family with hospitalization outcomes.

PARTICIPANTS AND SETTING

At our tertiary care hospital, we retrospectively queried hospital admissions of children ages 0-17 who had a Child Abuse and Neglect consultation ordered during an inpatient stay.

METHODS

Case manager documentation and consult notes from the inpatient response team were used to determine suspected or confirmed presence of household substance abuse.

RESULTS

We identified 185 children meeting inclusion criteria (59 % <1 year; 34 % 1-5 years; 7% 6-14 years of age). Drug abuse in the family was documented in 44 cases (24 %). Among 178 children surviving to discharge, drug abuse was associated with lower likelihood of discharge home (50 % vs. 70 % among children with no documented drug abuse, p = 0.018). After discharge, we found no statistically significant differences in rehospitalizations or emergency department visits according to documentation of drug abuse in the family.

CONCLUSION

Our study addresses the role of family drug abuse in outcomes of hospitalizations for NAT. Significantly, half of cases with suspected or known drug abuse had no prior CPS involvement, and drug abuse was associated with discharge outcomes after controlling for prior CPS involvement.