Infant Safe Sleep in the District of Columbia: Better for Both

Sudden unexpected infant death (SUID) rates within the District of Columbia (DC) vary, with rates 3 times higher in certain geographical areas than the cumulative rate in DC and 7 times higher than the national rate. The majority SUIDs are due to unsafe sleep practices. Although safe sleep education and resources are available in these areas, the high sleep-related infant mortality suggests unmet barriers to infant safe sleep. We sought to investigate potential contributions to local infant mortality through focus groups regarding infant sleep practices among DC caregivers. In this qualitative study, caregivers were probed regarding barriers and facilitators of infant sleep practices. Data were collected until thematic saturation was reached, then coded. Themes were developed and revised in an iterative manner. Fifteen caregivers participated in three focus groups. Themes included sources of infant sleep knowledge, challenges for infant sleep, and motivators for infant sleep choice. All caregivers reported knowledge of safe sleep practices. Infant sleep practices varied, and included unsafe practices such as bed sharing, co-sleeping, and use of swings or bouncers for infant sleep. Challenges of adhering to safe sleep practices included infant needs, competing family demands, the overwhelming nature of newborn sleep, threats, and conflicting information. Motivators for infant sleep practices included better sleep, convenience, safety, tradition, and needs of the infant and caregiver. Although caregivers report knowledge of safe sleep recommendations, actual infant sleep practices vary and include unsafe sleep practices. More focused interventions are needed to address this gap between safe sleep knowledge and practice.

Characteristics and Geographic Variation in Sudden Unexpected Infant Deaths in the District of Columbia

ABSTRACT

Sleep-related infant death is a major cause of infant mortality in the United States. In the District of Columbia, infant mortality varies widely among regions (2 to 14 per 1000 live births). The study objectives were to analyze the patient characteristics and related variables to sudden unexpected infant deaths at 2 pediatric emergency department (ED) sites and the geographic patterns of infant deaths and their relationship to social vulnerability. This retrospective cohort study examined infants under 1 year of age presenting with cardiac arrest at 2 ED sites from 2010 to 2020. Analysis showed 81 deaths with a median population age of 75 days (SD, 46 days). The most frequent demographics of deceased patients were African American Black (89%) with Medicaid insurance (63%), born at term gestation (66%), and without comorbidity (60%). The cause of death was most frequently undetermined (32%) and asphyxia (31%). Most cases involved bed-sharing (63%), despite more than half of those cases having a known safe sleep surface available. Infant death location showed that most deaths occurred in areas with the highest social vulnerability index, including near a community ED location. Understanding the etiologies of this geographic variability may enhance sleep-related infant death prevention strategies.

Liquid Nicotine, E-Cigarettes, and Vaping: Information for the Pediatric Emergency Medicine Provider

ABSTRACT

E-cigarettes, or electronic cigarettes, are electronic nicotine delivery systems that are marketed as a healthier alternative to tobacco cigarettes. There has been an exponential increase in their use among youth since their introduction to the United States market in 2007. With increased use and popularity, there has been an increase in calls to poison control centers regarding liquid nicotine toxicity in children and adolescents. Recent US Food and Drug Administration and other federal regulations of e-cigarettes have attempted to limit availability to youth. This article reviews trends in e-cigarette use among youth, the background and mechanism of action of e-cigarettes, liquid nicotine toxicity, management of liquid nicotine toxicity, and recent policy updates regarding e-cigarettes.

Variations in Safe Sleep Practices and Beliefs: Knowledge is not Enough

OBJECTIVES

Sleep-related infant deaths in the District of Columbia (DC) varies, with rates in certain geographical areas three times higher than DC and seven times higher than the national average. We sought to understand differences in infant sleep knowledge, beliefs, and practices between families in high-risk infant mortality and low-risk infant mortality areas in DC.

METHODS

Caregivers of infants presenting to the emergency department were surveyed. The associations between location and safe sleep knowledge, beliefs, and practices were analyzed.

