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Martin SR, Kain ZN. The intersection of pediatric anesthesiology and social determinants of health. Curr Opin Anaesthesiol 2024; 37:271-276. [PMID: 38441068 PMCID: PMC11042989 DOI: 10.1097/aco.0000000000001367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
PURPOSE OF REVIEW There is increasing evidence of racial and ethnic disparities in pediatric perioperative care, which indicates a need to identify factors driving disparities. Social determinants of health (SDOH) play a fundamental role in pediatric health and are recognized as key underlying mechanisms of healthcare inequities. This article summarizes recent research exploring the influence of SDOH on pediatric perioperative outcomes. RECENT FINDINGS Despite the scarcity of research exploring SDOH and pediatric perioperative outcomes, recent work demonstrates an association between SDOH and multiple outcomes across the perioperative care continuum. Measures of social disadvantage were associated with preoperative symptom severity, longer hospital stays, and higher rates of postoperative complications and mortality. In some studies, these adverse effects of social disadvantage persisted even when controlling for medical comorbidities and clinical severity. SUMMARY The existing literature offers compelling evidence of the impact of SDOH on perioperative outcomes in children and reveals a critical area in pediatric anesthesia that necessitates further exploration and action. To improve outcomes and address care inequities, future efforts should prioritize the integration of SDOH assessment into pediatric perioperative research and practice.
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Affiliation(s)
- Sarah R. Martin
- Department of Anesthesiology and Perioperative Care, University of California Irvine School of Medicine, Irvine CA
- Center on Stress & Health, University of California Irvine, Irvine, CA
- Emergency Medicine, Children’s Hospital of Orange County, Orange, CA
| | - Zeev N. Kain
- Department of Anesthesiology and Perioperative Care, University of California Irvine School of Medicine, Irvine CA
- Center on Stress & Health, University of California Irvine, Irvine, CA
- Yale University Child Study Center, New Haven, Connecticut
- Children’s Hospital of Orange County, Orange, CA
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Vinci RJ, Clapp DW, Reed A, Degnon L. A Flattening of the Curve: The Challenge of Disparate Growth Rates in the Pediatric Subspecialties. J Pediatr 2023; 261:113509. [PMID: 37301280 DOI: 10.1016/j.jpeds.2023.113509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/21/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Robert J Vinci
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| | - D Wade Clapp
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Ann Reed
- Department of Pediatrics, Duke Children's Hospital, Duke University School of Medicine, Durham, NC
| | - Laura Degnon
- Association of Medical School Pediatric Department Chairs, McLean, VA
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Adams SH, Park MJ, Brindis CD, Irwin CE. Adolescents' Receipt of Care in a Medical Home: Results From a National Survey. J Adolesc Health 2023; 73:790-794. [PMID: 37367704 DOI: 10.1016/j.jadohealth.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE Despite long-term emphasis on the medical home for children, little research focuses on adolescents. This study examines adolescent past-year attainment of medical home, its components, and subgroup differences among demographic and mental/physical health condition categories. METHODS Utilizing the 2020-21 National Survey of Children's Health (NSCH), ages 10-17 (N = 42,930), we determined medical home attainment and its 5 components and subgroup differences utilizing multivariable logistic regression: sex; race/ethnicity; income; caregiver education; insurance; language spoken at home; region; and health conditions: physical, mental, both, or none. RESULTS Forty-five percent had a medical home with lower rates among those who were as follows: not White non-Hispanic; lower income; uninsured; in non-English-speaking households; adolescents whose caregivers lacked a college degree; and adolescents with mental health conditions (p range = .01-<.0001). Differences for medical home components were similar. DISCUSSION Given low medical home rates, ongoing differences and high mental illness rates, efforts are needed to improve adolescent medical home access.
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Affiliation(s)
- Sally H Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California.
| | - M Jane Park
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Claire D Brindis
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California
| | - Charles E Irwin
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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Bouchard ME, Kan K, Tian Y, Casale M, Smith T, De Boer C, Linton S, Abdullah F, Ghomrawi HMK. Association Between Neighborhood-Level Social Determinants of Health and Access to Pediatric Appendicitis Care. JAMA Netw Open 2022; 5:e2148865. [PMID: 35171257 PMCID: PMC8851303 DOI: 10.1001/jamanetworkopen.2021.48865] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Presenting with complicated appendicitis, which is associated with higher rates of complications and readmissions compared with simple appendicitis, may indicate delayed access to care. Although both patient-level and neighborhood-level social determinants of health are associated with access to care, little is known about the association between neighborhood factors and access to acute pediatric surgical care. OBJECTIVE To examine the association between neighborhood factors and the odds of presenting with complicated appendicitis and unplanned postdischarge health care use. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of patients aged 18 years or younger diagnosed with appendicitis was conducted. Discharge data from October 1, 2015, to September 30, 2018, were obtained from the Pediatric Health Information System Database and linked to the Child Opportunity Index (COI) 2.0 Database. Data analysis was conducted from January 1 through July 1, 2021. EXPOSURES The COI, a composite score of zip code neighborhood opportunity level information, divided into quintiles ranging from very low to very high opportunity. MAIN OUTCOMES AND MEASURES Based on COI level, the main outcome was the odds of presenting with complicated appendicitis, which was defined using the Agency for Healthcare Research and Quality-specified International Statistical Classification of Diseases, 10th Edition, Clinical Modification codes. The secondary outcome was the odds of unplanned postdischarge health care use (emergency department visits and/or readmissions) for patients with simple and with complicated appendicitis. RESULTS A total of 67 489 patients (mean [SD] age, 10.5 [3.9] years) had appendicitis, with 31 223 cases (46.3%) being complicated. A total of 1699 patients (2.5%) were Asian, 24 234 (35.9%) were Hispanic, 4447 (6.6%) were non-Hispanic Black, and 29 234 (43.3%) were non-Hispanic White; 40 549 patients (60.1%) were male; and 32 343 (47.9%) were publicly insured. Patients living in very low-COI neighborhoods had 28% higher odds of presenting with complicated appendicitis (odds ratio, 1.28; 95% CI, 1.20-1.35) compared with those in very high-COI neighborhoods. There was no significant association between COI level and unplanned postdischarge health care use (very high COI, 20.8%; very low COI, 19.1%). CONCLUSIONS AND RELEVANCE In this cohort study, children from lower-COI neighborhoods had increased odds of presenting with complicated appendicitis compared with those from higher-COI neighborhoods, even after controlling for patient-level social determinants of health factors. These findings may inform policies and programs that seek to improve access to pediatric surgical care.
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Affiliation(s)
- Megan E. Bouchard
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kristin Kan
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Yao Tian
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mia Casale
- Population Health Analytics, Division of Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tracie Smith
- Population Health Analytics, Division of Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hassan M. K. Ghomrawi
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Perna-Barrull D, Murillo M, Real N, Gomez-Muñoz L, Rodriguez-Fernandez S, Bel J, Puig-Domingo M, Vives-Pi M. Prenatal Betamethasone Exposure and its Impact on Pediatric Type 1 Diabetes Mellitus: A Preliminary Study in a Spanish Cohort. J Diabetes Res 2022; 2022:6598600. [PMID: 35308094 PMCID: PMC8930272 DOI: 10.1155/2022/6598600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/24/2022] [Accepted: 02/18/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Betamethasone, a glucocorticoid used to induce lung maturation when there is a risk of preterm delivery, can affect the immune system maturation and type 1 diabetes (T1D) incidence in the progeny. It has been described that prenatal betamethasone protects offspring from experimental T1D development. The main aim of this study was to evaluate the possible association between betamethasone prenatal exposure and T1D in humans. Research Design and Methods. A retrospective case-control study with a total of 945 children, including 471 patients with T1D and 474 healthy siblings, was performed. Participants were volunteers from the Germans Trias i Pujol Hospital and DiabetesCero Foundation. Parents of children enrolled in the study completed a questionnaire that included questions about weeks of gestation, preterm delivery risk, weight at birth, and prenatal betamethasone exposure of their children. Multiple logistic regression was used to detect the association between betamethasone exposure and T1D. RESULTS We compared T1D prevalence between subjects prenatally exposed or unexposed to betamethasone. The percent of children with T1D in the exposed group was 37.5% (21 of 56), and in the unexposed group was 49.52% (410 of 828) (p = 0.139). The percentage of betamethasone-treated subjects with T1D in the preterm group (18.05%, 13 of 72) was significantly higher than that found in the control group (12.5%, 9 of 72) (p = 0.003). The odds ratio for T1D associated with betamethasone in the univariate logistic regression was 0.59 (95% confidence interval, 0.33; 1.03 [p = 0.062]) and in the multivariate logistic regression was 0.83 (95% confidence interval, 0.45; 1.52 [p = 0.389]). CONCLUSIONS The results demonstrate that the prenatal exposure to betamethasone does not increase T1D susceptibility, and may even be associated with a trend towards decreased risk of developing the disease. These preliminary findings require further prospective studies with clinical data to confirm betamethasone exposure effect on T1D risk.
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Affiliation(s)
- David Perna-Barrull
- Immunology Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
| | - Marta Murillo
- Pediatrics Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
| | - Nati Real
- Pediatrics Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
| | - Laia Gomez-Muñoz
- Immunology Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
| | - Silvia Rodriguez-Fernandez
- Immunology Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
| | - Joan Bel
- Pediatrics Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
| | - Manel Puig-Domingo
- Endocrinology Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
| | - Marta Vives-Pi
- Immunology Service Germans Trias i Pujol Research Institute and University Hospital, Autonomous University of Barcelona, 08916 Badalona, Spain
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Abdelaziz I, Mohammad El-Fatih T, Bushara L, Musa M, Elshami W, M Abuzaid M. Correlation between Computed Tomography Clinical Diagnosis and Findings in Pediatric Computed Tomography. Pak J Biol Sci 2021; 24:1063-1066. [PMID: 34842376 DOI: 10.3923/pjbs.2021.1063.1066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
<b>Background and Objective:</b> Pediatric Computed Tomography (CT) is a fast, accurate imaging examination using ionizing radiation to create detailed images of pathological conditions. The radiation benefit should be outweighing the risk through the procure justification and dose optimization. The study aimed to investigate the correlation between the physician's initial diagnosis and the CT findings to build procedure justification for a pediatric patient's head scan. <b>Materials and Methods:</b> The study included 81 children examined clinically and by CT scan to diagnose cranial and cerebral pathology. Eighty-one pediatric patients were investigated by CT scan and clinical diagnosis. <b>Results:</b> The patient age ranged between 1-15 years old, (44%) were male and (56%) females. The patients referred to the CT scan from emergency department n = 10 (7%), outpatient clinics n = 66, (84%) and inpatients clinics n = 5, (9%). The study showed that 46% of patients were normal with no CT findings. Almost half of the cases were negative and did not confirm the clinical diagnosis. <b>Conclusion:</b> The study concluded that most head CT scans in children were not justified. An effort towards improving the refereeing physician's awareness about radiation dose and request justification should be conducted.
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7
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Tomcho MM, Lou Y, O'Leary SC, Rinehart DJ, Thomas-Gale T, Douglas CM, Wu FJ, Penny L, Federico SG, Frost HM. An Intervention to Improve Chlamydia and Gonorrhea Testing Among Adolescents in Primary Care. Pediatrics 2021; 148:e2020027508. [PMID: 34675130 PMCID: PMC8972200 DOI: 10.1542/peds.2020-027508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Rates of chlamydia and gonorrhea among adolescents continue to rise. We aimed to evaluate if a universal testing program for chlamydia and gonorrhea improved testing rates in an urban general pediatric clinic and an urban family medicine clinic within a system of federally qualified health care centers and evaluated the feasibility, cost, and logistic challenges of expanding implementation across 28 primary care clinics within a federally qualified health care centers system. METHODS A universal testing quality improvement program for male and female patient 14 to 18 years old was implemented in a general pediatrics and family medicine clinic in Denver, Colorado. The intervention was evaluated by using a controlled pre-post quasi-experimental design. The difference in testing rates due to the intervention was assessed by using a difference-in-differences regression model weighted with the inverse probability of treatment. RESULTS In total, 15 541 pediatric encounters and 5420 family medicine encounters were included in the analyses. In pediatrics, the unadjusted testing rates increased from 32.0% to 66.7% in the intervention group and from 20.9% to 28.9% in the comparison group. For family medicine, the rates increased from 38.5% to 49.9% in the intervention group and decreased from 26.3% to 24.8% in the comparison group. The intervention resulted in an adjusted increase in screening rates of 25.2% (P < .01) in pediatrics and 11.8% (P < .01) in family medicine. The intervention was well received and cost neutral to the clinic. CONCLUSIONS Universal testing for chlamydia and gonorrhea in primary care pediatrics and family medicine is a feasible approach to improving testing rates .
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Affiliation(s)
| | - Yingbo Lou
- Ambulatory Care Services, Denver Health Medical Center, Denver, Colorado
| | - Sonja C O'Leary
- Departments of General Pediatrics
- Departments of General Pediatrics
| | | | - Tara Thomas-Gale
- Ambulatory Care Services, Denver Health Medical Center, Denver, Colorado
| | - Claudia M Douglas
- Departments of General Pediatrics
- Departments of General Pediatrics
- Internal Medicine
| | - Florence J Wu
- Departments of General Pediatrics
- Departments of General Pediatrics
| | - Lara Penny
- Family Medicine
- Family Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Holly M Frost
- Departments of General Pediatrics
- Center for Health Systems Research, Denver, Colorado
- Departments of General Pediatrics
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Bergevin A, Husain M, Cruz M, Blanc CL, Dieme A, Girardin ML, Toujouse C, Tkhayat RB, Slabab S, Corseri O, Maglorius M, Vercamer C, Eskander E, Desselas E, Lachaume N, Garraffo A, Sorge F, Roux EL, Gaschignard J, Caseris M, Faye A. Medical check-up of newly arrived unaccompanied minors: A dedicated pediatric consultation service in a hospital. Arch Pediatr 2021; 28:689-695. [PMID: 34756657 DOI: 10.1016/j.arcped.2021.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/15/2021] [Accepted: 09/26/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Healthcare for the increasing number of migrants in Europe, and particularly of unaccompanied minors (UMs) seeking asylum, has become a major challenge. We aimed to describe the health issues of UMs managed in a dedicated pediatric consultation service in a care center in Paris. METHODS All UMs attending a dedicated migrant medical consultation service in Robert Debré Hospital, Paris, France, were included in a single-center retrospective observational study from September 1, 2017, to September 30, 2018. RESULTS Out of the 107 UMs who were included, 87% had a health problem (n=93) and 52% had an infectious disease (n=56). The main infectious diagnoses were schistosomiasis (22%), latent tuberculosis (22%), intestinal parasitosis (16%), and chronic hepatitis B (8%). Posttraumatic stress disorder (PTSD) and overweight were common (35% and 20%, respectively). The median age was 15 years old (IQR, 14-16), the male/female ratio was 95/12. Most of the children were from sub-Saharan Africa (n=67), 46% had crossed Libya (n=49) and, when compared to the other migration routes, faced an increasing risk of violence (69%, p=0.04), imprisonment (53%, p=0.03), and forced labor (48%, p=0.02). The median duration of the trip before reaching France was 6 months (IQR, 2-13), the median time to consultation was 2 months (0-5) and was not associated with an increased risk of health problems. A total of 43 UMs were lost to follow-up. CONCLUSION Health problems, particularly infectious diseases and PTSD, are common among UMs and should prompt an early medical consultation with psychiatric evaluation. Follow-up is problematic and could be improved by an on-line health book.
