1
|
Rojas CR, Chapman J, Regier D. Hyperammonemia in the Pediatric Emergency Department. Pediatr Emerg Care 2024; 40:156-161. [PMID: 38295195 DOI: 10.1097/pec.0000000000003121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
ABSTRACT Hyperammonemia is a serious clinical condition associated with significant morbidity and mortality. In the pediatric population, this is often caused by urea cycle disorders, acute liver failure, or other less common underlying etiologies. Children and teens with hyperammonemia can have a broad range of clinical findings, including vomiting, respiratory distress, and changes in mental status. As ammonia levels worsen, this presentation can progress to respiratory failure, encephalopathy, cerebral edema, seizures, and death. Given the risk of neurologic damage, timely identification and management of hyperammonemia is critical and includes initial resuscitation, early consultation with subspecialists, and initiation of appropriate therapies. It is important for pediatric emergency medicine providers to understand the clinical findings, causes, diagnosis, and management of hyperammonemia because they play a key role in the provision of effective, multidisciplinary care of these patients.
Collapse
|
2
|
Atabaki SM, Shur NE, Munoz RA, Bhuvanendran S, Sable C, Rojas CR, Lopez-Magallon AJ, Clarke JC, Sabouriane CE, Krishnan A, Wessel DL. Direct-to-patient telemedicine: Expanding access to regional pediatric specialty care. J Investig Med 2024; 72:248-255. [PMID: 38102744 DOI: 10.1177/10815589231222197] [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] [Indexed: 12/17/2023]
Abstract
Telemedicine is seen as a useful tool in reducing gaps in health care but this technology-enabled care can also exacerbate health inequity if not implemented with a focus on inclusivity. Though many studies have reported improvements as well as exacerbation of disparities in access to care in their telehealth programs, there does not exist a common evaluation tool to assess these programs. To mitigate the impact of COVID-19 on health care workers and protect medically vulnerable children, in March 2020 we expanded our pre-established specialty and subspecialty direct-to-patient pediatric telemedicine program in a high volume urban pediatric health system. Our program aimed to prevent disparities in pediatric health care. In this study, using a "Pillars of Access" approach as a model to evaluate impact and access to care of our direct-to-patient telemedicine program, we analyzed the patients that were seen pre-COVID versus post-COVID. Our study demonstrated an increase in telemedicine visits for patients from diverse socioeconomic and racial backgrounds, and geographically underserved communities. We also observed an increase in telemedicine visits for mental health complaints and for certain categories of high-risk patients. This study was not designed to identify language and cultural barriers to telemedicine. Future identification of these specific barriers is needed. The tool to evaluate telehealth impact/access to care through a "Pillars of Access" approach presented here could serve as a model for implementation of telehealth programs. Our study highlights telemedicine programs as a mechanism to address healthcare inequity and overcome barriers to care.
Collapse
Affiliation(s)
| | | | | | | | - Craig Sable
- Children's National Hospital, Washington, DC, USA
| | | | | | | | | | | | | |
Collapse
|
3
|
Berkowitz D, Cohen JS, McCollum N, Rojas CR, Chamberlain JM. Delays in treatment and disposition attributable to undertriage of pediatric emergency medicine patients. Am J Emerg Med 2023; 74:130-134. [PMID: 37826993 DOI: 10.1016/j.ajem.2023.09.054] [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: 07/13/2023] [Revised: 09/20/2023] [Accepted: 09/30/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Triage, the initial assessment and sorting of patients in the Emergency Department (ED), determines priority of evaluation and treatment. Little is known about the impact of undertriage, the underestimation of disease severity at triage, on clinical care in pediatric ED patients. We evaluate the impact of undertriage on time to disposition and treatment decisions in pediatric ED patients. METHODS This was a case control study of ED visits for patients <22 years of age, with an assigned Emergency Severity Index (ESI) score of 4 or 5, and associated hospital admission, nebulized treatment, supplemental oxygen, and/or intravenous (IV) line placement, between January 1, 2018, to June 30, 2022. Controls were sampled from a pool of patient visits with an ESI score of 3, matched by intervention, disposition, and date and hour of arrival. Primary outcome measures were time to order of intervention (nebulized treatment, oxygen administration, or IV placement) and time to disposition decision. A secondary outcome measure was return visits requiring admission or emergency intervention within 14 days of the index visit. Continuous variables (time to orders) were analyzed using Wilcoxon rank sum test and dichotomous outcomes (return visits) were compared using odds ratios with 95% confidence intervals. Analysis was performed with Python v3.10. RESULTS The final analysis included 7245 undertriaged patients. Undertriaged patients had longer times to orders for nebulized treatments, (p < 0.001) IV placement, (p < 0.001) and admission (p < 0.001) when compared to controls. There were no significant differences in time to supplemental oxygen delivery and time to discharge compared to controls. Undertriaged patients were more likely to experience a return visit requiring admission or emergency intervention (OR 3.74, 95% CI 3.32,4.22). CONCLUSIONS Undertriage in the pediatric ED is associated with delays in care and disposition decisions and increases likelihood of return visits.
