Impact of elexacaftor-tezacaftor-ivacaftor on bacterial colonization and inflammatory responses in cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is a multisystem disease with progressive deterioration. Recently, CF transmembrane conductance regulator (CFTR) modulator therapies were introduced that repair underlying protein defects. Objective of this study was to determine the impact of elexacaftor-tezacaftor-ivacaftor (ETI) on clinical parameters and inflammatory responses in people with CF (pwCF).

METHODS

Lung function (FEV1 ), body mass index (BMI) and microbiologic data were collected at initiation and 3-month intervals for 1 year. Blood was analyzed at baseline and 6 months for cytokines and immune cell populations via flow cytometry and compared to non-CF controls.

RESULTS

Sample size was 48 pwCF, 28 (58.3%) males with a mean age of 28.8 ± 10.7 years. Significant increases in %predicted FEV1 and BMI were observed through 6 months of ETI therapy with no change thereafter. Changes in FEV1 and BMI at 3 months were significantly correlated (r = 57.2, p < 0.01). There were significant reductions in Pseudomonas and Staphylococcus positivity (percent of total samples) in pwCF through 12 months of ETI treatment. Healthy controls (n = 20) had significantly lower levels of circulating neutrophils, interleukin (IL)-6, IL-8, and IL-17A and higher levels of IL-13 compared to pwCF at baseline (n = 48). After 6 months of ETI, pwCF had significant decreases in IL-8, IL-6, and IL-17A levels and normalization of peripheral blood immune cell composition.

CONCLUSIONS

In pwCF, ETI significantly improved clinical outcomes, reduced systemic pro-inflammatory cytokines, and restored circulating immune cell composition after 6 months of therapy.

Impact of guideline adherence and race on asthma control in children

BACKGROUND

Asthma control in African Americans (AA) is considered more difficult to achieve than in Caucasian Americans (CA). The aim of this study was to compare asthma control over time among AA and CA children whose asthma is managed per NAEPP (EPR-3) guidelines.

METHODS

This was a one-year prospective study of children referred by their primary care physicians for better asthma care in a specialty asthma clinic. All children received asthma care per NAEPP guidelines. Results were compared between CA and AA children at baseline and then at three-month intervals for one year.

RESULTS

Of the 345 children, ages 2-17 years (mean = 6.2 ± 4), 220 (63.8%) were CA and 125 (36.2%) were AA. There were no significant differences in demographics other than greater pet ownership in CA families. At baseline, AA children had significantly more visits to the Emergency Department for acute asthma symptoms (mean = 2.3 [Formula: see text] compared to CA (1.4 ± 2.3, P = 0.003). There were no other significant differences in acute care utilization, asthma symptoms (mean days/month), or mean asthma control test (ACT) scores at baseline. Within 3-6 months, in both groups, mean ACT scores, asthma symptoms and acute care utilization significantly improved (P < 0.05 for all) and change over time in both groups was comparable except for a significantly greater decrease in ED visits in AA children compared to CA children (P = 002).

CONCLUSION

Overall, improvement in asthma control during longitudinal assessment was similar between AA and CA children because of  consistent use of NAEPP asthma care guidelines.

Impact of type of health care provider on long term asthma control

OBJECTIVE

Asthma prevalence is high and adherence to asthma guidelines is still less than adequate. The main objective of this study was to determine if there were significant differences in outcome measures if asthma care was provided per guidelines either by physicians (pediatric pulmonologists) or specialty trained advance practice nurses (APNs).

METHODS

This was a three-year, prospective cohort study of children referred by their primary care providers to a tertiary care center for better asthma control. Patients were provided asthma care per NAEPP guidelines including asthma education. Results were compared over time and between patients followed by physicians or APNs. Alpha level of significance was ≤0.05.

RESULTS

The sample included 471 children, ages 2-17 years (mean = 6.4 ± 2.4 years). Physicians and APN's provided asthma care. Of the 471 children enrolled in the study, 176 (37%) were followed for the full three-year study period. At the initial visit, physician group reported more short courses of oral steroids and more unscheduled visits to PCP for acute asthma care in the past 6 months compared to those followed by APNs (<0.05 for all). Among the total cohort and both subgroups, there were significant improvements in mean Asthma Control Test (ACT), acute care need and mean days/month with asthma symptoms over a three-year period (p < 0.05). There was significantly more improvement in use of oral steroids and urgent care visits in physician group (p < 0.05).

CONCLUSION

When asthma guidelines are followed, improvements in asthma control are achieved in children in both the MD and APN groups.