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Affiliation(s)
- A Bergevin
- General Pediatric Department, Nord Ouest Hospital, Villefranche sur Saône, 69655 France; Pediatric Residents Association, AJP, Paris, 75 France.
| | - M Husain
- Pediatric Residents Association, AJP, Paris, 75 France
| | - M Cruz
- Pediatric Residents Association, AJP, Paris, 75 France; APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France
| | - C Le Blanc
- Pediatric Residents Association, AJP, Paris, 75 France; APHP, General Pediatric Department Jean Verdier Hospital, Bondy 93140 France
| | - A Dieme
- Pediatric Residents Association, AJP, Paris, 75 France; General Pediatric Department Ambroise Paré, Boulogne-Billancourt 92100 France
| | - M-L Girardin
- Pediatric Residents Association, AJP, Paris, 75 France; Pediatric Intensive Care Unit, Hautepierre Hospital, Strasbourg 67200 France
| | - C Toujouse
- Pediatric Residents Association, AJP, Paris, 75 France
| | - R Ben Tkhayat
- Pediatric Residents Association, AJP, Paris, 75 France
| | - S Slabab
- Pediatric Residents Association, AJP, Paris, 75 France
| | - O Corseri
- Pediatric Residents Association, AJP, Paris, 75 France; APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France
| | - M Maglorius
- Pediatric Residents Association, AJP, Paris, 75 France
| | - C Vercamer
- Pediatric Residents Association, AJP, Paris, 75 France; APHP, General Pediatric Department Jean Verdier Hospital, Bondy 93140 France
| | - E Eskander
- Pediatric Residents Association, AJP, Paris, 75 France
| | - E Desselas
- Pediatric Residents Association, AJP, Paris, 75 France; General Pediatric Department Montpellier Hospital, Paris 34295 France
| | - N Lachaume
- APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France; APHP, General Pediatric Department Louis Mourier Hospital, Colombes, 92700 France
| | - A Garraffo
- APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France; Pediatric Department, Villeneuve-Saint-Georges Hospital, Villeneuve-Saint-Georges, 94190 France
| | - F Sorge
- APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France; APHP, General Pediatric Department Necker Hospital, Paris, 75015 France
| | - E Le Roux
- Clinical Epidemiology Department Robert Debré Hospital, Paris, 48 boulevard Sérurier 75019 France; Paris Diderot Medical University, 10 avenue de Verdun Paris, 75010 France; ECEVE, INSERM 1123, 10 avenue de Verdun Paris, 75010 France
| | - J Gaschignard
- APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France
| | - M Caseris
- APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France
| | - A Faye
- APHP, General Pediatric Department Robert Debré Hospital, Paris 75019 France; Clinical Epidemiology Department Robert Debré Hospital, Paris, 48 boulevard Sérurier 75019 France; Paris Diderot Medical University, 10 avenue de Verdun Paris, 75010 France.
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9
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Getz KD, Szymczak JE, Li Y, Madding R, Huang YSV, Aftandilian C, Arnold SD, Bona KO, Caywood E, Collier AB, Gramatges MM, Henry M, Lotterman C, Maloney K, Mian A, Mody R, Morgan E, Raetz EA, Rubnitz J, Verma A, Winick N, Wilkes JJ, Yu JC, Fisher BT, Aplenc R. Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia. JAMA Netw Open 2021; 4:e2128385. [PMID: 34709389 PMCID: PMC8554641 DOI: 10.1001/jamanetworkopen.2021.28385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Pediatric acute myeloid leukemia (AML) requires multiple courses of intensive chemotherapy that result in neutropenia, with significant risk for infectious complications. Supportive care guidelines recommend hospitalization until neutrophil recovery. However, there are little data to support inpatient over outpatient management. OBJECTIVE To evaluate outpatient vs inpatient neutropenia management for pediatric AML. DESIGN, SETTING, AND PARTICIPANTS This cohort study used qualitative and quantitative methods to compare medical outcomes, patient health-related quality of life (HRQOL), and patient and family perceptions between outpatient and inpatient neutropenia management. The study included patients from 17 US pediatric hospitals with frontline chemotherapy start dates ranging from January 2011 to July 2019, although the specific date ranges differed for the individual analyses by design and relative timing. Data were analyzed from August 2019 to February 2020. EXPOSURES Discharge to outpatient vs inpatient neutropenia management. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were course-specific bacteremia incidence, times to next course, and patient HRQOL. Course-specific mortality was a secondary medical outcome. RESULTS Primary quantitative analyses included 554 patients (272 [49.1%] girls and 282 [50.9%] boys; mean [SD] age, 8.2 [6.1] years). Bacteremia incidence was not significantly different during outpatient vs inpatient management (67 courses [23.8%] vs 265 courses [29.0%]; adjusted rate ratio, 0.73; 95% CI, 0.56 to 1.06; P = .08). Outpatient management was not associated with delays to the next course compared with inpatient management (mean [SD] 30.7 [12.2] days vs 32.8 [9.7] days; adjusted mean difference, -2.2; 95% CI, -4.1 to -0.2, P = .03). Mortality during intensification II was higher for patients who received outpatient management compared with those who received inpatient management (3 patients [5.4%] vs 1 patient [0.5%]; P = .03), but comparable with inpatient management at other courses (eg, 0 patients vs 5 patients [1.3%] during induction I; P = .59). Among 97 patients evaluated for HRQOL, outcomes did not differ between outpatient and inpatient management (mean [SD] Pediatric Quality of Life Inventory total score, 70.1 [18.9] vs 68.7 [19.4]; adjusted mean difference, -2.8; 95% CI, -11.2 to 5.6). A total of 86 respondents (20 [23.3%] in outpatient management, 66 [76.7%] in inpatient management) completed qualitative interviews. Independent of management strategy received, 74 respondents (86.0%) expressed satisfaction with their experience. Concerns for hospital-associated infections among caregivers (6 of 7 caregiver respondents [85.7%] who were dissatisfied with inpatient management) and family separation (2 of 2 patient respondents [100%] who were dissatisfied with inpatient management) drove dissatisfaction with inpatient management. Stress of caring for a neutropenic child at home (3 of 3 respondents [100%] who were dissatisfied with outpatient management) drove dissatisfaction with outpatient management. CONCLUSIONS AND RELEVANCE This cohort study found that outpatient neutropenia management was not associated with higher bacteremia incidence, treatment delays, or worse HRQOL compared with inpatient neutropenia management among pediatric patients with AML. While outpatient management may be safe for many patients, course-specific mortality differences suggest that outpatient management in intensification II should be approached with caution. Patient and family experiences varied, suggesting that outpatient management may be preferred by some but may not be feasible for all families. Further studies to refine and standardize safe outpatient management practices are warranted.
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Affiliation(s)
- Kelly D. Getz
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yimei Li
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel Madding
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yuan-Shung V. Huang
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine Aftandilian
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Stanford University, Palo Alto, California
| | - Staci D. Arnold
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Kira O. Bona
- Pediatric Hematology/Oncology, Children’s Hospital Boston, Boston, Massachusetts
| | - Emi Caywood
- A.I. Dupont Hospital for Children, Nemours, Wilmington, Delaware
| | | | | | | | | | - Kelly Maloney
- Children’s Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Amir Mian
- Arkansas Children’s Hospital, Little Rock
| | | | - Elaine Morgan
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Elizabeth A. Raetz
- Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, New York, New York
| | - Jeffrey Rubnitz
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Anupam Verma
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, Salt Lake City
| | - Naomi Winick
- Department of Pediatric Hematology Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Jennifer J. Wilkes
- Department of Pediatrics, University of Washington, Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle
| | - Jennifer C. Yu
- Division of Pediatric Hematology Oncology, Rady Children’s Hospital San Diego, San Diego, California
| | - Brian T. Fisher
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Coffey B, Jankovic J, Claassen DO, Jimenez-Shahed J, Gertz BJ, Garofalo EA, Stamler DA, Wieman M, Savola JM, Gordon MF, Alexander JK, Barkay H, Harary E. Efficacy and Safety of Fixed-Dose Deutetrabenazine in Children and Adolescents for Tics Associated With Tourette Syndrome: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2129397. [PMID: 34661664 PMCID: PMC8524312 DOI: 10.1001/jamanetworkopen.2021.29397] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Tourette syndrome is a neurodevelopmental disorder characterized by childhood onset of motor and phonic tics, often accompanied by behavioral and psychiatric comorbidities. Deutetrabenazine is a vesicular monoamine transporter 2 inhibitor approved in the US for the treatment of chorea associated with Huntington disease and tardive dyskinesia. OBJECTIVE To report results of the ARTISTS 2 (Alternatives for Reducing Tics in Tourette Syndrome 2) study examining deutetrabenazine for treatment of Tourette syndrome. DESIGN, SETTING, AND PARTICIPANTS This phase 3, randomized, double-blind, placebo-controlled, parallel-group, fixed-dose study was conducted over 8 weeks with a 1-week follow-up (June 21, 2018, to December 9, 2019). Children and adolescents aged 6 to 16 years with a diagnosis of Tourette syndrome and active tics causing distress or impairment were enrolled in the study. Children were recruited from 52 sites in 10 countries. Data were analyzed from February 4 to April 22, 2020. INTERVENTIONS Participants were randomized (1:1:1) to low-dose deutetrabenazine (up to 36 mg/d), high-dose deutetrabenazine (up to 48 mg/d), or a matching placebo, which were titrated over 4 weeks to the target dose followed by a 4-week maintenance period. MAIN OUTCOMES AND MEASURES The primary efficacy end point was change from baseline to week 8 in the Yale Global Tic Severity Scale-Total Tic Score (YGTSS-TTS) for high-dose deutetrabenazine. Key secondary end points included changes in YGTSS-TTS for low-dose deutetrabenazine, Tourette Syndrome Clinical Global Impression score, Tourette Syndrome Patient Global Impression of Impact score, and Child and Adolescent Gilles de la Tourette Syndrome-Quality of Life Activities of Daily Living subscale score. Safety assessments included incidence of treatment-emergent adverse events, laboratory parameters, vital signs, and questionnaires. RESULTS The study included 158 children and adolescents (mean [SD] age, 11.7 [2.6] years). A total of 119 participants (75%) were boys; 7 (4%), Asian; 1 (1%), Black; 32 (20%), Hispanic; 4 (3%), Native American; 135 (85%), White; 2 (1%), multiracial; 9 (6%), other race; and 1 (0.6%), of unknown ethnic origin. Fifty-two participants were randomized to the high-dose deutetrabenazine group, 54 to the low-dose deutetrabenazine group, and 52 to the placebo group. Baseline characteristics for participants were similar between groups. Of the total 158 participants, 64 (41%) were aged 6 to 11 years, and 94 (59%) were aged 12 to 16 years at baseline. Mean time since Tourette syndrome diagnosis was 3.3 (2.8) years, and mean baseline YGTSS-TTS was 33.8 (6.6) points. At week 8, the difference in YGTSS-TTS was not significant between the high-dose deutetrabenazine and placebo groups (least-squares mean difference, -0.8 points; 95% CI, -3.9 to 2.3 points; P = .60; Cohen d, -0.11). There were no nominally significant differences between groups for key secondary end points. Treatment-emergent adverse events were reported for 34 participants (65%) treated with high-dose deutetrabenazine, 24 (44%) treated with low-dose deutetrabenazine, and 25 (49%) treated with placebo and were generally mild or moderate. CONCLUSIONS AND RELEVANCE In this fixed-dose randomized clinical trial of deutetrabenazine in children and adolescents with Tourette syndrome, the primary efficacy end point was not met. No new safety signals were identified. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03571256.
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Affiliation(s)
- Barbara Coffey
- University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | | | | | | | - Maria Wieman
- Teva Pharmaceuticals, West Chester, Pennsylvania
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Mallenahalli S, Fifolt M, Gundeti M, Lakshmanan Y, Gargollo P, Ost MC, Dangle PP. Survey of COVID-19 impact on pediatric urology services. Can J Urol 2021; 28:10834-10840. [PMID: 34657656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION To better understand how the COVID-19 pandemic has forced rapid operational changes in the global healthcare industry, changes implemented on an individual, institutional basis must be considered. There currently is not adequate literature about the overall impact COVID-19 has had on pediatric urology services worldwide. We believe that they have dramatically decreased during the COVID-19 crisis, but have adapted to accommodate changes. We hypothesize that patient care was widely variant due to inadequate standardized recommendations or crisis planning. MATERIALS AND METHODS A web-based survey was deployed to 377 pediatric urologists globally via email to analyze COVID-19's impact on various types of pediatric urology practices. Key categories included impacts on elective services, telemedicine use, finances, and recovery operations. A total of 114 responses were collected between April 29th - May 22nd, 2020. RESULTS The widespread cancellation of elective surgical procedures caused significant disturbances in the field. There was a uniform, significant increase (75%) in telemedicine use across practices. The pandemic has created many changes in care provision for physicians, institutions, and patients themselves. Furthermore, the sudden economic burden on healthcare facilities could lead to cost-cutting measures, creating further strain within institutions. Though telemedicine has its limitations, it is a very viable option when traditional services are unavailable. CONCLUSIONS Immediate steps should be taken to ensure that the recovery phases of pediatric urology practices are as efficient as possible. Institutions should develop task forces to develop critical workflow processes in the event of health crises, while still maintaining patient-centered care. This will be essential in maximizing appropriate care allocation.