Collapse
Affiliation(s)
- Deena Berkowitz
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.
| | - Joanna S Cohen
- Division of Pediatric Emergency Medicine, Johns Hopkins University, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nichole McCollum
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
| | - Christina R Rojas
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
| |
Collapse
|
4
|
Gula AL, Merkel E, Bouchelle Z, Nelin T, Rojas CR, Hwang J, Johnson V, Ronan J, Bamat T. Primary Palliative Care for Pediatric Residents: A Curricular Framework and Pilot. Acad Pediatr 2023; 23:1133-1137. [PMID: 36935040 DOI: 10.1016/j.acap.2023.03.006] [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: 09/15/2022] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/21/2023]
Abstract
PROBLEM Palliative care (PC) is high-value, holistic care for a child and their family across the entire arc of an illness. All physicians should be competent in symptom management and providing goal-concordant care that acknowledges the quality of life; however, there is insufficient education in pediatric residency to develop competence in basic or ..úPrimary..Ñ PC. APPROACH We completed a needs assessment and developed a longitudinal, comprehensive, and integrated primary PC curriculum for pediatric residents with the goal of developing foundational primary PC skills regardless of eventual career trajectory. After 1 year of implementation, we assessed resident comfort with primary PC skills via a retrospective pre-post survey. OUTCOMES We found a statistically significant (P.ß<.ß.05) increase in residents... comfort with pain management, delivering serious news, and discussing goals of care. An increase in comfort with the management of other symptoms was not statistically significant. NEXT STEPS After 1 year of implementation, residents describe an increase in comfort with primary PC skills. The next steps include more rigorous evaluation and expansion to include more education in medical ethics. While the educational need is universal, resident needs are constantly evolving and each institution should tailor this curriculum to fit their specific trainee needs and institutional expertise.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Tara Bamat
- Children...s Hospital of Philadelphia, Pa.
| |
Collapse
|
5
|
Rojas CR, Chamberlain JM, Cohen JS, Badolato GM, Cook LJ, Goyal MK, Berkowitz D. Undertriage for Children With Caregivers Preferring Languages Other Than English. Pediatrics 2023:191273. [PMID: 37190962 DOI: 10.1542/peds.2022-059386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES Undertriage, the underestimation of acuity, can result in delayed care and potential morbidity in the emergency department (ED). Although inequities in ED care based on language preference have been noted, little is known about its association with undertriage. We evaluated for differences in undertriage based on caregiver language preference. METHODS This was a retrospective cross-sectional study of patients aged younger than 21 years, triaged as Emergency Severity Index (ESI) level 4 or 5 (nonurgent), to the pediatric ED from January 1, 2019, through January 31, 2021. Indicators of undertriage were defined as hospital admission, significant ED resource use, or return visits with admission. We used logistic regression with generalized estimating equations to measure the association of preferred language with undertriage. RESULTS Of 114 266 ED visits included in the study, 22 525 (19.8%) represented patients with caregivers preferring languages other than English. These children were more likely to experience undertriage compared with those with caregivers preferring English (3.7% [English] versus 4.6% [Spanish] versus 5.9% [other languages]; Spanish versus English: odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2-1.4] and other languages versus English: OR, 1.6; 95% CI, 1.2-2.2). Differences remained after adjusting for sex, insurance, mode of arrival, and clustering by triage nurse (Spanish versus English: adjusted OR, 1.3; 95% CI, 1.3-1.5) and other languages versus English: adjusted OR, 1.6; 95% CI, 1.2-2.2). CONCLUSIONS Children accompanied by caregivers preferring languages other than English are more likely to be undertriaged in the pediatric ED. Efforts to improve the triage process are needed to promote equitable care for this population.