Impact of asthma severity on long-term asthma control

Background: Asthma is a common childhood disease with significant morbidity. Severe asthma accounts for just 4-6% of patients, but this group is more difficult to treat and is responsible for up to 40% of asthma expenses.Objective: The relationship between asthma severity and control is not well characterized. The main objective of this study was to determine impact of asthma severity on asthma control over time.Methods: This was a three year, prospective observational cohort study at a tertiary care children's hospital. Results were compared over time and between patients with severe and non-severe persistent asthma. Intervention included therapy based on severity and control, accompanied by a NAEPP (EPR-3) guidelines based structured asthma education program.Results: The sample included 471 children referred from primary care offices with the diagnosis of persistent asthma, mean age 6.4 ± 2.4 years. Forty-one children (8.7%) had severe persistent asthma and 430 (91.3%) children had non-severe persistent asthma (mild-moderate persistent). Our sample size decreased over the three-year period and the number of patients completing the third year were 176 (38%) and among them 20 (11.4%) had severe asthma. At the initial visit, children with severe persistent asthma had significantly more acute care needs, more daily symptoms, and lower mean Asthma Control Test™ scores compared to children with non-severe persistent asthma. Differences between groups decreased within six months with significant improvements in most indicators persisting throughout three-year follow up in both groups (p < 0.05).Conclusion: Asthma control improves independent of severity if asthma guidelines are followed.

A Novel Approach to Assessing Head Injury Severity in Pediatric Patient Falls

INTRODUCTION

Pediatric patient falls with head-to-floor impact have the greatest potential for injury.

METHODS

An objective measure of head injury severity, the Head Injury Criterion (HIC₁₅), was calculated from anthropometric and biomechanical components of patient falls. A secondary aim was to compare HIC₁₅ levels with the hospital's subjective assignment of level of harm (1-9 scale) used for regulatory reports.

RESULTS

Adverse event reports yielded a sample of 49 falls from heights of 72.5 to 1793.0 cm by children ages 11 months through 17 years. Contact velocity from beginning to end was 2.81 to 6.16 ms. Mean acceleration was 19.5 to 95.3g. HIC₁₅ levels of impact ranged from 26.4 to 1,330.0, and mean force upon contact was 2.0 to 9.8 N/kg body mass. Seven (14.3%) children's HIC₁₅ levels exceeded age-specific thresholds, with no follow-up scheduled. Hospital-assigned levels of harm were not correlated with HIC₁₅ levels (r = .23, R² = .05, p = .12).

DISCUSSION

A point-of-care computerized HIC₁₅ algorithm would be useful for diagnostic and follow-up decisions.

Erratum to: Racial differences in pet ownership in families of children with asthma

In the article by Sheikh SI, et al, "Racial differences in pet ownership in families of children with asthma" in World Journal of Pediatrics 2016;12(3):343-346 (doi: 10.1007/s12519-016-0027-9), the last author's name was incorrectly listed as "Don Hayes". His name should have read "Don Hayes Jr".

Operational Failures Detected by Frontline Acute Care Nurses

Frontline nurses encounter operational failures (OFs), or breakdowns in system processes, that hinder care, erode quality, and threaten patient safety. Previous research has relied on external observers to identify OFs; nurses have been passive participants in the identification of system failures that impede their ability to deliver safe and effective care. To better understand frontline nurses' direct experiences with OFs in hospitals, we conducted a multi-site study within a national research network to describe the rate and categories of OFs detected by nurses as they provided direct patient care. Data were collected by 774 nurses working in 67 adult and pediatric medical-surgical units in 23 hospitals. Nurses systematically recorded data about OFs encountered during 10 work shifts over a 20-day period. In total, nurses reported 27,298 OFs over 4,497 shifts, a rate of 6.07 OFs per shift. The highest rate of failures occurred in the category of Equipment/Supplies, and the lowest rate occurred in the category of Physical Unit/Layout. No differences in OF rate were detected based on hospital size, teaching status, or unit type. Given the scale of this study, we conclude that OFs are frequent and varied across system processes, and that organizations may readily obtain crucial information about OFs from frontline nurses. Nurses' detection of OFs could provide organizations with rich, real-time information about system operations to improve organizational reliability. © 2017 Wiley Periodicals, Inc.

Improved quality-of-life of caregivers of children with asthma through guideline-based management

OBJECTIVE

The quality of life (QOL) of caregivers of children with asthma may be related to children's responses to asthma management.

AIM

To evaluate change in QOL over time of caregivers of children with asthma through guideline-based management.

DESIGN

This was a 3-year prospective cohort study of children with asthma referred to our pediatric asthma center. Families completed Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), the Asthma Control Test™ (ACT), and reported the number of days/month of albuterol use and wheezing at each clinic visit.

RESULTS

We enrolled 143 children, ages 7-17 years (mean = 10.6 ± 2.9), 56.6% male, 70.6% Caucasian. Patients were managed by the same MD (n = 65,45.5%) or APN (n = 78,54.5%) over time. The mean total PACQLQ significantly increased over the 3-year period (F = 67.418, p < .001). Total scores at the first visit were 4.8 ± 1.6, which improved to 6.1 ± 1 at the 3-month follow-up visit. This improvement was sustained at the 1, 2, and 3-year clinic visits. PACQLQ emotional function (F = 60.798, p < .001) and activity limitation (F = 41.517, p < .001) domains significantly improved as well. PACQLQ scores were significantly associated with improved ACT scores (r = .37 to .47, p < .05), fewer days/month of albuterol use (r = -.25 to -.36., p < .05), and wheezing (r = -.28 to -.33, p < .05). There were no significant differences in PACQLQ, or asthma clinical outcome measures between MD and APN providers.