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Affiliation(s)
| | - Matthew Fifolt
- University of Alabama at Birmingham School of Public Health, Alabama, USA
| | - Mohan Gundeti
- The University of Chicago Medicine Comer Children's Hospital and Pritzker School of Medicine Chicago, Illinois, USA
| | | | | | - Michael C Ost
- West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - Pankaj P Dangle
- Department of Urology, University of Alabama at Birmingham, Alabama, USA
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Porter AS, Zalud K, Applegarth J, Woods C, Gattas M, Rutt E, Williams K, Baker JN, Kaye EC. Community Hospice Nurses' Perspectives on Needs, Preferences, and Challenges Related to Caring for Children With Serious Illness. JAMA Netw Open 2021; 4:e2127457. [PMID: 34605916 PMCID: PMC8491107 DOI: 10.1001/jamanetworkopen.2021.27457] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Many of the 50 000 children who die annually are eligible for provision of community-based hospice care, yet few hospice organizations offer formal pediatric services. Population-level data demonstrate that hospice nurses lack training, experience, and comfort in caring for children, but their specific educational needs and preferences are poorly understood. OBJECTIVE To assess the pediatric-specific training and support needs of hospice nurses caring for children in the community. DESIGN, SETTING, AND PARTICIPANTS For this qualitative study, 41 nurses were purposively seletected from a population-level cohort of 551 hospice nurses who completed a previous mixed-methods survey; these 41 nurses participated in semistructured interviews between February and April 2019. Hospice nurses were recruited from all accredited hospice organizations in Tennessee, Mississippi, and Arkansas that offer care to pediatric patients. Content analysis of interview transcripts was conducted. MAIN OUTCOMES AND MEASURES The interview guide probed for topics related to prior pediatric hospice training experiences, desires and preferences for training, and perceived barriers to training. RESULTS Interviews were conducted with 41 nurses representing different geographic regions and levels of comfort with pediatric hospice provision (as self-reported in the prior survey). Thirty-eight of the nurses were women (92.7%), with a median age of 40-49 years (range, 20-29 to ≥60 years) and median tenure of 5-9 years (range, <1 to ≥20 years) as a hospice nurse. Respondents included 1 American Indian or Alaska Native nurse (2.4%), 1 Black nurse (2.4%), and 39 White nurses (95.1%). Across interviews, most hospice nurses reported feeling uncomfortable caring for children with serious illness, and all nurses used language to express the immediacy behind the need for pediatric-specific training and support. Nurses explained why further training and support are needed and clear preferences for who should provide the education, educational modalities, and specific training topics. Nurses also articulated barriers to training and support opportunities and proposed innovative suggestions for overcoming these challenges. Notably, nurses emphasized the need for connection with experts, a sense of community, and solidarity to support frontline clinicians providing end-of-life care to children in the community. CONCLUSIONS AND RELEVANCE In this qualitative study, community hospice nurses expressed an urgent need for improvements in pediatric-specific training opportunities and support, clear preferences for how education should be provided, and recommendations for circumventing barriers to training. These findings are a call to action for the palliative care community to collaborate in rapid implementation of educational programs and networks to systematically support hospice nurses caring for children in the community.
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Affiliation(s)
- Amy S. Porter
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kristina Zalud
- St Louis Children’s Hospital, Washington University School of Medicine, St Louis, Missouri
| | | | - Cameka Woods
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Melanie Gattas
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Emily Rutt
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Karen Williams
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Erica C. Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
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De Smidt JJA, Odendaal HJ, Nel DG, Nolan H, Du Plessis C, Brink LT, Oelofse A. The effects of in utero exposure to teratogens on organ size: a prospective paediatric study. J Dev Orig Health Dis 2021; 12:748-757. [PMID: 33198841 PMCID: PMC8536468 DOI: 10.1017/s2040174420001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In low-income countries, prospective data on combined effects of in utero teratogen exposure are lacking and necessitates new research. The aim of the present study was to explore the effect of in utero teratogen exposure on the size of the kidneys and pancreas 5 years after birth in a low-income paediatric population. Data was collected from 500 mother-child pairs from a low-income setting. Anthropometric measurements included body weight, (BW) body height, mid-upper arm and waist circumference (WC). Clinical measurements included blood pressure (BP), mean arterial pressure and heart rate. Ultrasound measurements included pancreas, and kidney measurements at age 5 years. The main outcome of interest was the effect of maternal smoking and alcohol consumption on ultrasound measurements of organ size at age 5 years. Left and right kidney length measurements were significantly lower in smoking exposed children compared to controls (p = 0.04 and p = 0.03). Pancreas body measurements were significantly lower in smoking exposed children (p = 0.04). Multiple regression analyses were used to examine the associations between the independent variables (IDVs), maternal age, body mass index (BMI), mid-upper arm circumference (MUAC) and BW of the child, on the dependent variables (DVs) kidney lengths and kidney volumes. Also, the association between in utero exposure to alcohol and nicotine and pancreas size. WC was strongest (r = 0.28; p < 0.01) associated with pancreas head [F (4, 454) = 13.44; R2 = 0.11; p < 0.01] and tail (r = 0.30; p < 0.01) measurements at age 5 years, with in utero exposure, sex of the child and BMI as covariates. Kidney length and pancreas body measurements are affected by in utero exposure to nicotine at age 5 years and might contribute to cardiometabolic risk in later life. Also, findings from this study report on ultrasound reference values for kidney and pancreas measurements of children at age 5 years from a low-income setting.
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Affiliation(s)
- J. J. A. De Smidt
- Department of Medical Biosciences, University of the Western Cape, Cape Town, South Africa
| | - H. J. Odendaal
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa
| | - D. G. Nel
- Department of Statistics and Actuarial Science, Stellenbosch University, Stellenbosch, South Africa
| | - H. Nolan
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa
| | - C. Du Plessis
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa
| | - L. T. Brink
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa
| | - A. Oelofse
- Department of Medical Biosciences, University of the Western Cape, Cape Town, South Africa
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Saunders N, Guttmann A, Brownell M, Cohen E, Fu L, Guan J, Sarkar J, Mahar A, Gandhi S, Fiksenbaum L, Katz A, Eze N, Stukel TA. Pediatric primary care in Ontario and Manitoba after the onset of the COVID-19 pandemic: a population-based study. CMAJ Open 2021; 9:E1149-E1158. [PMID: 34906990 PMCID: PMC8687490 DOI: 10.9778/cmajo.20210161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND There were large disruptions to health care services after the onset of the COVID-19 pandemic. We sought to describe the extent to which pandemic-related changes in service delivery and access affected use of primary care for children overall and by equity strata in the 9 months after pandemic onset in Manitoba and Ontario. METHODS We performed a population-based study of children aged 17 years or less with provincial health insurance in Ontario or Manitoba before and during the COVID-19 pandemic (Jan. 1, 2017-Nov. 28, 2020). We calculated the weekly rates of in-person and virtual primary care well-child and sick visits, overall and by age group, neighbourhood material deprivation level, rurality and immigrant status, and assessed changes in visit rates after COVID-19 restrictions were imposed compared to expected baseline rates calculated for the 3 years before pandemic onset. RESULTS Among almost 3 million children in Ontario and more than 300 000 children in Manitoba, primary care visit rates declined to 0.80 (95% confidence interval [CI] 0.77-0.82) of expected in Ontario and 0.82 (95% CI 0.79-0.84) of expected in Manitoba in the 9 months after the onset of the pandemic. Virtual visits accounted for 53% and 29% of visits in Ontario and Manitoba, respectively. The largest monthly decreases in visits occurred in April 2020. Although visit rates increased slowly after April 2020, they had not returned to prerestriction levels by November 2020 in either province. Children aged more than 1 year to 12 years experienced the greatest decrease in visits, especially for well-child care. Compared to prepandemic levels, visit rates were lowest among rural Manitobans, urban Ontarians and Ontarians in low-income neighbourhoods. INTERPRETATION During the study period, the pandemic contributed to rapid, immediate and inequitable decreases in primary care use, with some recovery and a substantial shift to virtual care. Postpandemic planning must consider the need for catch-up visits, and the long-term impacts warrant further study.
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Affiliation(s)
- Natasha Saunders
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man.
| | - Astrid Guttmann
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Marni Brownell
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Eyal Cohen
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Longdi Fu
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Jun Guan
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Joykrishna Sarkar
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Alyson Mahar
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Sima Gandhi
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Lisa Fiksenbaum
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Alan Katz
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Nkiruka Eze
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
| | - Therese A Stukel
- The Hospital for Sick Children (Saunders, Guttmann, Cohen); Department of Paediatrics (Saunders, Guttmann, Cohen), University of Toronto; ICES Central (Saunders, Guttmann, Cohen, Fu, Guan, Gandhi, Stukel); Child Health Evaluative Sciences (Saunders, Guttmann, Cohen, Fiksenbaum), SickKids Research Institute; Institute of Health Policy, Management and Evaluation (Saunders, Guttmann, Cohen, Stukel), Temerty Faculty of Medicine (Saunders, Guttmann, Cohen) and Edwin S.H. Leong Centre for Healthy Children (Saunders, Guttmann, Cohen), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar, Katz), University of Manitoba; Manitoba Centre for Health Policy (Brownell, Sarkar, Mahar, Katz, Eze); Children's Hospital Research Institute of Manitoba (Brownell); Department of Family Medicine (Katz), University of Manitoba, Winnipeg, Man
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Garner CD, Brazelton de Cardenas J, Suganda S, Hayden RT. Accuracy of Broad-Panel PCR-Based Bacterial Identification for Blood Cultures in a Pediatric Oncology Population. Microbiol Spectr 2021; 9:e0022121. [PMID: 34232100 PMCID: PMC8552719 DOI: 10.1128/spectrum.00221-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/05/2021] [Indexed: 11/20/2022] Open
Abstract
Bloodstream infections are a major cause of morbidity and mortality and result in significant costs to health care systems. Rapid identification of the causative agent of bloodstream infections is critical for patient treatment and improved outcomes. Multiplex PCR systems that provide bacterial identification directly from the blood culture bottle allow for earlier detection of pathogens. The GenMark Dx ePlex blood culture identification (BCID) panels have an expanded number of targets for both identification and genotypic markers of antimicrobial resistance. The performance of the ePlex BCID Gram-negative (GN) and Gram-positive (GP) panels were evaluated in a predominantly pediatric oncology population. A total of 112 blood cultures were tested by the ePlex BCID GN and GP panels and results were compared to those from standard-of-care testing. Accuracy for on-panel organisms was 89% (CI, 76% to 95%) for the Gram-positive panel, with four misidentifications and one not detected, and 93% (CI, 82% to 98%) for the Gram-negative panel, with two misidentifications and one not detected. The results showed good overall performance of these panels for rapid, accurate detection of bloodstream pathogens in this high-risk population. IMPORTANCE Bloodstream infections are a major cause of morbidity and mortality and result in significant costs to health care systems. Rapid identification of the causative agent of bloodstream infections is critical for patient treatment and improved outcomes. Multiplex PCR systems that provide bacterial identification directly from the blood culture bottle allow for earlier characterization of pathogens. The GenMark Dx ePlex blood culture identification (BCID) panels, recently cleared by the FDA, have an expanded number of targets for both identification and resistance, much larger than other, automated, broad-panel PCR assays. The performance of the ePlex BCID Gram-negative and Gram-positive panels was evaluated in a predominantly pediatric oncology population, providing a unique look at its performance in a high-risk group, where rapid diagnostic information for bloodstream infections could be of particular value for clinical care providers.
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Affiliation(s)
- C. D. Garner
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | | | - S. Suganda
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - R. T. Hayden
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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16
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Newgard CD, Lin A, Olson LM, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Malveau S, Smith M, Dai M, Nathens AB, Glass NE, Jenkins PC, McConnell KJ, Remick KE, Hewes H, Mann NC. Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers. JAMA Pediatr 2021; 175:947-956. [PMID: 34096991 PMCID: PMC8185631 DOI: 10.1001/jamapediatrics.2021.1319] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/25/2021] [Indexed: 01/20/2023]
Abstract
Importance The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers. Objective To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers. Design, Setting, and Participants A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources. Exposures Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment. Main Outcomes and Measures In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100. Results There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers. Conclusions and Relevance In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Lenora M. Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | | | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care, and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - McKenna Smith
- Department of Biostatistics, The University of Utah School of Medicine, Salt Lake City
| | - Mengtao Dai
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - K. John McConnell
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Katherine E. Remick
- Departments of Pediatrics and Surgery, Dell Medical School, The University of Texas at Austin
| | - Hilary Hewes
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - N. Clay Mann
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
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Rochani HD, Modlesky CM, Li L, Weissman B, Vova J, Colquitt G. Association of Chronic Pain With Participation in Motor Skill Activities in Children With Cerebral Palsy. JAMA Netw Open 2021; 4:e2115970. [PMID: 34232305 PMCID: PMC8264638 DOI: 10.1001/jamanetworkopen.2021.15970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This cross-sectional study examines the association between pain and activities requiring motor skill performance among a nationally representative sample of US children with cerebral palsy.
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Affiliation(s)
- Haresh D. Rochani
- Karl E. Peace Center for Biostatistics, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro
| | | | - Li Li
- Department of Health Sciences and Kinesiology, Georgia Southern University, Statesboro
| | - Barbara Weissman
- Department of Neurology, Children’s Healthcare of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Joshua Vova
- Department of Physical Medicine and Rehabilitation, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Gavin Colquitt
- Department of Health Sciences and Kinesiology, Georgia Southern University, Statesboro
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Abstract
INTRODUCTION Hypersensitivity pneumonitis (HP) is one of the most common forms of interstitial lung disease in children. Due to its common association with occupational environment, it used to be considered an exclusively adult disease; however, hypersensitivity pneumonitis also affects the paediatric population, and is often associated with exposure to antigens in the home environment and with the pastime activities of children. OBJECTIVE The aim of the study is to present the current state of knowledge on hypersensitivity pneumonitis in children with a focus on the peculiarities of diagnostic investigation and management of the disease in this age group. The study includes a case report of the disease in a child. STATE OF KNOWLEDGE In children, the most common factors causing HP are avian and fungal antigens present in the home environment. Diagnosis is based on the co-occurrence of characteristic clinical presentation, radiographic and pulmonary function tests findings, and a history of exposure to a potential triggering antigen. The main strategy in the management of HP is to eliminate the trigger factor with the use of a systemic corticosteroids therapy in severe or advanced cases. CONCLUSIONS Due to the risk of irreversible changes in the respiratory tract, an early diagnosis is very important. A quick identification of the trigger factor and its elimination from the patient's environment makes it possible to apply a less aggressive treatment, and to improve the patient's prognosis. Unfortunately, due to its infrequent occurrence, hypersensitivity pneumonitis is often not taken into account in a differential diagnosis of respiratory diseases in children, which leads to a delayed diagnosis despite the characteristic clinical presentation of the disease.