Collapse
Affiliation(s)
- Christina R Rojas
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; and
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; and
| | - Joanna S Cohen
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; and
| | - Gia M Badolato
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; and
| | - Lawrence J Cook
- University of Utah Department of Pediatrics, Salt Lake City, Utah
| | - Monika K Goyal
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; and
| | - Deena Berkowitz
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; and
| |
Collapse
|
6
|
Rojas CR, Coffin A, Taylor A, Ortiz P, Jenicek G, Hart J, Callahan JM, Shaw KN. Resident Communication With Patients and Families Preferring Languages Other Than English. Hosp Pediatr 2023:191228. [PMID: 37125495 DOI: 10.1542/hpeds.2022-007003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVES Patients and families preferring languages other than English (LOE) often experience inequitable communication with their health care providers, including the underutilization of professional interpretation. This study had 2 aims: to characterize resident-perceived communication with families preferring LOE and to evaluate the impact of language preference on frequency of resident interactions with hospitalized patients and families. METHODS This was a cross-sectional study at a quaternary care children's hospital. We developed a questionnaire for residents regarding their interactions with patients preferring LOE. We concurrently developed a communication tracking tool to measure the frequency of resident communication events with hospitalized patients. Data were analyzed with logistic and Poisson regression models. RESULTS Questionnaire results demonstrated a high level of resident comfort with interpretation, though more than 30% of residents reported "sometimes" or "usually" communicating with families preferring LOE without appropriate interpretation (response rate, 47%). The communication tracking tool was completed by 36 unique residents regarding 151 patients, with a 95% completion rate. Results demonstrated that patients and families preferring LOE were less likely to be present on rounds compared with their counterparts preferring English (adjusted odds ratio, 0.17; 95% confidence interval [CI], 0.07-0.39). Similarly, patients and families preferring LOE were less likely to receive a resident update after rounds (adjusted odds ratio, 0.29; 95% CI, 0.13-0.62) and received fewer resident updates overall (incidence rate ratio, 0.45; 95% CI, 0.30-0.69). CONCLUSIONS Hospitalized patients and families preferring LOE experience significant communication-related inequities. Ongoing efforts are needed to promote equitable communication with this population and should consider the unique role of residents.
Collapse
Affiliation(s)
- Christina R Rojas
- Department of Pediatrics
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia; and
| | | | | | | | | | - Jessica Hart
- Department of Pediatrics
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Callahan
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathy N Shaw
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Rojas CR, Moore A, Coffin A, McClam C, Ehritz C, Hogan A, Hart J, Galligan MM. Medication Rounds: A Tool to Promote Medication Safety for Children with Medical Complexity. Jt Comm J Qual Patient Saf 2023; 49:226-234. [PMID: 36775713 DOI: 10.1016/j.jcjq.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
Children with medical complexity (CMC) often have lengthy medication lists and are at risk of experiencing suboptimal medication management. This tool tutorial describes a novel and pragmatic strategy for the development and implementation of medication rounds, a model that promotes medication safety for hospitalized CMC. An interprofessional group designed and implemented a pharmacy-led medication rounding care model, in which clinicians and pharmacists partner weekly to conduct reviews of all patient medications on a general pediatrics CMC team using a comprehensive checklist. This approach fosters medication safety for hospitalized CMC and could be adapted to other complex inpatient populations.