CONCLUSION

Use of National Asthma Education and Prevention Program (NAEPP) guidelines significantly improved QOL of caregivers of children with asthma and in asthma-related symptoms. Improvements over time were independent of type of providers.

Racial differences in pet ownership in families of children with asthma

BACKGROUND

Exposure to household domestic animals such as cats and dogs in early life may have some role in pathogenesis of asthma. Racial differences exist in the prevalence of asthma. We hypothesized that there may also be racial differences in pet ownership in families with asthma.

METHODS

A cross sectional study was conducted from June 2011 to December 2014 on 823 of 850 (97%) families of children with asthma for pet ownership. Comparisons among racial groups were done using chi square analysis and one-way analysis of variance.

RESULTS

The mean age of the cohort was 6.9±4.4 years. A total of 540 (65.62%) patients were Caucasian, 195 (23.7%) African American, 42 (5.1%) hispanics, and 26 (3.2%) biracial with one Caucasian parent. Pets in the home were reported by 470 (58.5%) households. Significantly fewer African American and hispanic families had pets in the home (26.9% and 44.7%) than biracial and Caucasian families (72% and 69.9%, P<0.001). Likewise, significantly more biracial and Caucasian families were noted to have dogs (52% and 54.4%) or cats (25.4% and 40%) or both cats and dogs (28% and 18%) than African Americans families (20.3%, P<0.001; 7.1%, P<0.001) and (4.6%, P<0.001), respectively.

CONCLUSIONS

Among families with asthmatic children, pet ownership is significantly more likely in Caucasian families compared with African-American and Hispanic families, thus there is a racial diversity in pet ownership among families of children with asthma.

Wrist Actigraphy Validation of Exercise Movement in COPD

A wrist actigraph is a device used in sleep research studies to measure whole body movements. The purpose of this study was to evaluate the feasibility, sensitivity, and validity of wrist actigraphy during pulmonary rehabilitation (PR) upper-extremity exercise in chronic obstructive pulmonary disease (COPD) patients. In this study, 20 patients wore Octagonal Basic Motionlogger® actigraphs during two 90-minute PR sessions while the investigator recorded details of the subject's upper-extremity movements. Concurrent validity with supervised exercise records was supported for upper-extremity endurance (UEE) intensity at baseline ( r = .885, p < .001) and 1 week ( r = .935, p < .001). Criterion validity was supported for UEE ( r = .56, p = .01) and combined lower- and upper-extremity resistance ( r = .72, p < .01) compared with rank-ordered type of exercise. Wrist actigraphy is shown to be a feasible, sensitive, and valid instrument to measure upper-extremity movement during PR in COPD patients.

Novel Computed Tomography Scoring System for Sinus Disease in Adults With Cystic Fibrosis

OBJECTIVE

There is no easy to use scoring system for computed tomography (CT) scans of the sinuses that is specific to cystic fibrosis (CF). We propose a simple and easily implemented scoring system to quantify severity of sinus disease in adults with CF.

STUDY DESIGN

Case series with chart review.

SETTING

Academic tertiary-care referral center.

SUBJECTS

Sixty-nine adult patients with CF and 50 age-matched controls.

METHODS

We validated a scoring system for CF sinus disease. The CT scans were interpreted by 3 physicians on 2 separate sittings. Parameters include maxillary opacification, nasal obstruction, lateral nasal wall displacement, uncinate process absence/demineralization, and presence/absence of mucocele.

RESULTS

Patients with CF aged 21 to 30 years (mean = 24.7 ± 2.49). In CF cohort (n = 69), intrarater reliability for the 10 CT categories ranged from .70 to 1.00. Twenty-six (87%) were in the excellent range, and the remaining 4 (13%) were evaluated as good. In the non-CF cohort (n = 50), reliabilities ranged from .44 to 1.00. Twenty-seven (90%) were in the excellent range. For interrater reliability, in the CF cohort, 10 CT categories across the 3 raters ranged from .55 to 1.00. Excellent reliability was achieved in 15 (50%) of the observations. In the non-CF cohort, reliabilities ranged from .44 to 1.00.

CONCLUSION

A novel and easy to use CT scoring system for CF sinus disease in adults was validated with inter- and intrarater reliability. This new CF sinus disease-specific scoring system can be used by clinicians, surgeons, and radiologists.

Improving pediatric asthma care: A partnership between pediatric primary care clinics and a free-standing Children's Hospital

BACKGROUND

Asthma is a common chronic disease of childhood. Providers' adherence to asthma guidelines is still less than optimal.

OBJECTIVES

To determine if an Asthma Education Program aimed at primary care practices can improve asthma care within practices and if the results vary by duration of the program.