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Affiliation(s)
- Maria Wawszczak
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Poland
| | - Teresa Bielecka
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Poland
| | - Maciej Szczukocki
- Department of Paediatrics, Paediatric and Social Nursing, Institute of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, Poland
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Cohn I, Manshaei R, Liston E, Okello JBA, Khan R, Curtis MR, Krupski AJ, Jobling RK, Kalbfleisch K, Paton TA, Reuter MS, Hayeems RZ, Verstegen RHJ, Goldman A, Kim RH, Ito S. Assessment of the Implementation of Pharmacogenomic Testing in a Pediatric Tertiary Care Setting. JAMA Netw Open 2021; 4:e2110446. [PMID: 34037732 PMCID: PMC8155824 DOI: 10.1001/jamanetworkopen.2021.10446] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Pharmacogenomic (PGx) testing provides preemptive pharmacotherapeutic guidance regarding the lack of therapeutic benefit or adverse drug reactions of PGx targeted drugs. Pharmacogenomic information is of particular value among children with complex medical conditions who receive multiple medications and are at higher risk of developing adverse drug reactions. OBJECTIVES To assess the implementation outcomes of a PGx testing program comprising both a point-of-care model that examined targeted drugs and a preemptive model informed by whole-genome sequencing that evaluated a broad range of drugs for potential therapy among children in a pediatric tertiary care setting. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted at The Hospital for Sick Children in Toronto, Ontario, from January 2017 to September 2020. Pharmacogenomic analyses were performed among 172 children who were categorized into 2 groups: a point-of-care cohort and a preemptive cohort. The point-of-care cohort comprised 57 patients referred to the consultation clinic for planned therapy with PGx targeted drugs and/or for adverse drug reactions, including lack of therapeutic benefit, after the receipt of current or past medications. The preemptive cohort comprised 115 patients who received exploratory whole-genome sequencing-guided PGx testing for their heart conditions from the cardiac genome clinic at the Ted Rogers Centre for Heart Research. EXPOSURES Patients received PGx analysis of whole-genome sequencing data and/or multiplex genotyping of 6 pharmacogenes (CYP2C19, CYP2C9, CYP2D6, CYP3A5, VKORC1, and TPMT) that have established PGx clinical guidelines. MAIN OUTCOMES AND MEASURES The number of patients for whom PGx test results warranted deviation from standard dosing regimens. RESULTS A total of 172 children (mean [SD] age, 8.5 [5.6] years; 108 boys [62.8%]) were enrolled in the study. In the point-of-care cohort, a median of 2 target genes (range, 1-5 genes) were investigated per individual, with CYP2C19 being the most frequently examined; genotypes in 21 of 57 children (36.8%) were incompatible with standard treatment regimens. As expected from population allelic frequencies, among the 115 children in the whole-genome sequencing-guided preemptive cohort, 92 children (80.0%) were recommended to receive nonstandard treatment regimens for potential drug therapies based on their 6-gene pharmacogenetic profile. CONCLUSIONS AND RELEVANCE In this cohort study, among both the point-of-care and preemptive cohorts, the multiplex PGx testing program provided dosing recommendations that deviated from standard regimens at an overall rate that was similar to the population frequencies of relevant variants.
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Affiliation(s)
- Iris Cohn
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roozbeh Manshaei
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eriskay Liston
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John B. A. Okello
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Reem Khan
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Meredith R. Curtis
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abby J. Krupski
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rebekah K. Jobling
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Genome Diagnostics, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kelsey Kalbfleisch
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tara A. Paton
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Miriam S. Reuter
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Canada’s Genomic Enterprise (CGEn), The Hospital for Sick Children, Toronto, Ontario, Canada
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robin Z. Hayeems
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ruud H. J. Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Raymond H. Kim
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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20
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Łoś K, Chmielewski J, Cebula G, Bielecki T, Torres K, Łuczyński W. Relationship between mindfulness, stress, and performance in medical students in pediatric emergency simulations. GMS J Med Educ 2021; 38:Doc78. [PMID: 34056067 PMCID: PMC8136353 DOI: 10.3205/zma001474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/22/2020] [Accepted: 01/25/2021] [Indexed: 06/12/2023]
Abstract
Objectives: Pediatric teams of emergency departments work under extreme stress, which affects high-level cognitive functions, specifically attention and memory. Therefore, the methods of stress management are being sought. Mindfulness as a process of intentionally paying attention to each moment with acceptance of each experience without judgment can potentially contribute to improving the performance of medical teams. Medical simulation is a technique that creates a situation to allow persons to experience a representation of a real event for the purpose of education. It has been shown that emergency medicine simulation may create a high physiological fidelity environment similarly to what is observed in a real emergency room. The aim of our study was to determine whether the technical and non-technical skills of medical students in the course of pediatric high fidelity simulations are related to their mindfulness and stress. Participants and methods: A total of 166 standardized simulations were conducted among students of medicine in three simulation centers of medical universities, assessing: stress sensation (subjectively and heart rate/blood pressure), technical (checklists) and non-technical skills (Ottawa scale) and mindfulness (five facet mindfulness questionnaire): ClinicalTrials.gov ID: NCT03761355. Results: The perception of stress among students was lower and more motivating if they were more mindful. Mindfulness of students correlated positively with avoiding fixation error. In the consecutive simulations the leaders' non-technical skills improved, although no change was noted in their technical skills. Conclusion: The results of our research indicate that mindfulness influence the non-technical skills and the perception of stress of medical students during pediatric emergency simulations. Further research is needed to show whether mindfulness training leads to improvement in this field.
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Affiliation(s)
- Kacper Łoś
- Medical University of Białystok, Department of Medical Simulations, Białystok, Poland
| | - Jacek Chmielewski
- Medical University of Białystok, Department of Psychiatry, Białystok, Poland
| | - Grzegorz Cebula
- Jagiellonian University Medical College, Department of Medical Education, Kraków, Poland
| | - Tomasz Bielecki
- Medical University of Lublin, Department of Didactics and Medical Simulations, Lublin, Poland
| | - Kamil Torres
- Medical University of Lublin, Department of Didactics and Medical Simulations, Lublin, Poland
| | - Włodzimierz Łuczyński
- Medical University of Białystok, Department of Medical Simulations, Białystok, Poland
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21
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Young J, Rodrigues KK, Imam B, Johnson-Agbakwu C. Female Genital Mutilation/Cutting-Pediatric Physician Knowledge, Training, and General Practice Approach. J Immigr Minor Health 2021; 22:668-674. [PMID: 31602532 DOI: 10.1007/s10903-019-00938-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Female genital mutilation/cutting (FGM/C) is outlawed in much of the world but still mainly occurs from infancy-age 15. Many at-risk and FGM/C-affected girls live in the US. No standard pediatric training exists. A questionnaire assessing FGM/C education, knowledge, diagnostic confidence and external genital examination (EGE) approach was sent to pediatric listservs at 3 hospitals and a child abuse pediatrician (CAP) network. Analysis used χ2 and Fisher's exact tests. Compared to general pediatricians, CAP reported more FGM/C education (RR 2.0 [95% CI 1.3-3.2]), awareness of ICD-9/10 codes (RR 3.2 [95% CI 1.4-7.3]), confidence in identifying sub-types (RR 4.5 [95% CI 2.3-8.7]) and discussing FGM/C (RR 4.2 [95% CI 2.3-7.6]). For 6-12 month olds, 10% of general pediatricians reported never performing EGE at female well child visits (WCV), increasing to > 50% for 17-18 year olds. Pediatric physicians are not trained to diagnose or manage FGM/C. EGE are not done at WCVs and FGM/C diagnoses are missed.
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Affiliation(s)
- Janine Young
- Department of General Pediatrics, Denver Health and Hospital Authority, University of Colorado School of Medicine, 1001 Yosemite St., Denver, CO, 80230, USA.
| | - Kristine Knuti Rodrigues
- Department of General Pediatrics, Denver Health and Hospital Authority, University of Colorado School of Medicine, 1001 Yosemite St., Denver, CO, 80230, USA
| | - Basel Imam
- Department of Pediatric and Adolescent Gynecology, Phoenix Children's Hospital, Phoenix, AZ, USA
- Department of Obstetrics and Gynecology, Edward Hospital, Naperville, IL, USA
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Moratilla Lapeña L, Delgado-Miguel C, Sarmiento Caldas MC, Estefanía K, Velayos M, Muñoz-Serrano A, De Ceano-Vivas M, López-Santamaría M, Martínez L. Impact of SARS-CoV-2 pandemic on emergency department activity at the pediatric surgery unit of a third-level hospital. Cir Pediatr 2021; 34:85-89. [PMID: 33826261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION As a result of the emergence of the SARS-CoV-2 respiratory virus in Wuhan in December 2019, the Spanish Government declared the state of emergency with restrictions such as stay-at-home lockdown. The objective of this study was to analyze emergency activity at a referral pediatric surgery unit in its territory and determine whether surgical pathologies had decreased or not. METHODS A retrospective study of pediatric patients presenting at the emergency department and referred to the pediatric surgery unit from March 14, 2020 to April 20, 2020 was carried out. The results were compared with those from the same dates of the previous year. Demographic variables, pathologies, and management strategies were studied for each case. The number of patients with abdominal pain requiring surgical assessment was also analyzed. RESULTS 161 patients were included - 91 from 2019 and 70 from 2020. Of the 2020 patients, 62 (88.6%) underwent surgery and 8 (11.4%) were admitted, whereas in 2019, patient distribution was 67 (73.6%) and 24 (26.4%), which means there were fewer admissions in 2020 (p= 0.018). There were no differences in terms of hours to emergency department consultation - just an increase in the case of appendicular pathologies in the 2020 period, with 24 [23-48] hours vs. 24 [12-30] hours (p = 0.045). CONCLUSION The current pandemic has not caused emergency surgeries to decrease. It has only increased time to consultation in patients with appendicular pathologies.
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Affiliation(s)
| | - C Delgado-Miguel
- Pediatric Surgery Unit. La Paz Pediatric Hospital, Madrid (Spain)
| | | | - K Estefanía
- Pediatric Surgery Unit. La Paz Pediatric Hospital, Madrid (Spain)
| | - M Velayos
- Pediatric Surgery Unit. La Paz Pediatric Hospital, Madrid (Spain)
| | - A Muñoz-Serrano
- Pediatric Surgery Unit. La Paz Pediatric Hospital, Madrid (Spain)
| | - M De Ceano-Vivas
- Pediatric Emergency Department. La Paz Pediatric Hospital, Madrid (Spain)
| | | | - L Martínez
- Pediatric Surgery Unit. La Paz Pediatric Hospital, Madrid (Spain). La Paz Biomedical Research Institute (IdiPaz), Maternal, Child, and Development Health (SAMID) network
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Flores G, Mendoza F, Brimacombe MB, Frazier W. Program Evaluation of the Research in Academic Pediatrics Initiative on Diversity (RAPID): Impact on Career Development and Professional Society Diversity. Acad Med 2021; 96:549-556. [PMID: 32496290 DOI: 10.1097/acm.0000000000003531] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE Despite a demographic surge in U.S. minority children, pediatric workforce diversity has failed to keep pace. The study aim was to evaluate the Research in Academic Pediatrics Initiative on Diversity (RAPID), a research-education program aimed at recruiting, retaining, and professionally advancing diverse early-career faculty in general pediatrics who are pursuing research careers. METHOD RAPID includes the following components: small research grants, mentoring by nationally renowned senior investigators, mentoring and networking at an annual breakfast, an annual career-development conference, and monthly mentoring conference calls. Outcomes data from the first 5 years (2012-2017) of RAPID were analyzed. Data sources were Academic Pediatric Association (APA) membership data and postconference, baseline, and end-of-program/follow-up surveys. Outcome measures included mentoring quality, presentations, publications, subsequent grants, impact on career success, conference ratings, and APA membership diversity. RESULTS For the 10 Scholars from the first 4 cohorts, mean scores were 4.5 (5 = strongly agree) for RAPID fostering mentoring, developing research skills, and helping Scholars feel more comfortable as underrepresented minority (URM) faculty; 78% delivered platform or poster presentations on their project. They published 56 total articles and received a mean of 2.5 subsequent grants. Their mean score for RAPID "advancing my career by facilitating promotion or getting a job" was 4.6. The first 4 RAPID Conferences were highly rated (mean scores = 4.2-4.8) and brought in 33 additional URM young investigators. Pre-RAPID, URM APA membership stagnated at 6%-7% for 5 years. In RAPID's first year, URM APA membership rose to 8%, then to 10% by 2017 (43% increase; P < .001). CONCLUSIONS RAPID Scholars generated multiple presentations and publications. RAPID mentoring and Conferences were highly rated. RAPID was associated with career advancement and increased professional society diversity. RAPID could serve as a national model for enhancing URM career development and professional society diversity.
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Affiliation(s)
- Glenn Flores
- G. Flores is director, Health Services Research Institute, Connecticut Children's Medical Center, Hartford, Connecticut, professor, Department of Pediatrics, UConn Health, Farmington, Connecticut, and director and principal investigator, Research in Academic Pediatrics Initiative on Diversity
| | - Fernando Mendoza
- F. Mendoza is professor of pediatrics and associate dean of minority advising and programs, Stanford University School of Medicine and Lucile Salter Packard Children's Hospital, Stanford, California, and co-director, Research in Academic Pediatrics Initiative on Diversity
| | - Michael B Brimacombe
- M.B. Brimacombe is senior biostatistician, Department of Research, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Willie Frazier
- W. Frazier III is research program manager, Connecticut Children's Medical Center, Hartford, Connecticut
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Schulga J, Mitchell H, Ahmed SF, Albanese A, Warner J, Davies JH, Shaw N, Banerjee I, Patel L. Peer Review of Paediatric Endocrine Services in the UK: A Template for Quality and Service Improvement. Horm Res Paediatr 2021; 93:616-621. [PMID: 33789302 DOI: 10.1159/000515238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Independent peer review of healthcare services can complement existing internal-, institutional-, and national-level regulatory mechanisms aimed at improving quality of healthcare. However, this has not been reported for paediatric endocrinology services in the UK. We aimed to test feasibility and acceptability through a first cycle of a national peer review of paediatric endocrine services. METHODS Tertiary centres in paediatric endocrinology across the UK were assessed against 54 quality standards, developed by the British Society for Paediatric Endocrinology and Diabetes (BSPED) in five domains of healthcare by a team comprising paediatric endocrinologists and specialist nurses. The evaluation was supported by a self-assessment. A post-peer-review questionnaire was used as feedback. RESULTS All 22 centres in the UK underwent independent peer review between 2011 and 2017. Each served a median population of 2.6 million (range 1-8 million) and offered 1,872 (range 779-6,738) outpatient consultations annually. A total of 43 (range 30-49) standards were met in combined evaluation of all centres. Variance of adherence for essential standards ranged from 52 to 97% at individual centres with 90% adherence demonstrated by 32% of centres. Post-review feedback showed 20/22 (95%) validating the utility of the peer review. CONCLUSIONS The BSPED peer review of all UK centres providing paediatric endocrine services is shown to be feasible and provides a quality benchmark for replication by national services.