Collapse
|
8
|
Rojas CR. Allyship and Admissions Amidst Racism. Acad Pediatr 2022; 22:171-172. [PMID: 34348170 DOI: 10.1016/j.acap.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Christina R Rojas
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa.
| |
Collapse
|
9
|
Rojas CR. An Unspoken Inequity: Communication With Patients and Families With Limited English Proficiency. Hosp Pediatr 2021; 11:e126-e128. [PMID: 34583320 DOI: 10.1542/hpeds.2021-005940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Christina R Rojas
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Abstract
OBJECTIVE The attention towards optimal signals for measuring electrical bioimpedance (EBI) has increased recently due to the many advantages they offer such as, for example, reduced measuring time. Here, the design of a three-harmonic optimized multisine input power spectrum for measuring bioimpedance is considered. APPROACH The approach is based on designing the input power spectrum multisine excitation by optimizing a scalar function of the information matrix using the Fricke-Morse model. MAIN RESULTS Simple analytical equations are provided that can be adopted by the reader to optimize the multisine input power spectrum to satisfy any specific application-related EBI measurement. SIGNIFICANCE The presented signal may be a good choice of excitation signal in EBI applications where optimal excitation power spectrum is desired.
Collapse
Affiliation(s)
- H Kwon
- College of Science & Technology, Yonsei University, Wonju 26493, Republic of Korea
| | | | | | | |
Collapse
|
11
|
Satelli A, Batth I, Brownlee Z, Mitra A, Zhou S, Noh H, Rojas CR, Li H, Meng QH, Li S. EMT circulating tumor cells detected by cell-surface vimentin are associated with prostate cancer progression. Oncotarget 2018; 8:49329-49337. [PMID: 28521303 PMCID: PMC5564771 DOI: 10.18632/oncotarget.17632] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 04/21/2017] [Indexed: 01/22/2023] Open
Abstract
Recent advances in the field of circulating tumor cells (CTC) have shown promise in this liquid biopsy-based prognosis of patient outcome. However, not all of the circulating cells are tumor cells, as evidenced by a lack of tumor-specific markers. The current FDA standard for capturing CTCs (CellSearch) relies on an epithelial marker and cells captured via CellSearch cannot be considered to have undergone EMT. Therefore, it is difficult to ascertain the presence and relevance of any mesenchymal or EMT-like CTCs. To address this gap in technology, we recently discovered the utility of cell-surface vimentin (CSV) as a marker for detecting mesenchymal CTCs from sarcoma, breast, and colon cancer. Here we studied peripheral blood samples of 48 prostate cancer (PCA) patients including hormone sensitive and castration resistant sub-groups. Blood samples were analyzed for three different properties including our own CSV-based CTC enumeration (using 84-1 mAb against CSV), CellSearch-based epithelial CTC counts, and serum prostate-specific antigen (PSA) quantification. Our data demonstrated that in comparison with CellSearch, the CSV-based method had greater sensitivity and specificity. Further, we observed significantly greater numbers of CTCs in castration resistant patients as measured by our CSV method but not CellSearch. Our data suggests CSV-guided CTC enumeration may hold prognostic value and should be further validated as a possible measurement of PCA progression towards the deadly, androgen-independent form.
Collapse
Affiliation(s)
- Arun Satelli
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Izhar Batth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zachary Brownlee
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abhishek Mitra
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shouhao Zhou
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hyangsoon Noh
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christina R Rojas
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Heming Li
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Qing H Meng
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shulin Li
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
12
|
Ugarte SU, Rojas CR, Herrera C. High-frequency oscillatory ventilation in adults: experience in Chile. Crit Care 2011. [PMCID: PMC3066867 DOI: 10.1186/cc9613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
13
|
Montilla Y, Rojas CR, Senges E, Bongioanni H, Lindado CE, Diaz R, Sainz O. [Adenocarcinoma of the adrenal gland. An accidental finding. Report of a case and review of the literature]. G E N 1993; 47:105-10. [PMID: 8112534] [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] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Carcinoma of the adrenal gland is a very unusual entity with a very poor prognosis. Even though the great advances in imaging during the last few years, the possibility of an early diagnosis of these tumors has not been reached. In a high percentage of cases, the diagnosis was made as incidentalomas while doing some complementary tests. A multidisciplinary team is necessary for the diagnosis and management of this pathology. We report a case of non functional adrenal cortex carcinoma, it's diagnosis, management and evolution.
Collapse
Affiliation(s)
- Y Montilla
- Servicio de Gastroenterología, Hospital Carlos J. Bello, Cruz Roja Venezolana, Caracas
| | | | | | | | | | | | | |
Collapse
|