METHODS

Ten practices were randomly assigned to an Early Asthma Education Intervention (EI) group or a Delayed Asthma Education Intervention (DI) group. The EI group received the intervention for 12 months and was monitored for 6 additional months. The DI group was observed without intervention for 12 months, then received the intervention for 6 months, and was monitored for 6 additional months. The program included training of asthma educators in each practice and then monitoring for improvement in medical record documentation of National Asthma Education and Prevention Program (NAEPP) asthma quality indicators by blinded random review of patient charts.

RESULTS

In the EI group, 6-, 12-, and 18-month data revealed significant improvement in documentation of asthma severity, education, action plan, night time symptoms, and symptoms with exercise compared to baseline and compared to DI group at baseline and at the 12-month interval. In the DI group, significant improvement in documentation in all of the above endpoints and also in documentation of NAEPP treatment guidelines was noted at 18 and 24 months. In both groups, documentation levels remained relatively stable at 6 months after the intervention, with no significant differences between groups. While improved, guideline adherence was <80% for half of the indicators.

CONCLUSION

In-office training of non-physician asthma providers improves the quality of asthma care.

Environmental exposures and family history of asthma

BACKGROUND

Asthma pathogenesis is a complex interaction of genetic, ethnic, environmental and social/life style risk factors.

AIM

The goal of this study was to identify associations, if any, in children with asthma, between environmental risk factors (exposure to second-hand tobacco smoke (STS), pet ownership, race and a family history of asthma.

METHODS

After IRB approval, from June 2011 to December 2014, 823 children with asthma were enrolled in this prospective cross sectional study. At the initial visit, families completed a questionnaire with information on family history of asthma, having a pet at home and exposure to STS by parents at home. Chi square analyses were calculated, with alpha level of significance ≤0.05.

RESULTS

History of asthma in parents, siblings or grandparents was reported by 575 (69.8%) patients including father (n = 154, 17.8%) and mother (n = 235, 26.5%). Children with family history of asthma (n = 575) were significantly more likely to have a pet at home and exposure to STS (n = 347, 60.3% and n = 198, 34.4%, respectively) compared to families without a history of asthma (n = 124, 50%, p = 0.006 and n = 44, 17.7%, p < 0.001, respectively). Similarly, asthmatic children with exposure to STS (n = 241) were significantly more likely to have a pet at home and a family history of asthma (n = 153, 63.5% and n = 197, 81.7%, respectively) compared to children with no STS exposure (n = 315, 55.5%, p = 0.034 and n = 371, 65.3%, p < 0.001 respectively).

CONCLUSIONS

Significantly more asthmatic children with immediate relatives with a history of asthma have a pet at home and experience STS exposure compared to children without relatives with a history of asthma, suggesting association between life style choices/environmental exposures and family history of asthma.

Screening high-risk children for asthma through a community intervention

OBJECTIVE

Many children, particularly those from inner city neighborhoods, have undiagnosed asthma. This study was done to evaluate the effectiveness of an asthma screening, referral and follow-up intervention in an inner city community setting in early identification of children at risk for undiagnosed asthma.

METHODS

A descriptive longitudinal cohort design was used to assess children at baseline and at a 2-year follow-up. Parents of children in a private day school and a church Sunday school (N = 103) completed a validated Asthma Screening Tool at both time periods. Children with asthma and at risk for asthma were referred to a primary care provider (PCP).

RESULTS

At baseline, screening of 103 children, ages 3-17 years (mean=7.7 ± 2.9), were categorized as known asthma diagnosis (n = 22), at-risk for undiagnosed asthma (n = 52) and not at-risk for asthma (n = 29). Sixty-two (60.2%) parents responded to the 2-year follow-up. Referral to PCP was kept by 61.5% from the known asthma group and by 24% of children at-risk for asthma. At 2-year follow-up, among not at-risk group, no one converted to at risk status, but majority of children among known asthma group continued to have uncontrolled asthma symptoms, and very few received daily preventive asthma medications.

CONCLUSIONS

The asthma screening, referral and follow-up intervention for inner city children in a community setting was successful in early identification of patients at-risk for asthma. More education for PCPs on guidelines for diagnosis and management of asthma is needed to decrease childhood asthma morbidity.

Changes in Pulmonary Function and Controlled Ventilation-High Resolution CT of Chest After Antibiotic Therapy in Infants and Young Children with Cystic Fibrosis

BACKGROUND

Infants with cystic fibrosis (CF) develop early progressive lung disease which may be asymptomatic. Infant pulmonary function tests (IPFT) and controlled ventilation-high resolution computed tomography (CV-HRCT) of chest can detect early asymptomatic lung disease. It is not well established that these objective measures can detect changes in lung disease after clinical interventions.

OBJECTIVE

The purpose of this study was to evaluate usefulness of IPFT and CV-HRCT to detect changes in lung disease after intravenous (IV) antibiotic therapy in infants with early CF-related lung disease.

STUDY DESIGN

IPFTs and CV-HRCT done before and after 2 weeks of IV antibiotics in infants at our institution over the last 12 years were compared. CV-HRCTs were compared using the modified Brody scoring system.