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Affiliation(s)
- John Schulga
- NHS Forth Valley Women & Children Department, Forth Valley Royal Hospital, Larbert, UK
| | - Heather Mitchell
- Paediatrics Department, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - S Faisal Ahmed
- Child Health, School of Medicine, Dentistry and Nursing, Royal Hospital for Children, Glasgow, UK
| | - Assunta Albanese
- Department of Paediatric Endocrinology, St. George's University Hospital NHS Foundation Trust, London, UK
| | - Justin Warner
- Department of Paediatric Endocrinology, Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | - Justin H Davies
- Child Health Directorate, University Hospital Southampton, Southampton, UK
| | - Nicholas Shaw
- Deparment of Endocrinology & Diabetes, Birmingham Women's & Children's Hospital, and Institute of Metabolism & Systems Research, University of Birmingham, Birmingham, UK
| | - Indraneel Banerjee
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Leena Patel
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, and Division of Medical Education, The University of Manchester, Manchester, UK
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Van de Velde SK, Cola K, Bompadre V, Steinman SE. Seasonal Variation in Parental Satisfaction With Pediatric Orthopaedics. J Pediatr Orthop 2021; 41:e296-e300. [PMID: 33417390 DOI: 10.1097/bpo.0000000000001747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The degree of parental satisfaction with health care is determined by the family's characteristics and expectations. Many aspects of human physiology and behavior have seasonal rhythms. The purpose of the present study was to determine whether parental satisfaction scores vary across the year in a pediatric orthopaedic outpatient population. METHODS We retrospectively reviewed a total of 22,951 parental satisfaction scores related to outpatient pediatric orthopaedic encounters between October 2015 and April 2019. Parental satisfaction was measured using the provider subdomain of the shortened version of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Families were stratified according to various pediatric orthopaedic subspecialty services. RESULTS The satisfaction scores of all pediatric orthopaedic encounters combined did not vary significantly across the year (P=0.8745). When the families were stratified into groups by pediatric orthopaedic subspecialty clinic, variation in seasons was not associated with statistically significant variation in satisfaction scores for the elective surgery, sports medicine, trauma/fracture care, and hand/upper extremity services. However, satisfaction with the spine service was significantly lower in the winter compared with the summer and fall (73.9±3.8 vs. 83.5±5.3 and 82.6±3.6, respectively; P=0.0147). CONCLUSIONS The provision of pediatric spine care in a region with 4 distinct seasons received lower parental satisfaction scores during the winter than during the summer and fall. This seasonal variation is an additional source of bias in the measurement of satisfaction with health care. LEVEL OF EVIDENCE Level II-retrospective study.
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Affiliation(s)
| | - Kristin Cola
- Pediatric Orthopedics of Southwest Florida, Fort Myers, FL
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Ryan MS, Lee B, Richards A, Perera RA, Haley K, Rigby FB, Park YS, Santen SA. Evaluating the Reliability and Validity Evidence of the RIME (Reporter-Interpreter-Manager-Educator) Framework for Summative Assessments Across Clerkships. Acad Med 2021; 96:256-262. [PMID: 33116058 DOI: 10.1097/acm.0000000000003811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE The ability of medical schools to accurately and reliably assess medical student clinical performance is paramount. The RIME (reporter-interpreter-manager-educator) schema was originally developed as a synthetic and intuitive assessment framework for internal medicine clerkships. Validity evidence of this framework has not been rigorously evaluated outside of internal medicine. This study examined factors contributing to variability in RIME assessment scores using generalizability theory and decision studies across multiple clerkships, thereby contributing to its internal structure validity evidence. METHOD Data were collected from RIME-based summative clerkship assessments during 2018-2019 at Virginia Commonwealth University. Generalizability theory was used to explore variance attributed to different facets through a series of unbalanced random-effects models by clerkship. For all analyses, decision (D-) studies were conducted to estimate the effects of increasing the number of assessments. RESULTS From 231 students, 6,915 observations were analyzed. Interpreter was the most common RIME designation (44.5%-46.8%) across all clerkships. Variability attributable to students ranged from 16.7% in neurology to 25.4% in surgery. D-studies showed the number of assessments needed to achieve an acceptable reliability (0.7) ranged from 7 in pediatrics and surgery to 11 in internal medicine and 12 in neurology. However, depending on the clerkship each student received between 3 and 8 assessments. CONCLUSIONS This study conducted generalizability- and D-studies to examine the internal structure validity evidence of RIME clinical performance assessments across clinical clerkships. Substantial proportion of variance in RIME assessment scores was attributable to the rater, with less attributed to the student. However, the proportion of variance attributed to the student was greater than what has been demonstrated in other generalizability studies of summative clinical assessments. Overall, these findings support the use of RIME as a framework for assessment across clerkships and demonstrate the number of assessments required to obtain sufficient reliability.
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Affiliation(s)
- Michael S Ryan
- M.S. Ryan is assistant dean for clinical medical education and associate professor of pediatrics, Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: https://orcid.org/0000-0003-3266-9289
| | - Bennett Lee
- B. Lee is associate professor of internal medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Alicia Richards
- A. Richards is a doctoral student in the department of biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Robert A Perera
- R.A. Perera is associate professor of biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Kellen Haley
- K. Haley is a resident in neurology at the University of Michigan School of Medicine, Ann Arbor, Michigan. At the time of initial drafting of this manuscript, Dr. Haley was a fourth-year medical student at Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Fidelma B Rigby
- F.B. Rigby is associate professor and clerkship director of obstetrics and gynecology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Yoon Soo Park
- Y.S. Park is associate professor and associate head, department of medical education, and director of research, office of educational affairs, University of Illinois at Chicago College of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0001-8583-4335
| | - Sally A Santen
- S.A. Santen is senior associate dean for evaluation, assessment and scholarship, and professor of emergency medicine Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: https://orcid.org/0000-0002-8327-8002
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Katashima R, Matsumoto M, Watanabe Y, Moritani M, Yokota I. Identification of Novel GCK and HNF4α Gene Variants in Japanese Pediatric Patients with Onset of Diabetes before 17 Years of Age. J Diabetes Res 2021; 2021:7216339. [PMID: 34746319 PMCID: PMC8570896 DOI: 10.1155/2021/7216339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/14/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Maturity-onset diabetes of the young (MODY) is commonly misdiagnosed as type 1 or type 2 diabetes. Common reasons for misdiagnosis are related to limitations in genetic testing. A precise molecular diagnosis is essential for the optimal treatment of patients and allows for early diagnosis of their asymptomatic family members. OBJECTIVE The aim of this study was to identify rare monogenic variants of common MODY genes in Japanese pediatric patients. METHODS We investigated 45 Japanese pediatric patients based on the following clinical criteria: development of diabetes before 17 years of age, a family history of diabetes, testing negative for glutamate decarboxylase-65 (GAD 65) antibodies and insulinoma-2-associated autoantibodies (IA-2A), no significant obesity, and evidence of endogenous insulin production. Genetic screening for MODY1 (HNF4α), MODY2 (GCK), MODY3 (HNF1α), and MODY5 (HNF1β) was performed by direct sequencing followed by multiplex ligation amplification assays. RESULTS We identified 22 missense variants (3 novel variants) in 27 patients (60.0%) in the GCK, HNF4α, and HNF1α genes. We also detected a whole exon deletion in the HNF1β gene and an exon 5-6 aberration in the GCK gene, each in one proband (4.4%). There were a total of 29 variations (64.4%), giving a relative frequency of 53.3% (24/45) for GCK, 2.2% (1/45) for HNF4α, 6.7% (3/45) for HNF1α, and 2.2% (1/45) for HNF1β genes. CONCLUSIONS Clinicians should consider collecting and assessing detailed clinical information, especially regarding GCK gene variants, in young antibody-negative patients with diabetes. Correct molecular diagnosis of MODY better predicts the clinical course of diabetes and facilitates individualized management.
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Affiliation(s)
- Rumi Katashima
- Laboratory for Pediatric Genome Medicine, Department of Clinical Research, National Hospital Organization Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji City, Kagawa 765-8507, Japan
| | - Mari Matsumoto
- Laboratory for Pediatric Genome Medicine, Department of Clinical Research, National Hospital Organization Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji City, Kagawa 765-8507, Japan
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kagawa University, 1750-1, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Yuka Watanabe
- Laboratory for Pediatric Genome Medicine, Department of Clinical Research, National Hospital Organization Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji City, Kagawa 765-8507, Japan
| | - Maki Moritani
- Laboratory for Pediatric Genome Medicine, Department of Clinical Research, National Hospital Organization Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji City, Kagawa 765-8507, Japan
| | - Ichiro Yokota
- Laboratory for Pediatric Genome Medicine, Department of Clinical Research, National Hospital Organization Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji City, Kagawa 765-8507, Japan
- Department of Pediatric Endocrinology and Metabolism, National Hospital Organization Shikoku Medical Center for Children and Adults, 2-1-1, Senyu-cho, Zentsuji City, Kagawa 765-8507, Japan
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Mehta NS, Mytton OT, Mullins EWS, Fowler TA, Falconer CL, Murphy OB, Langenberg C, Jayatunga WJP, Eddy DH, Nguyen-Van-Tam JS. SARS-CoV-2 (COVID-19): What Do We Know About Children? A Systematic Review. Clin Infect Dis 2020; 71:2469-2479. [PMID: 32392337 PMCID: PMC7239259 DOI: 10.1093/cid/ciaa556] [Citation(s) in RCA: 258] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/13/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Few pediatric cases of coronavirus disease 2019 (COVID-19) have been reported and we know little about the epidemiology in children, although more is known about other coronaviruses. We aimed to understand the infection rate, clinical presentation, clinical outcomes, and transmission dynamics for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in order to inform clinical and public health measures. METHODS We undertook a rapid systematic review and narrative synthesis of all literature relating to SARS-CoV-2 in pediatric populations. The search terms also included SARS-CoV and MERS-CoV. We searched 3 databases and the COVID-19 resource centers of 11 major journals and publishers. English abstracts of Chinese-language papers were included. Data were extracted and narrative syntheses conducted. RESULTS Twenty-four studies relating to COVID-19 were included in the review. Children appear to be less affected by COVID-19 than adults by observed rate of cases in large epidemiological studies. Limited data on attack rate indicate that children are just as susceptible to infection. Data on clinical outcomes are scarce but include several reports of asymptomatic infection and a milder course of disease in young children, although radiological abnormalities are noted. Severe cases are not reported in detail and there are few data relating to transmission. CONCLUSIONS Children appear to have a low observed case rate of COVID-19 but may have rates similar to adults of infection with SARS-CoV-2. This discrepancy may be because children are asymptomatic or too mildly infected to draw medical attention and be tested and counted in observed cases of COVID-19.
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Affiliation(s)
- Nisha S Mehta
- Department of Health and Social Care (England), London, United Kingdom
| | | | - Edward W S Mullins
- Imperial College London, London, United Kingdom
- Obstetrics and Gynecology, Queen Charlotte’s and Chelsea Hospital, London, United Kingdom
| | | | | | - Orla B Murphy
- Department of Health and Social Care (England), London, United Kingdom
| | - Claudia Langenberg
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
- Public Health England, London, United Kingdom
- The Francis Crick Institute, London, United Kingdom
| | | | | | - Jonathan S Nguyen-Van-Tam
- Department of Health and Social Care (England), London, United Kingdom
- University of Nottingham School of Medicine, Nottingham, United Kingdom
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Macy ML, Huetteman P, Kan K. Changes in Primary Care Visits in the 24 Weeks After COVID-19 Stay-at-Home Orders Relative to the Comparable Time Period in 2019 in Metropolitan Chicago and Northern Illinois. J Prim Care Community Health 2020; 11:2150132720969557. [PMID: 33174495 PMCID: PMC7675908 DOI: 10.1177/2150132720969557] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE In this brief report, we characterize pediatric primary care service utilization in metropolitan Chicago over the first 24 weeks of the COVID-19 pandemic response in relation to the comparable time period in 2019. METHODS We examined retrospective visit and billing data, regardless of payer, from 16 independent pediatric practices that utilize a common electronic medical record platform within an Accountable Care Organization of 252 pediatricians in 71 offices throughout metropolitan Chicago. We categorized visits as Well-Child and Immunization-Only (WC-IO) or Other types and identified visits with a telemedicine billing modifier. Diagnoses for Other visits were tallied and categorized using the Agency for Healthcare Research and Quality Clinical Classification System. We summarized counts of visits and the proportion of visits with a telemedicine billing modifier in one-week epochs for 2020 compared with 2019. RESULTS There were 102 942 total visits (72 030 WC-IO; 30 912 Other) in 2020 and 144 672 visits (80 578 WC-IO; 64 094 Other) in 2019. WC-IO visits in 2020 were half of 2019 visits at the start of the Illinois Stay-at-Home Order and returned greater than 90% of 2019 visits in 8 weeks. Other visit types have remained below 70% of 2019 visits. A telemedicine billing modifier peaked in mid-April (21% of all visits) and declined to <10% of all visits in June (Phase 2 reopening). The top 10 most common diagnoses differed between years. CONCLUSIONS Recovery of well child and immunization visits suggests that practice-level efforts and policy change can ensure children receive recommended care as the pandemic evolves.
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Affiliation(s)
- Michelle L. Macy
- Department of Pediatrics, Northwestern
University, Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, IL, USA
- Michelle L. Macy, Department of Pediatrics,
Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Ave,
Chicago, IL 60611, USA.
| | | | - Kristin Kan
- Department of Pediatrics, Northwestern
University, Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children’s
Hospital of Chicago, Chicago, IL, USA
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Zimmermann P, Schmidt T, Nelson J, Gosemann JH, Bassler S, Stahmeyer JT, Hirsch FW, Lacher M, Zeidler J. Pediatric solid organ injury - frequency of abdominal imaging is determined by the treating department. Medicine (Baltimore) 2020; 99:e23057. [PMID: 33157961 PMCID: PMC7647522 DOI: 10.1097/md.0000000000023057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the use of abdominal CT scanning in the management of pediatric blunt abdominal trauma in pediatric and non-pediatric departments.In this observational cohort study, anonymized data were extracted from 2 large German statutory health insurances (∼5.9 million clients) in a 7-year period (2010-2016). All patients with inpatient International Classification of Diseases (ICD) codes S36.- and S37.- (injury of intra-abdominal organs; injury of urinary and pelvic organs) aged ≤18 years were included. Demographic and clinical data were analyzed by logistic regression analysis for associations with the use of abdominal CT.A total of 524 children with blunt abdominal trauma (mean age 11.0 ± 5.2 years; 62.6% males) were included; 164 patients (31.3%) received abdominal CT-imaging. There were no significant differences in traumatic non-intraabdominal comorbidity patterns (injuries of external causes; injuries to the head or thorax). There was substantial variability in the rate of abdominal CT imaging among different medical disciplines ranging from 11.6% to 44.5%. Patients admitted to pediatric departments (Pediatrics and Pediatric Surgery) underwent abdominal CT imaging significantly less frequently (19.7%; N = 55) compared to patients treated in non-pediatric departments (General/Trauma Surgery: 44.5%; N = 109) irrespective of concomitant injuries. The estimated OR for the use of abdominal CT by General/Trauma Surgery was 6.2-fold higher (OR: 6.15 [95-%-CI:3.07-13.21]; P < .001) compared to Pediatric Surgery. Other risk factors associated with the use of abdominal CT were traumatic extra-abdominal comorbidities, increasing age, male gender, and admission to a university hospital.Abdominal CT imaging was significantly less frequently used in pediatric departments. The substantial variability of the abdominal CT rate among different medical disciplines and centers indicates a potential for reduction of CT imaging by implementation of evidence-based guidelines. Furthermore, our study underlines the need for centralization of pediatric trauma care in Germany not only to improve patient outcome but to avoid radiation-induced cancer mortality.
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Affiliation(s)
| | - Torben Schmidt
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
| | - Jana Nelson
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | | | - Stefan Bassler
- AOK PLUS - Die Gesundheitskasse für Sachsen und Thüringen, Dresden
| | | | | | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
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Rosenbaum PE, Locandro C, Chrisman SPD, Choe MC, Richards R, Pacchia C, Cook LJ, Rivara FP, Gioia GA, Giza CC. Characteristics of Pediatric Mild Traumatic Brain Injury and Recovery in a Concussion Clinic Population. JAMA Netw Open 2020; 3:e2021463. [PMID: 33196804 PMCID: PMC7670312 DOI: 10.1001/jamanetworkopen.2020.21463] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Pediatric mild traumatic brain injury (TBI) and concussion are a public health challenge with up to 30% of patients experiencing prolonged recovery. Pediatric patients presenting to concussion clinics often have ongoing impairments and may be at increased risk for persistent symptoms. Understanding this population is critical for improved prognostic estimates and optimal treatment. OBJECTIVE To describe pediatric patients presenting to concussion clinics and characterize factors associated with their recovery. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included patients enrolled at multicenter concussion specialty clinics from the Four Corners Youth Consortium from December 2017 to July 2019, with up to 12-month follow-up. Patients were eligible if they were aged 5 to 18.99 years with a diagnosis of mild TBI or concussion presenting to participating clinics within 8 weeks of injury. Patients were excluded if the patient or their parents were unable to read or sign the consent document, or if the patient had a Glasgow Coma Scale score less than 13 or a penetrating injury. Data were analyzed from February 2019 to April 2020. EXPOSURES Diagnosis of mild TBI or concussion. MAIN OUTCOMES AND MEASURES This study used National Institute of Neurological Disorders and Stroke common data elements, including data on demographic characteristics, injury details, history, neurological and neuropsychological assessments, and treatment. RESULTS A total of 600 patients were consecutively enrolled, among whom 324 (54.0%) were female and 435 (72.5%) were adolescents (ie, aged 13-18 years). A higher proportion of girls and women (248 patients [76.5%]) were adolescents compared with boys and men (187 patients [67.8%]) (P = .02), and girls and women reported significantly more preexisting anxiety compared with boys and men (80 patients [26.7%] vs 46 patients [18.7%]; P = .03). Significantly more adolescents reported preexisting migraines compared with preadolescents (82 patients [20.9%] vs 15 patients [10.9%]; P = .01). Girls and women recovered more slowly than boys and men (persistent symptoms after injury: week 4, 217 patients [81.6%] vs 156 patients [71.2%]; week 8, 146 patients [58.9%] vs 89 patients [44.3%]; week 12, 103 patients [42.6%] vs 58 patients [30.2%]; P = .01). Patients with history of migraine or anxiety or depression recovered more slowly than those without, regardless of sex. CONCLUSIONS AND RELEVANCE These findings suggest that identification of subgroups of pediatric patients with mild TBI or concussion at risk for prolonged recovery could aid in better prognostic estimates and more targeted treatment interventions.
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Affiliation(s)
- Philip E. Rosenbaum
- David Geffen School of Medicine, Department of Neurosurgery, University of California, Los Angeles
- Steve Tisch BrainSPORT Program, University of California, Los Angeles
| | | | - Sara P. D. Chrisman
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle
- Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Meeryo C. Choe
- Steve Tisch BrainSPORT Program, University of California, Los Angeles
- David Geffen School of Medicine, Department of Pediatrics, UCLA Mattel Children’s Hospital, Los Angeles, California
| | | | | | | | - Frederick P. Rivara
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle
- Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Gerard A. Gioia
- Departments of Pediatrics and Psychiatry and Behavioral Sciences, George Washington University School of Medicine, Washington, District of Columbia
- Children’s National Hospital, Rockville, Maryland
| | - Christopher C. Giza
- David Geffen School of Medicine, Department of Neurosurgery, University of California, Los Angeles
- Steve Tisch BrainSPORT Program, University of California, Los Angeles
- David Geffen School of Medicine, Department of Pediatrics, UCLA Mattel Children’s Hospital, Los Angeles, California
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Darr A, Senior A, Argyriou K, Limbrick J, Nie H, Kantczak A, Stephenson K, Parmar A, Grainger J. The impact of the coronavirus (COVID-19) pandemic on elective paediatric otolaryngology outpatient services - An analysis of virtual outpatient clinics in a tertiary referral centre using the modified paediatric otolaryngology telemedicine satisfaction survey (POTSS). Int J Pediatr Otorhinolaryngol 2020; 138:110383. [PMID: 33152974 PMCID: PMC7515596 DOI: 10.1016/j.ijporl.2020.110383] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Virtual outpatient clinics (VOPC) have been integrated into both paediatric and based adult outpatient services due to a multitude of factors, including increased demand for services, technological advances and rising morbidity secondary to ageing populations. The novel coronavirus disease (COVID-19) has accentuated pressures on the National Health Service (NHS) infrastructure, particularly elective services, whilst radically altering patterns of practice. AIM To evaluate the impact of the COVID-19 pandemic on paediatric otolaryngology outpatient services whilst collating patient feedback to elicit long-term sustainability post COVID-19. METHOD A retrospective analysis of VOPCs was undertaken at a tertiary paediatric referral centre over a 3-month capture period during the COVID-19 pandemic. Demographic, generic clinic (presenting complaint, new vs. follow-up, consultation type), as well as outcome data (medical or surgical intervention, discharge vs. ongoing review, onward referral, investigations, and conversion to face-to-face) was collated. Additionally a modified 15-point patient satisfaction survey was created. The Paediatric Otolaryngology Telemedicine Satisfaction survey (POTSS), was an adaptation of 4 validated patient satisfaction tools including the General Medical Council (GMC) patient questionnaire, the telehealth satisfaction scale (TESS), the telehealth usability questionnaire (TUQ), and the telemedicine satisfaction and usefulness questionnaire (TSUQ). RESULTS Of 514 patients reviewed virtually over a 3-month period, 225 (45%) were randomly selected to participate, of which 200 met our inclusion criteria. The most common mode of consultation was telephony (92.5%, n = 185). Non-attendance rates were reduced when compared to face-to-face clinics during an equivalent period prior to the COVID-19 pandemic. A significant proportion of patients (29% compared to 26% pre-VOPC) were discharged to primary care. Nine percent were listed for surgery compared to 19% pre-VOPC. A subsequent face-to-face appointment was required in 10% of participants. Overall, the satisfaction when assessing the doctor-patient relationship, privacy & trust, as well as consultation domains was high, with the overwhelming majority of parents' content with the future integration and participation in VOPCs. CONCLUSION An evolving worldwide pandemic has accelerated the need for healthcare services to reform in order to maintain a steady flow of patients within an elective outpatient setting without compromising patient care. Solutions must be sustainable long-term to account for future disruptions, whilst accounting for evolving patient demographics. Our novel survey has demonstrated the vast potential that the integration of VOPCs can offer paediatric otolaryngology services within a carefully selected cohort of patients.
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Affiliation(s)
- Adnan Darr
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
| | - Andrew Senior
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
| | - Kalliopi Argyriou
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
| | - Jack Limbrick
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
| | - Huimin Nie
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom
| | - Ada Kantczak
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
| | - Kate Stephenson
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
| | - Amit Parmar
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
| | - Joe Grainger
- Birmingham Women's and Children's NHS Foundation Trust, United Kingdom.
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Dexter F, Epstein RH, Rodriguez LI. Decline of Pediatric Ambulatory Surgery Cases Performed at Florida General Hospitals Between 2010 and 2018: An Historical Cohort Study. Anesth Analg 2020; 131:1557-1565. [PMID: 33079879 DOI: 10.1213/ane.0000000000004676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the province of Ontario, nonphysiologically complex surgical procedures have increased at 4 pediatric hospitals with a reciprocal decline among the other (general) hospitals performing pediatric surgery. Given the differences between the Canadian and US health systems, we studied whether a similar shift occurred in the state of Florida and examined the age dependence of the shift. METHODS We used outpatient pediatric surgery data from all nonfederal hospitals, hospital-owned facilities, and independent ambulatory surgery centers in Florida, 2010-2018. Inferential analyses were performed comparing 2010-2011 with 2017-2018. Annual caseloads are reported as cases per workday by dividing by 250 workdays per year. RESULTS Statewide, comparing 2010-2011 with 2017-2018, among children 1-17 years, pediatric hospitals' caseload increased overall by 50.7 cases per workday, overall meaning collectively among all hospitals combined. The caseload at general hospitals and ambulatory surgery centers, combined, decreased by 97.7 cases per workday. The general hospitals performed 54.7 fewer cases per workday. Among the 112 general hospitals, the mean pairwise decline was -0.49 cases per workday (99% confidence interval, -0.87 to -0.10; P < .0001). The changes were due to multiple categories of procedures, not just a few. Comparing 2010-2011 with 2017-2018, among 3 age cohorts (1-5, 6-12, and 13-17 years), the pediatric hospitals, statewide, performed overall 16.2, 15.1, and 19.3 more cases per workday, respectively. The general hospitals and ambulatory surgery centers, combined, performed fewer cases per workday for each cohort: 49.4, 21.4, and 26.9, respectively. The general hospitals overall performed fewer cases per workday for each cohort: 27.3, 12.1, and 15.4, respectively. Among general hospitals, the mean pairwise difference in the declines between patients 1-5 years vs 6-17 years was 0.00 cases per workday (99% confidence interval, -0.13 to +0.14). CONCLUSIONS The decline across all age groups was inconsistent with multiple general hospitals increasing their minimum age threshold for surgical patients because, otherwise, the younger patients would have accounted for a larger share of the decreases in caseload. Pediatric hospitals and their anesthesiologists have greater surgical growth than expected from population demographics. Many general hospitals can expect either needing fewer pediatric anesthesiologists or that their pediatric anesthesiologists, who also care for adults, will have smaller proportions of pediatric patients in their practices.
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Affiliation(s)
- Franklin Dexter
- From the Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Richard H Epstein
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Luis I Rodriguez
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Sadozai L, Sable S, Le Roux E, Coste P, Guillot C, Boizeau P, Berthe-Aucejo A, Angoulvant F, Lorrot M, Bourdon O, Prot-Labarthe S. International consensus validation of the POPI tool (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions) to identify inappropriate prescribing in pediatrics. PLoS One 2020; 15:e0240105. [PMID: 33017423 PMCID: PMC7535059 DOI: 10.1371/journal.pone.0240105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/19/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION While drug prescription should be based on established recommendations stemming from clinical trials but in pediatrics, many drugs are used without marketing authorization. Consequently recommendations are often based on clinical experience and the risk of inappropriate prescription (IP) is high. A tool for detecting IP in pediatrics-called POPI (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions)-has been developed in France. However the relevance of its use at an international level is not known. Our aim has been to adapt POPI for a worldwide use. MATERIAL AND METHOD A two-round Delphi online questionnaire was completed and validated by international experts to identify consensual items. They were asked to rate the validity of each items taking into account the recommendations and practices in their countries. Only propositions obtaining a median score in the upper tertile with an agreement of more than 75% of the panel-for the first round-and 85%-for the second round-were retained. RESULTS Our panel included 11 pharmacists (55%) and 9 physicians (45%). The panelists came from 12 different countries: England, Belgium, Brazil, Canada, China, Ivory Coast, Ireland, Malaysia, Portugal, Switzerland, Turkey and Vietnam. At the end of the first round, of the 105 items of the original POPI tool, 80 items were retained including 16 items reworded and 25 items were deleted. In the second round, 14 experts participated in the study. This final international POPI tool is composed of 73 IP and omissions of prescriptions in the fields of neuropsychiatry, dermatology, infectiology, pneumology, gastroenterology, pain and fever. DISCUSSION AND CONCLUSION This study highlights international consensus on prescription practice in pediatrics. The use of this tool in everyday practice could reduce the risk of inappropriate prescription. The impact of the diffusion of POPI tool will be assessed in a prospective multicentric study.