RESULTS

The sample included 21 infants, mean age 85.2 ± 47.6 weeks. Mean change in weight was 0.4 ± 0.38 kg (p = 0.001). Significant changes in IPFT included mean % predicted FEV(0.5) (+13.5 %, p = 0.043), mean %FEF(25-75) (+30.2 %, p = 0.008), mean %RV/TLC (-11.2 %, p = 0.008), and mean %FRC/TLC (-4.5 %, p = 0.001). Total Brody scores improved from a median of 10 to 5 (p < 0.001) as did mean scores for airway wall thickening (p = 0.050), air trapping (p < 0.001), and parenchymal opacities (p = 0.003).

CONCLUSION

IPFT and CV-HRCT can be used as objective measures of improvement in lung disease for infants with CF treated with antibiotics.

Outcomes of surgical management of severe GERD in patients with cystic fibrosis

BACKGROUND

Patients with cystic fibrosis (CF) are at high risk for gastroesophageal reflux disease (GERD) and medical management of GERD improves pulmonary symptoms. Some patients with worsening CF and GERD symptoms undergo Nissen fundoplication, but the extent to which surgical management of GERD improves respiratory symptoms is not well studied. The purpose of this retrospective study was to evaluate the safety and efficacy of Nissen fundoplication in 48 patients with CF and uncontrolled GERD.

RESULTS

Patients exhibited significantly fewer pulmonary exacerbations, increased weight gain and slower decline in % predicted FEV1 at 2 years after the surgery, compared to 2 years before surgery. Mean change in % predicted FEV1 in 2 years before surgery was--13.57% and mean change in % predicted FEV1 in 2 years after the surgery was +1.5% and difference was significant P = 0.001. Better pulmonary and nutritional outcomes were noted among patients with milder lung disease compared to those with severe lung disease, and among patients who received gastrostomy tube feedings for ≥6 months compared to those with no G-tube or tube feedings for <6 months. There was no mortality associated with surgery.

CONCLUSION

In CF patients with worsening lung disease and uncontrolled GERD, Nissen fundoplication not only slows the decline in lung function but leads to significant improvement in weight, and decrease in CF exacerbations. Patients with milder disease and patients receiving G-tube feedings for ≥6 months after surgery benefited the most.

Demographics, clinical course, and outcomes of children with status asthmaticus treated in a pediatric intensive care unit: 8-year review

OBJECTIVE

This study was done to understand the demographics, clinical course, and outcomes of children with status asthmaticus treated in a tertiary care pediatric intensive care unit (PICU).

METHODS

The medical charts of all patients above 5 years of age admitted to the PICU at Nationwide Children's Hospital, Columbus, OH, USA, with status asthmaticus from 2000 to 2007 were reviewed retrospectively. Data from 222 encounters by 183 children were analyzed.

RESULTS

The mean age at admission in years was 11 ± 3.8. The median PICU stay was 1 day (range, 1-12 days) and median hospital stay was 3 days. The ventilated group (n = 17) stayed a median of 2 days longer in the PICU and hospital. Nearly half of the children (n = 91; 50%) did not receive daily controller asthma medications. Adherence to asthma medications was reported in 125 patient charts of whom 43 (34%) were compliant. Exposure to smoking was reported in 167 of whom 70 (42%) were exposed. Among patients receiving metered dose inhaler (MDI), only 39 (18%) were using it with a spacer. Among 105 patient charts asthma severity data were available, of them 21 (20%) were labeled as mild intermittent, 29 (28%) were mild persistent, 26 (25%) were moderate persistent, and 29 (28%) were severe persistent. Compared to children with only one PICU admission during the study period (n = 161), children who had multiple PICU admissions (n = 22) experienced more prior emergency department visits and hospitalizations for asthma symptoms. There were no fatalities.

CONCLUSION

Asthmatics with any disease severity are at risk for life-threatening asthma exacerbations requiring PICU stay, especially those who are not adherent with their daily medications.

An interdisciplinary momentary confluence of events model to explain, minimize, and prevent pediatric patient falls and fall-related injuries

PURPOSE

This article reviews theoretical, empirical, and clinical evidence to support the hypothesis that pediatric patient fall episodes are rarely predictable; rather, falls and fall-related injuries occur during the momentary convergence of child, parent, and caregiver human factors, and environmental, biomechanical, and system factors.

CONCLUSIONS

We propose an interdisciplinary pediatric fall and injury prevention model to guide future research toward interventions to prevent or minimize pediatric patient falls and injuries.

PRACTICE IMPLICATIONS

When falls and near miss falls occur, nurses' detailed descriptions of each model component are critical to discovery of more effective pediatric fall and injury prevention methods.

Pediatric medical line safety: the prevalence and severity of medical line entanglements

The purpose of this cross-sectional study was to describe the prevalence and severity of medical line entanglements among pediatric patients (N = 486). Most patients, with ages from birth to 6 years, had at least 1 medical line (n = 444, 91%), and 294 children (60%) had 2 to 11 medical lines. Observed entanglements included lines around body parts (n = 31), lines under the body (n = 71), and lines tangled with other lines (n = 50). One third of the children were at risk for adverse events due to entanglements, and 1 patient actually experienced real harm.

Uncomplicated UTIs in women

Empirical diagnosis and treatment of lower urinary tract infection (UTI) in women is the most common clinical approach due to the urgency of symptoms and cost. This study examines the importance of recognizing common symptoms and accurately diagnosing UTIs in the primary care setting.

Challenges and conundrums in the validation of Pediatric Fall Risk Assessment tools

The 10-item Pediatric Fall Risk Assessment (PFRA) was developed to evaluate patients at low- or high-risk for falling. To avoid the unnecessary use of resources for children not likely to fall, children evaluated as high-risk are targeted for more intensive fall prevention interventions. In a retrospective, case-control design, the precision, accuracy, and error rate of the PFRA with patients ages 1 month to 24 years were evaluated. Cases included children who fell (n = 326), and controls (n = 326) were children from the same cohort who did not fall. Inter-rater agreement (precision) on PFRA cut-off scores was 95.1%, but accuracy was unacceptably low due to 60% false-positive and 58.5% false-negative risk ratings. Neither the PFRA nor three other widely used pediatric fall risk scales have sufficient precision or accuracy to justify implementing or withholding a high-risk fall prevention protocol. Several logistic and methodological challenges must be addressed before further development of these tools.

Factorial structure of the perception of risk factors for type 2 diabetes scale: exploratory and confirmatory factor analyses

RATIONALE, AIMS AND OBJECTIVES

The extent to which individuals' perceptions of risk for type 2 diabetes are related to their actual risks and health-promoting behaviours is not well known. Yet perception of risk for type 2 diabetes may influence the likelihood that individual would engage in preventive behaviours. The purpose of this study was to evaluate the psychometric properties of the perception of risk factors for type 2 diabetes (PRF-T2DM).

METHODS

A descriptive, correlational, methodological design was used to conduct this study. The sample consisted of 629 adults from 42 states of the United States. A demographic questionnaire, the PRF-T2DM, the health-promoting lifestyle profile II and the depressive cognition scale were used to collect the data. Data analyses consisted of descriptive statistics, scale and item analyses, Pearson's correlation analysis, and exploratory and confirmatory factor analyses.

RESULTS

The PRF-T2DM has a Cronbach's alpha of 0.81. Both extracted factors had Cronbach's alphas of 0.74 and 0.80, respectively. Most inter-item and item-to-total correlation coefficients for factor 1 and factor 2 met the recommended criteria of r=0.30 to r=0.70. The PRF-T2DM achieved all minimum recommended criteria for model fit (χ(2) /d.f.=2.33, goodness of fit index=0.95, adjusted goodness of fit index=0.93, comparative fit index=0.94, root mean square error of approximation=0.05, root mean residual=0.05 and the P value for test of close fit=0.33).

CONCLUSIONS

All statistical estimates and measures of model fit were above the standard recommended criteria. The scale has potential uses in research and clinical practice. Further development and psychometric evaluation of the PRF-T2DM is warranted.

Critical care air transport team (CCATT) nurses' deployed experience

The objective of this study was to use descriptive and phenomenological methods with Critical Care Air Transport Team (CCATT) nurses to identify knowledge and skills required to provide care for critically ill patients in a combat environment. Unstructured interviews, focus groups, written narratives, group interviews, participant observation, and review of in-flight documentation of care were used to obtain data from 23 registered nurses who had deployed with CCATT missions. Dimensions that emerged from the data included: clinical and operational competence, personal, physical, and psychosocial readiness, soldier and survival skills, leadership, administrative concerns, group identification and integration, aircraft air and evacuation familiarity, and nurse characteristics. This information should be shared with CCATT trainers and unit personnel to better prepare them for the realities of future deployments. Future research could incorporate these data into a self-assessment scale to evaluate CCATT nurses' readiness for future deployments.

Accuracy of vaginal symptom self-diagnosis algorithms for deployed military women

BACKGROUND

Deployed military women have an increased risk for development of vaginitis due to extreme temperatures, primitive sanitation, hygiene and laundry facilities, and unavailable or unacceptable healthcare resources. The Women in the Military Self-Diagnosis (WMSD) and treatment kit was developed as a field-expedient solution to this problem.

OBJECTIVES

The primary study aims were to evaluate the accuracy of women's self-diagnosis of vaginal symptoms and eight diagnostic algorithms and to predict potential self-medication omission and commission error rates.

METHOD

Participants included 546 active duty, deployable Army (43.3%) and Navy (53.6%) women with vaginal symptoms who sought healthcare at troop medical clinics on base.In the clinic lavatory, women conducted a self-diagnosis using a sterile cotton swab to obtain vaginal fluid, a FemExam card to measure positive or negative pH and amines, and the investigator-developed WMSD Decision-Making Guide. Potential self-diagnoses were "bacterial infection" (bacterial vaginosis [BV] and/or trichomonas vaginitis [TV]), "yeast infection" (candida vaginitis [CV]), "no infection/normal," or "unclear." The Affirm VPIII laboratory reference standard was used to detect clinically significant amounts of vaginal fluid DNA for organisms associated with BV, TV, and CV.