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Affiliation(s)
- Laily Sadozai
- Pharmacy Department, Robert-Debré Hospital, AP-HP, Paris, France
| | - Shaya Sable
- Pharmacy Department, Robert-Debré Hospital, AP-HP, Paris, France
| | - Enora Le Roux
- Unité d’épidémiologie clinique, Hôpital Universitaire Robert Debré, AP-HP.Nord-Université de Paris, Inserm, CIC 1426, Paris, France
- ECEVE UMR 1123, Université de Paris, Inserm, Paris, France
| | - Pierre Coste
- Unité d’épidémiologie clinique, Hôpital Universitaire Robert Debré, AP-HP.Nord-Université de Paris, Inserm, CIC 1426, Paris, France
- ECEVE UMR 1123, Université de Paris, Inserm, Paris, France
| | - Clémence Guillot
- Pharmacy Department, Robert-Debré Hospital, AP-HP, Paris, France
| | - Priscilla Boizeau
- Unité d’épidémiologie clinique, Hôpital Universitaire Robert Debré, AP-HP.Nord-Université de Paris, Inserm, CIC 1426, Paris, France
- ECEVE UMR 1123, Université de Paris, Inserm, Paris, France
| | - Aurore Berthe-Aucejo
- Pharmacy Department, Robert-Debré Hospital, AP-HP, Paris, France
- ECEVE UMR 1123, Université de Paris, Inserm, Paris, France
| | | | | | - Olivier Bourdon
- Pharmacy Department, Robert-Debré Hospital, AP-HP, Paris, France
- Clinical Pharmacy, Paris Descartes University, Paris, France
- Education and Health Practices, Paris XIII University, Bobigny, France
| | - Sonia Prot-Labarthe
- Pharmacy Department, Robert-Debré Hospital, AP-HP, Paris, France
- ECEVE UMR 1123, Université de Paris, Inserm, Paris, France
- Pediatric Group, Société Française de Pharmacie Clinique, Paris, France
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Siedner MJ, Kraemer JD, Meyer MJ, Harling G, Mngomezulu T, Gabela P, Dlamini S, Gareta D, Majozi N, Ngwenya N, Seeley J, Wong E, Iwuji C, Shahmanesh M, Hanekom W, Herbst K. Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: an interrupted time series analysis. BMJ Open 2020; 10:e043763. [PMID: 33020109 PMCID: PMC7536636 DOI: 10.1136/bmjopen-2020-043763] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/13/2020] [Accepted: 09/18/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES We evaluated whether implementation of lockdown orders in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN). DESIGN Observational cohort SETTING: Data were analysed from 11 primary healthcare clinics in northern KZN. PARTICIPANTS A total of 46 523 individuals made 89 476 clinic visits during the observation period. EXPOSURE OF INTEREST We conducted an interrupted time series analysis to estimate changes in clinic visitation with a focus on transitions from the prelockdown to the level 5, 4 and 3 lockdown periods. OUTCOME MEASURES Daily clinic visitation at ambulatory clinics. In stratified analyses, we assessed visitation for the following subcategories: child health, perinatal care and family planning, HIV services, non-communicable diseases and by age and sex strata. RESULTS We found no change in total clinic visits/clinic/day at the time of implementation of the level 5 lockdown (change from 90.3 to 84.6 mean visits/clinic/day, 95% CI -16.5 to 3.1), or at the transitions to less stringent level 4 and 3 lockdown levels. We did detect a >50% reduction in child healthcare visits at the start of the level 5 lockdown from 11.9 to 4.7 visits/day (-7.1 visits/clinic/day, 95% CI -8.9 to 5.3), both for children aged <1 year and 1-5 years, with a gradual return to prelockdown within 3 months after the first lockdown measure. In contrast, we found no drop in clinic visitation in adults at the start of the level 5 lockdown, or related to HIV care (from 37.5 to 45.6, 8.0 visits/clinic/day, 95% CI 2.1 to 13.8). CONCLUSIONS In rural KZN, we identified a significant, although temporary, reduction in child healthcare visitation but general resilience of adult ambulatory care provision during the first 4 months of the lockdown. Future work should explore the impacts of the circulating epidemic on primary care provision and long-term impacts of reduced child visitation on outcomes in the region.
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Affiliation(s)
- Mark J Siedner
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - John D Kraemer
- Department of Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
| | - Mark J Meyer
- Department of Mathematics and Statistics, Georgetown University, Washington, District of Columbia, USA
| | - Guy Harling
- Institute for Global Health, University College London, London, UK
- Department of Social Sciences, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Thobeka Mngomezulu
- Department of Population Research, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Patrick Gabela
- Department of Population Research, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Siphephelo Dlamini
- Department of Nursing, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Dickman Gareta
- Research Data Management, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Nomathamsanqa Majozi
- Public Engagement, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Nothando Ngwenya
- Department of Social Sciences, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Janet Seeley
- Research Unit on AIDS, Medical Research Council and Ugandan Virus Research Institute, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Emily Wong
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Collins Iwuji
- Department of Sexual Health and HIV Medicine, Brighton and Sussex Medical School, Brighton, Brighton and Hove, UK
| | - Maryam Shahmanesh
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Willem Hanekom
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Kobus Herbst
- Department of Population Research, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
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Lebbink CA, Dekker BL, Bocca G, Braat AJAT, Derikx JPM, Dierselhuis MP, de Keizer B, Kruijff S, Kwast ABG, van Nederveen FH, Nieveen van Dijkum EJM, Nievelstein RAJ, Peeters RP, Terwisscha van Scheltinga CEJ, Tissing WJE, van der Tuin K, Vriens MR, Zsiros J, van Trotsenburg ASP, Links TP, van Santen HM. New national recommendations for the treatment of pediatric differentiated thyroid carcinoma in the Netherlands. Eur J Endocrinol 2020; 183:P11-P18. [PMID: 32698145 DOI: 10.1530/eje-20-0191] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/21/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Currently, there are no European recommendations for the management of pediatric thyroid cancer. Other current international guidelines are not completely concordant. In addition, medical regulations differ between, for instance, the US and Europe. We aimed to develop new, easily accessible national recommendations for differentiated thyroid carcinoma (DTC) patients <18 years of age in the Netherlands as a first step toward a harmonized European Recommendation. METHODS A multidisciplinary working group was formed including pediatric and adult endocrinologists, a pediatric radiologist, a pathologist, endocrine surgeons, pediatric surgeons, pediatric oncologists, nuclear medicine physicians, a clinical geneticist and a patient representative. A systematic literature search was conducted for all existing guidelines and review articles for pediatric DTC from 2000 until February 2019. The Appraisal of Guidelines, Research and Evaluation (AGREE) instrument was used for assessing quality of the articles. All were compared to determine dis- and concordances. The American Thyroid Association (ATA) pediatric guideline 2015 was used as framework to develop specific Dutch recommendations. Discussion points based upon expert opinion and current treatment management of DTC in children in the Netherlands were identified and elaborated. RESULTS Based on the most recent evidence combined with expert opinion, a 2020 Dutch recommendation for pediatric DTC was written and published as an online interactive decision tree (www.oncoguide.nl). CONCLUSION Pediatric DTC requires a multidisciplinary approach. The 2020 Dutch Pediatric DTC Recommendation can be used as a starting point for the development of a collaborative European recommendation for treatment of pediatric DTC.
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Affiliation(s)
- C A Lebbink
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital (WKZ)/University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - B L Dekker
- Department of Endocrinology, Internal Medicine, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - G Bocca
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - A J A T Braat
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - J P M Derikx
- Department of Pediatric Surgery, Pediatric Surgical Center of Amsterdam, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - M P Dierselhuis
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - B de Keizer
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - S Kruijff
- Division of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - A B G Kwast
- Comprehensive Cancer Center, The Netherlands
| | | | - E J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - R A J Nievelstein
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Radiology and Nuclear Medicine, Imaging Division, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - R P Peeters
- Department of Endocrinology, Erasmus Medical Center (EMC), Rotterdam, The Netherlands
| | | | - W J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pediatric Oncology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - K van der Tuin
- Department of Clinical Genetics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - M R Vriens
- Department of Surgery, Wilhelmina Children's Hospital (WKZ)/University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - J Zsiros
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - A S P van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - T P Links
- Department of Endocrinology, Internal Medicine, University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - H M van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital (WKZ)/University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Ehwerhemuepha L, Yu PT, Guner YS, Wallace E, Feaster W. A Nested Mixed Effects Multicenter Model Examining the Risk Factors for Pediatric Trauma Return Visits Within 72 Hours. J Surg Res 2020; 257:370-378. [PMID: 32892133 DOI: 10.1016/j.jss.2020.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Return visits within 72 h are an important metric in evaluating the performance of emergency rooms. This has not been well studied in the pediatric trauma population. We sought to determine novel risk factors for return visits to the emergency department (ED) after trauma that may assist in identifying patients most at risk of revisit. METHODS We used the Cerner Health Facts Database to retrieve data from 34 EDs across the United States that care for pediatric trauma patients aged <15 y. The data consist of 610,845 patients and 816,571 ED encounters. We retrieved variables encompassing demographics, payor, current and past health care resource utilization, trauma diagnoses, other diagnoses/comorbidities, medications, and surgical procedures. We built a nested mixed effects logistic regression model to provide statistical inference on the return visits. RESULTS Traumas resulting from burns and corrosion, injuries to the shoulder and arms, injuries to the hip and legs, and trauma to the head and neck are all associated with increased odds of returning to the ED. Patients suffering from poisoning relating to drugs and other biological substances and patients with trauma to multiple body regions have reduced odds of returning to the ED. Longer ED length of stay and prior health care utilization (ED or inpatient) are associated with increased odds of a return visit. The sex of the patient and payor had a statistically significant effect on the risk of a return visit to the ED within 72 h of discharge. CONCLUSIONS Certain traumas expose patients to an increased risk for return visits to the ED and, as a result, provide opportunity for improved quality of care. Targeted interventions that include education, observation holds, or a decision to hospitalize instead of discharge home may help improve patient outcomes and decrease the rate of ED returns. LEVEL OF EVIDENCE III (Prognostic and Epidemiology).
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Affiliation(s)
- Louis Ehwerhemuepha
- CHOC Children's, Orange, California; Chapman University School of Computational and Data Science, Orange, California.
| | - Peter T Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County and Department of Surgery, University of California Irvine, Orange, California
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County and Department of Surgery, University of California Irvine, Orange, California
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Kurahara D, Hamamura FD, Ifuku C, Chen JJ, Liu CA, Seamon EM, Miwa CS, Maestas B, Oba R, Patel SJ, Shiramizu B. Medical School Location and Sex Affect the In-State Retention of Pediatric Residency Program Graduates in Hawai'i. Hawaii J Health Soc Welf 2020; 79:240-245. [PMID: 32789294 PMCID: PMC7417638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The objective of this study was to assess the impact of medical school, sex, career choice, and location of practice of one pediatric residency program on physician workforce. This is a retrospective study of all categorical pediatric graduates of a residency program located in Honolulu, Hawai'i from 1968 to 2015. Information on medical school training, sex, career choice (general pediatrics or specialty), and location of practice were studied by examining data into five 10-year graduation periods. The program graduated 319 residents over nearly a 50-year timespan. Of these, 181 (56.7%) residents remained in Hawai'i to practice (adjusted odds ratio [OR] = 7.46, 95% confidence interval [CI]: 3.61-15.43). There were 125 (39.1%) graduates who relocated to the continental US with the majority moving to the West (55.2%), while other graduates moved to the South, Midwest, and Northeast (25.6%, 13.6%, and 5.6%, respectively). The remaining 13 (4.1%) graduates moved internationally. Female residents steadily increased over time (P < .001), with females significantly choosing general pediatrics (OR = 3.05, 95% CI: 1.91-4.89). In the time periods with the highest percentage of University of Hawai'i medical school graduates, there was an increased percentage of graduates staying in Hawai'i. This study examined the regional and national impact of a small residency program. The results indicated that trends in gender and the impact of medical school location were important in establishing a pediatrician workforce for local communities. Support of both medical school and residency education should be considered when assessing future workforce needs.
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Affiliation(s)
- David Kurahara
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Faith D. Hamamura
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Christine Ifuku
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | | | - Chloe A. Liu
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Elisabeth M. Seamon
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Chloe S. Miwa
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Brienna Maestas
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Ria Oba
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Shilpa J. Patel
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
| | - Bruce Shiramizu
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (DK, FDH, CI, CAL, EMS, CSM, BM, RO, SJP, BS)
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Abstract
This cross-sectional study examines the association between article citations, Altmetric attention scores, and cumulative page views of pediatric research articles from 4 high-impact medical journals.
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Affiliation(s)
- Andrew J. Giustini
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - David M. Axelrod
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Brian P. Lucas
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- White River Junction Veterans Affairs Hospital, White River Junction, Virginia
| | - Alan R. Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Johansson EW, Lindsjö C, Weiss DJ, Nsona H, Selling KE, Lufesi N, Hildenwall H. Accessibility of basic paediatric emergency care in Malawi: analysis of a national facility census. BMC Public Health 2020; 20:992. [PMID: 32580762 PMCID: PMC7315502 DOI: 10.1186/s12889-020-09043-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 06/03/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Emergency care is among the weakest parts of health systems in low-income countries with both quality and accessibility constraints. Previous studies estimated accessibility to surgical or emergency care based on population travel times to nearest hospital with no assessment of hospital readiness to provide such care. We analysed a Malawi national facility census with comprehensive inventory audits and geocoded facility locations to identify hospitals equipped to provide basic paediatric emergency care with estimated travel times to these hospitals from non-equipped facilities and in relation to Malawi's population distribution. METHODS We analysed a Malawi national facility census in 2013-2014 to identify hospitals equipped to manage critically ill children according to an extended version of WHO Emergency Triage, Assessment and Treatment (ETAT) guidelines. These guidelines include 25 components including staff, transport, equipment, diagnostics, medications, fluids, feeds and consumables that defined an emergency-equipped hospital in our study. We estimated travel times to emergency-equipped hospitals from non-equipped facilities and relative to population distributions using geocoded facility locations and an established accessibility mapping approach using global road network datasets from OpenStreetMap and Google. RESULTS Four (3.5, 95% CI: 1.3-8.9) of 116 Malawi hospitals were emergency-equipped. Least available items were nasogastric tubes in 34.5% of hospitals (95% CI: 26.4-43.6), blood typing services (40.4, 95% CI: 31.9-49.6), micro nebulizers (50.9, 95% CI: 41.9-60.0), and radiology (54.2, 95% CI: 45.1-63.0). Nationally, the median travel time from non-equipped facilities to the nearest emergency-equipped hospital was 73 min (95% CI: 67-77) ranging 1-507 min. Approximately one-quarter (27%) of Malawians lived over 120 min from an emergency-equipped hospital with significantly better accessibility in Central than North and South regions (16% vs. 38 and 35%, p < 0.001). CONCLUSIONS There are unacceptable deficiencies in accessibility of basic paediatric emergency care in Malawi. Reliable supply chains for essential drugs and commodities are needed, particularly nasogastric tubes, asthma drugs and blood, along with improved capacity for time-sensitive referral. Further child mortality reductions will require substantial investments to expand basic paediatric emergency care into all Malawi hospitals for better managing critically ill children at highest mortality risk.