RESULTS

Women's self-diagnostic accuracy was 56% for BV/TV and 69.2% for CV. False-positives would have led to a self-medication commission error rate of 20.3% for BV/TV and 8% for CV. Potential self-medication omission error rates due to false-negatives were 23.7% for BV/TV and 24.8% for CV. The positive predictive value of diagnostic algorithms ranged from 0% to 78.1% for BV/TV and 41.7% for CV.

DISCUSSION

The algorithms were based on clinical diagnostic standards. The nonspecific nature of vaginal symptoms, mixed infections, and a faulty device intended to measure vaginal pH and amines explain why none of the algorithms reached the goal of 95% accuracy. The next prototype of the WMSD kit will not include nonspecific vaginal signs and symptoms in favor of recently available point-of-care devices that identify antigens or enzymes of the causative BV, TV, and CV organisms.

Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard

OBJECTIVE

To estimate the accuracy of the clinical diagnosis of the three most common causes of acute vulvovaginal symptoms (bacterial vaginosis, candidiasis vaginitis, and trichomoniasis vaginalis) using a traditional, standardized clinical diagnostic protocol compared with a DNA probe laboratory standard.

METHODS

This prospective clinical comparative study had a sample of 535 active-duty United States military women presenting with vulvovaginal symptoms. Clinical diagnoses were made by research staff using a standardized protocol of history, physical examination including pelvic examination, determination of vaginal pH, vaginal fluid amines test, and wet-prep microscopy. Vaginal fluid samples were obtained for DNA analysis. The research clinicians were blinded to the DNA results.

RESULTS

The participants described a presenting symptom of abnormal discharge (50%), itching/irritation (33%), malodor (10%), burning (4%), or others such as vulvar pain and vaginal discomfort. According to laboratory standard, there were 225 cases (42%) of bacterial vaginosis, 76 cases (14%) of candidiasis vaginitis, 8 cases (1.5%) of trichomoniasis vaginalis, 87 cases of mixed infections (16%), and 139 negative cases (26%). For each single infection, the clinical diagnosis had a sensitivity and specificity of 80.8% and 70.0% for bacterial vaginosis, 83.8% and 84.8% for candidiasis vaginitis, and 84.6% and 99.6% for trichomoniasis vaginalis when compared with the DNA probe standard.

CONCLUSION

Compared with a DNA probe standard, clinical diagnosis is 81-85% sensitive and 70-99% specific for bacterial vaginosis, Candida vaginitis, and trichomoniasis. Even under research conditions that provided clinicians with sufficient time and materials to conduct a thorough and standardized clinical evaluation, the diagnosis and, therefore, subsequent treatment of these common vaginal problems remains difficult.

LEVEL OF EVIDENCE

II.

Children's Adjustment to Parental Cancer

There is growing empirical evidence that various child and family factors are associated with children's reactions to parental cancer. Children having parents with cancer may respond to parental cancer in different ways in terms of bonadjustment and maladjustment. Children's maladjustment to this pervasive stressor is manifested by a wide variety of physiologic, psychologic, and behavioral stress responses. To date, research on children's adjustment to parental cancer has focused almost exclusively on documenting children's adjustment problems and on describing simple, direct association between the characteristics of children and/or their families, and children's adjustment. The gap in research and clinical practice lies in the lack of a comprehensive model to illuminate children's coping with parental cancer and to guide intervention programs. Based on a synthesis of the literature, this article proposes a model that specifies the relationships among the stressor of having a parent with cancer, moderators and mediator variables, and adjustment. This model can serve as a basis for future research and intervention programs.

Health status in an invisible population: carnival and migrant worker children

One goal of Healthy People 2010 (2003) is to close the gap of disparities in access to care and health. The purpose of this descriptive exploratory study was to evaluate health status indicators in the children of itinerant carnival and migrant farmworkers aged birth to 12 years. Health status outcomes (immunization records, well-child examinations, dental health status, and growth parameters) were compared between the two groups and to national averages to identify health disparities. All forms were available in Spanish and English. A total of 97 children were recruited for this study: 45 carnival children and 52 migrant farmworker children.

Factors associated with vaginal douching in military women

Objectives of this secondary analysis were to describe the prevalence of vaginal douching among 1,432 women on active duty in the military and to examine demographic and behavioral factors associated with douching. More than one-half (54.5%) of the respondents reported douching at least once in their lifetimes; 63.5% of those douched during the previous year, and 45.8% of those douched in > or = 6 of the past 12 months. Multiple regression analysis showed that being African American, using tampons, having sexual intercourse, having more than one sexual partner in a month, using spermicides, and being in the enlisted and noncommissioned officer ranks were associated with more frequent douching (20.1% of the variance in douching behavior was explained). Despite access to regular gynecological examinations and related health counseling, a significant number of military women continue to douche. These women may benefit from specific intensive information on normal vaginal self-cleansing mechanisms and the health hazards of douching. Military efforts to diminish this self-care behavior and to enhance providers' knowledge about the scope of the problem may improve women's health and military readiness by decreasing the incidence of negative consequences of douching.

Reliability and Validity Testing of a Short Form of the Readiness Estimate and Deployability Index Revised for Air Force Nurses

OBJECTIVE

The purpose of this study was to test the reliability and validity of the Readiness Estimate and Deployability Index Revised for Air Force Nurses Short Form, with a sample of 205 Air Force nurses. Participants were mostly female (70%), 36.31 +/- 9.3 years of age, with 11.52 +/- 7.17 years of nursing experience.

METHODS

With structural equation modeling, the initial model did not fit the data (chi2/df = 5.45) and was revised.

RESULTS

Revisions based on modification indices provided evidence of reliability (alpha coefficients of 0.70-0.94; the majority of R2 values were >0.50) and improved the fit of the model (chi2 difference, 35.54; df difference, 3.76; p < 0.05). Hypothesis testing provided evidence of construct validity.

CONCLUSIONS

The 40-item Readiness Estimate and Deployability Index Revised for Air Force Nurses Short Form provides evidence of reliability and validity as a self-assessment measure of deployment preparedness.

Changes in children's stressors over the past 30 years

Social and political changes have introduced new sources of stressors for children. Two studies of 7- to 12-year-old children (n=194; n=402) identified stressors from their perspective, compared them to items in existing instruments, analyzed changes in stressors over the past 30 years, and determined the need for a new instrument. The children named 908 stressors that were inductively sorted into 54 mutually exclusive categories of stressors. Only 24% to 50% of the categories were represented in existing instruments. Stressors that emerged in 2000 included being alone, tests, family fighting, too many things to do, and boyfriend/girlfriend issues. These findings provide insight into differences between adults' versus children's perspectives on stressors and invite speculation on the reasons why new stressors emerge over the years. The findings also support the need for a new instrument that captures the full range of stressors that children experience today.

Factors Predicting Health Behaviors among Army Reserve, Active Duty Army, and Civilian Hospital Employees

This study identified health-risk and health-promoting behaviors in military and civilian personnel employed in hospitals. Intrinsic self-motivation and extrinsic organizational workplace factors were examined as predictors of health behaviors. Because reservists represent a blend of military and civilian lifestyles, descriptive analyses focused on comparing Army Reserve personnel (n = 199) with active duty Army (n = 218) and civilian employees (n = 193), for a total sample of 610. Self-motivation and social support were significant factors contributing to the adoption of health-promoting behaviors; however, organizational workplace cultures were inconsistent predictors of health among the three groups. Only the active Army subgroup identified a hierarchical culture as having an influence on health promotion, possibly because of the Army's mandatory physical fitness and weight control standards. Social support and self-motivation are essential to promoting health among employees, thus hospital commanders and chief executive officers should encourage strategies that enhance and reward these behaviors.

Military women's risk factors for and symptoms of genitourinary infections during deployment

Symptoms of vaginitis and urinary tract infections are miserable, distracting, and significantly affect women's quality of life. Among civilian women, these symptoms account for 10.5 million office visits per year. To examine the scope of the problem for military women during deployment situations, surveys were sent to randomly selected Army and Navy units. Of 841 women who completed the anonymous survey and had been deployed, vaginal infections were experienced by 30.1% and urinary tract infections by 18.4% of them during deployment. Vaginal symptoms were consistent with symptoms associated with the three most common vaginal infections (candida, bacterial, and trichomonas vaginitis). A variety of risk factors, both behavioral and situational, significantly differentiated women with and without infections. Urinary tract infections and vaginal infections are common during deployment situations where resources for self-care and appropriate primary health care for women are scarce or unavailable. One solution is a self-diagnosis and treatment kit for deployed military women.

Selection of growth parameters to define failure to thrive

Failure to thrive (FTT) is a syndrome of growth failure due to undernutrition. Determining whether an infant has FTT is based on the use of an anthropometric indicator and a selected cutoff value for that indicator. These anthropometric indicators include weight for age, weight for length, and length for age, and the cutoff values include the 10th, 5th, and 3rd percentiles. Each indicator and selected cutoff value provide unique information about an infant's growth. However, these parameters are often used interchangeably to explain the same growth phenomenon. The sensitivity and specificity of each anthropometric indicator are a function of the cutoff value selected and dictate which infants will be classified as having FTT and which infants will be classified as healthy. Depending on the sensitivity and specificity of the indicator, some infants with FTT will be classified as healthy, and some healthy infants will be classified as having FTT. A clear rationale for the selection of an anthropometric indicator and a cutoff value for defining FTT are important for increasing the generalizability of research findings and thereby expanding the current knowledge base related to FTT.

Impact of the threat of war on children in military families

The potential for war is a pervasive threat to the security and family structure of children in military families. This study compared children of active-duty, reserve, and civilian families with respect to their perceptions of war, origin of fears related to war, levels of manifest anxiety, coping strategies, and projection of emotional problems in human figure drawings.