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Affiliation(s)
- Emily White Johansson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Akademiska Sjukhuset, SE-751 85, Uppsala, Sweden.
| | - Cecilia Lindsjö
- Department of Public Health Sciences, Global Health - Health System and Policy Research Group, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Daniel J Weiss
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7LF, UK
| | - Humphreys Nsona
- Ministry of Health, Integrated Management of Childhood Illness (IMCI) Unit, Lilongwe, Malawi
| | - Katarina Ekholm Selling
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Akademiska Sjukhuset, SE-751 85, Uppsala, Sweden
| | - Norman Lufesi
- Ministry of Health, Community Health Sciences Unit, Lilongwe, Malawi
| | - Helena Hildenwall
- Department of Public Health Sciences, Global Health - Health System and Policy Research Group, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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Abstract
Data on protocol biopsies (PBs) after pediatric kidney transplantation are rare.We evaluated 6-month post-transplantation renal function in 86 children after PB as observational study. Patients were divided into 3 groups:Glomerular filtration rate (GFR) and delta GFR were determined.PBs 6 months post-kidney transplantation did not influence the clinical course in stable pediatric patients and are therefore of questionable value. Decreased kidney function may however be stabilized by therapeutic intervention according to results of PB.
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Affiliation(s)
| | | | | | - Jan H. Bräsen
- Department of Pathology, Hannover Medical School, Hannover, Germany
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Abstract
BACKGROUND Specialist paediatric palliative care services are promoted as an important component of palliative care provision, but there is uncertainty about their role for children with cancer. AIM To examine the impact of specialist paediatric palliative care for children and young people with cancer and explore factors affecting access. DESIGN A mixed-methods systematic review and narrative synthesis (PROSPERO Registration No. CRD42017064874). DATA SOURCES Database (CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO) searches (2000-2019) identified primary studies of any design exploring the impact of and/or factors affecting access to specialist paediatric palliative care. Study quality was assessed using The Mixed Methods Appraisal Tool. RESULTS An evidence base of mainly low- and moderate-quality studies (n = 42) shows that accessing specialist paediatric palliative care is associated with less intensive care at the end of life, more advance care planning and fewer in-hospital deaths. Current evidence cannot tell us whether these services improve children's symptom burden or quality of life. Nine studies reporting provider or family views identified uncertainties about what specialist paediatric palliative care offers, concerns about involving a new team, association of palliative care with end of life and indecision about when to introduce palliative care as important barriers to access. There was evidence that children with haematological malignancies are less likely to access these services. CONCLUSION Current evidence suggests that children and young people with cancer receiving specialist palliative care are cared for differently. However, little is understood about children's views, and research is needed to determine whether specialist input improves quality of life.
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Affiliation(s)
- Johanna Taylor
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
| | - Alison Booth
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
| | - Bryony Beresford
- Martin House Research Centre, University of York, York, UK
- Social Policy Research Unit, University of York, York, UK
| | - Bob Phillips
- Martin House Research Centre, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
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44
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Johnson SC, Kosut J, Ching N. Disseminated Cat Scratch Disease in Pediatric Patients in Hawai'i. Hawaii J Health Soc Welf 2020; 79:64-70. [PMID: 32490388 PMCID: PMC7260883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Cat scratch disease is known to be a generally benign, self-resolving illness associated with non-specific symptoms, including lymphadenopathy, fever, fatigue, anorexia, and headaches. However, it can also cause disseminated disease with a wide range of manifestations, including liver and spleen microabscesses, osteomyelitis, encephalitis, and uveitis. Eighteen pediatric cases of disseminated cat scratch disease at a single center in Hawai'i are described. This case series emphasizes the importance of disease recognition and use of appropriate diagnostic tools and disease management. The disease burden of pediatric patients with disseminated cat scratch disease in the state of Hawai'i has a high incidence and should be considered in pediatric patients with prolonged febrile illnesses.
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Affiliation(s)
| | - Jessica Kosut
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI
| | - Natascha Ching
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI
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Hamby T, Pueringer MR, Noorani S, Khanna A, Barrow J, Razzouk R. Time to referral to a nephrology clinic for pediatric hypertension. Pediatr Nephrol 2020; 35:907-910. [PMID: 32060821 DOI: 10.1007/s00467-020-04490-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/07/2020] [Accepted: 01/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rates of pediatric hypertension have increased, but adherence to the current diagnostic criteria for hypertension (HTN) in pediatrics is not well known. We investigated the timeline and predictors of time to referral for those referred to nephrology for elevated blood pressure (EBP). METHODS A retrospective study was conducted on patients, aged 3-18 years, referred to a nephrology clinic for EBP over a 3-year period. Patients were excluded if they were referred previously, were referred for other conditions, or did not have ≥ 1 prior visit with EBP. Analyses were performed to determine whether sex, age, ethnicity, socioeconomic status, and obesity predicted number of prior visits with EBP and time to referral. RESULTS There were 120 patients (64% male; 53% obese) included and 82 (68%) had ≥ 3 prior visits with EBP ≥ 95%. Medians were as follows: 15.08 years of age at referral; 5 visits with EBP and 3.45 years from first EBP ≥ 90%; 4 visits with EBP and 1.42 years from third EBP ≥ 95%. No variables significantly predicted number of prior visits with EBP or time to referral from the first EBP. Starting with the third EBP ≥ 95%, only obesity significantly predicted number of prior visits and time to referral: Obese patients had more visits (p = 0.01), and took longer to be referred (p = 0.03) than healthy patients. CONCLUSION Patients with EBP were generally not referred to nephrology promptly, which was especially true for obese patients. Further research is needed to identify interventions to improve time to referral for EBP.
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Affiliation(s)
- Tyler Hamby
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA.
- Department of Research Operations, Cook Children's Health Care System, 801 7th Ave., Fort Worth, TX, 76104, USA.
| | - Matthew R Pueringer
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Sahil Noorani
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Alisha Khanna
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Julie Barrow
- Department of Nephrology, Cook Children's Health Care System, Fort Worth, TX, USA
| | - Randa Razzouk
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX, USA
- Department of Nephrology, Cook Children's Health Care System, Fort Worth, TX, USA
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46
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Purohit PJ, Yamamoto L, Tanaka LY, Xoinis K, Harrington J, Chang R, Feng A. Pediatric Code Blue: How Prepared Are We? A Self-Efficacy Assessment Project. Hawaii J Health Soc Welf 2020; 79:122-126. [PMID: 32490399 PMCID: PMC7260870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Pediatric advanced life support (PALS) recertification every two years is inadequate to maintain proficiency. The authors hypothesized that a standardized, recurring curriculum may enhance retention of cardiopulmonary resuscitation (CPR) skills. Monthly in situ mock code training and an annual online self-directed learning module were implemented for pediatric intensive care unit nurses, pediatric residents, and respiratory therapists at a women and children's hospital. The in situ mock codes were linked to PALS training self-efficacy (pre- and post-mock code) and feedback related surveys. CPR knowledge was assessed using an online module with pre- and post-tests. A total of 82 in situ mock code surveys and 137 online modules were completed over a 20-month period. Medical knowledge (P < .05 for 7/10 questions) and self-confidence improved (P < .001. Several staff reported a negative impact on their patient care assignments in order to participate in the mock code. However, a significant number of participants (65%) concurred with the benefits of monthly mock codes. The curriculum improved CPR efficacy by improving knowledge-based retention as well as self-confidence in their skills.
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Affiliation(s)
- Prashant J. Purohit
- Department of Pediatrics and Division of Pediatric Critical Care at Kapi‘olani Medical Center for Women and Children, Honolulu, HI and Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Laurie Yamamoto
- Department of Pediatrics and Division of Pediatric Critical Care at Kapi‘olani Medical Center for Women and Children, Honolulu, HI and Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Len Y. Tanaka
- Department of Pediatrics and Division of Pediatric Critical Care at Kapi‘olani Medical Center for Women and Children, Honolulu, HI and Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Konstantine Xoinis
- Department of Pediatrics and Division of Pediatric Critical Care at Kapi‘olani Medical Center for Women and Children, Honolulu, HI and Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - John Harrington
- Department of Pediatrics and Division of Pediatric Critical Care at Kapi‘olani Medical Center for Women and Children, Honolulu, HI and Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Rupert Chang
- Department of Pediatrics and Division of Pediatric Critical Care at Kapi‘olani Medical Center for Women and Children, Honolulu, HI and Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Andrew Feng
- Department of Pediatrics and Division of Pediatric Critical Care at Kapi‘olani Medical Center for Women and Children, Honolulu, HI and Department of Pediatrics, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
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Abstract
OBJECTIVES The optimal size of the health workforce for children's surgical care around the world remains poorly defined. The goal of this study was to characterise the surgical workforce for children across Brazil, and to identify associations between the surgical workforce and measures of childhood health. DESIGN This study is an ecological, cross-sectional analysis using data from the Brazil public health system (Sistema Único de Saúde). SETTINGS AND PARTICIPANTS We collected data on the surgical workforce (paediatric surgeons, general surgeons, anaesthesiologists and nursing staff), perioperative mortality rate (POMR) and under-5 mortality rate (U5MR) across Brazil for 2015. PRIMARY AND SECONDARY OUTCOME MEASURES We performed descriptive analyses, and identified associations between the workforce and U5MR using geospatial analysis (Getis-Ord-Gi analysis, spatial cluster analysis and linear regression models). FINDINGS There were 39 926 general surgeons, 856 paediatric surgeons, 13 243 anaesthesiologists and 103 793 nurses across Brazil in 2015. The U5MR ranged from 11 to 26 deaths/1000 live births and the POMR ranged from 0.11-0.17 deaths/100 000 children across the country. The surgical workforce is inequitably distributed across the country, with the wealthier South and Southeast regions having a higher workforce density as well as lower U5MR than the poorer North and Northeast regions. Using linear regression, we found an inverse relationship between the surgical workforce density and U5MR. An U5MR of 15 deaths/1000 births across Brazil is associated with a workforce level of 5 paediatric surgeons, 200 surgeons, 100 anaesthesiologists or 700 nurses/100 000 children. CONCLUSIONS We found wide disparities in the surgical workforce and childhood mortality across Brazil, with both directly related to socioeconomic status. Areas of increased surgical workforce are associated with lower U5MR. Strategic investment in the surgical workforce may be required to attain optimal health outcomes for children in Brazil, particularly in rural regions.
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Affiliation(s)
| | - Joao Vissoci
- Duke University Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Nubia Rocha
- Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Dan Poenaru
- Pediatric Surgery, Montreal Children\'s Hospital Research Institute, Montreal, Quebec, Canada
| | - Mark Shrime
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otology and Laryngology and Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Emily R Smith
- Duke University Global Health Institute, Duke University, Durham, North Carolina, USA
- Health, Human Performance, and Recreation, Baylor University, Waco, Texas, USA
| | - Henry E Rice
- Duke University Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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48
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Sharma N, Negandhi H, Kalra S, Gupta P. Prophylactic Vitamin D Supplementation Practices for Infants: A Survey of Pediatricians From Delhi. Indian Pediatr 2020; 57:259-260. [PMID: 32198869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This survey was conducted among 125 pediatricians working in public and private child care facilities of Delhi. Prescription rates of routine vitamin D supplementation varied between 70-100% for various groups of infants, despite non-availability of government guidelines. Pediatricians in private practice more frequently prescribed vitamin D supplementation to term healthy infants as compared to government pediatrician (91.4% vs 71.6%; P=0.005).
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Affiliation(s)
- Nisha Sharma
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Delhi.
| | - Himanshu Negandhi
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Delhi
| | | | - Piyush Gupta
- Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi
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49
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Bretherton I, Grossmann M, Leemaqz SY, Zajac JD, Cheung AS. Australian endocrinologists need more training in transgender health: A national survey. Clin Endocrinol (Oxf) 2020; 92:247-257. [PMID: 31845345 DOI: 10.1111/cen.14143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE An increasing number of trans and gender diverse (TGD) individuals are seeking gender-affirming hormone therapy for gender transition. Little is known about the levels of training, experience and confidence of endocrinologists in providing care and lack of training and experience is a potential barrier to individuals seeking appropriate and timely health care. We aimed to assess the level of training and confidence of Australian endocrinologists and trainees in the endocrine management of trans and gender diverse individuals in a representative sample. DESIGN Endocrinologist and trainee members of the Endocrine Society of Australia were invited to participate in an anonymous 14-item survey. Of the 545 members, 147 clinicians (95 adult endocrinologists, 2 paediatric endocrinologists and 50 endocrinology trainees) responded. RESULTS When presented with a scenario regarding commencement of gender-affirming hormone therapy, only 19% felt confident providing clinical care to TGD individuals. Compared to other areas of endocrinology, 75% felt less or not at all confident in commencing hormone therapy in a TGD patient. No training in transgender medicine during medical school or during their endocrinology training was reported by 96% and 60%, respectively. There were significantly higher levels of confidence in all aspects including performing a consultation in those who had previously seen a TGD patient. The desire for more training was high (91%). CONCLUSIONS These results highlight the shortfall in training in TGD health care amongst endocrinologists and show that prior clinical experience is associated with higher levels of confidence. Medical schools and endocrinology fellowship training programmes will need to adapt to meet the increasing demand for quality TGD health services.
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Affiliation(s)
- Ingrid Bretherton
- Department of Endocrinology, Austin Health, Heidelberg, Vic., Australia
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Vic., Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Heidelberg, Vic., Australia
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Vic., Australia
| | - Shalem Y Leemaqz
- Robinson Research Institute, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Jeffrey D Zajac
- Department of Endocrinology, Austin Health, Heidelberg, Vic., Australia
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Vic., Australia
| | - Ada S Cheung
- Department of Endocrinology, Austin Health, Heidelberg, Vic., Australia
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Vic., Australia
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50
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Wagner RS. Where Are Pediatric Ophthalmologists Submitting Their Manuscripts for Publication? J Pediatr Ophthalmol Strabismus 2020; 57:77. [PMID: 32203589 DOI: 10.3928/01913913-20200218-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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