RESULTS

Two hundred and eighty-four caregivers were surveyed; 105 (37%) were from the high-risk infant mortality area. The majority (68%) of caregivers reported placing their infant to sleep on their backs, sleeping in a crib, bassinet, or pack and play (72%), and were familiar with the phrase "safe sleep" (72%). Caregivers from the high-risk infant mortality area were more likely to report that their infants sleep in homes other than their own (aOR 1.53; 95% CI 1.23, 2.81) and other people took care of their infants while sleeping (aOR 1.76; 95% CI 1.17, 3.19), adjusting for race/ethnicity, education, marital status, and help with childcare. No differences in safe sleep knowledge, beliefs, and practices were present.

CONCLUSIONS FOR PRACTICE

Infants from the high-risk infant mortality area were more likely to sleep in homes other than their own and have other caretakers while sleeping. Lack of differences in caregiver awareness of safe sleep recommendation or practices suggests effective safe sleep messaging. Outreach to other caregivers and study of unmet barriers is needed.

Triple threat: New presentation with diabetic ketoacidosis, COVID-19, and cardiac arrhythmias

Patients with diabetes have increased susceptibility to infection with Severe acute respiratory syndrome-coronavirus 2 and increased morbidity and mortality from Coronavirus disease 2019 (COVID-19) infection. Mortality from COVID-19 is sometimes caused by cardiac arrhythmias. Electrolyte disturbances in patients with diabetic ketoacidosis (DKA) can increase the risk of cardiac arrhythmias. Despite these correlations, little has been reported about the co-incidence of these three conditions: COVID-19, DKA and cardiac arrhythmias. In this case report we describe two children with COVID-19, new-onset DKA and cardiac arrhythmias. These cases emphasize the importance of close cardiac and electrolyte monitoring in patients with COVID-19 infection.

So much nuance: A qualitative analysis of parental perspectives on child passenger safety

OBJECTIVE

To explore barriers and facilitators to optimal child restraint system (CRS) use for diverse parents of newborn infants and to obtain input from parents on the use of technology-assisted remote car seat checks as tools for promoting optimal CRS use.

METHODS

Parents were recruited using purposive sampling. Interviews were conducted with English- or Spanish-speaking parents with a full term newborn and regular access to a car. Interviews were conducted by phone, and recorded and transcribed verbatim. Interviews were conducted until thematic saturation was reached. Data were organized for analysis using Atlas.ti, and codes grouped by theme using constant comparison.

RESULTS

30 parents were enrolled. Barriers and facilitators to optimal CRS use were classified into three themes, as were thoughts on the pros and cons regarding remote car seat checks. Themes on barriers and facilitators included motor vehicle and CRS features (such as age and size of the motor vehicle and presence of the Lower Anchors and Tethers for Children LATCH system), resources (availability, accessibility, and accuracy of resources), and parental factors (parental emotions and characteristics). Themes related to pros and cons of remote car seat checks included the ability (and challenge) of remote car seat checks to identify and correct errors, the potential use of remote car seat checks in certain situations (such as CRS transitions and periods of growth), and convenience of remote car seat checks (including increased availability and ease of access). Subthemes with further detail were arranged within each theme identified.

CONCLUSION

From a parent perspective, there are several identified barriers and facilitators of optimal CRS use. Although car seat checks were identified as a resource, in-person accessibility was an issue, and there were mixed opinions on technology-assisted remote car seat checks. These results provide a foundation for additional study on targeted interventions, including remote interventions for which there is an increased need due to the COVID-19 pandemic.

The Joys and Frustrations of Breastfeeding and Rooming-In Among Mothers With Opioid Use Disorder: A Qualitative Study

OBJECTIVES

To investigate perspectives of mothers with opioid use disorder regarding breastfeeding and rooming-in during the birth hospitalization and identify facilitators and barriers.

METHODS

We conducted in-depth qualitative interviews with 25 mothers with opioid use disorder 1-12 weeks after delivery. Grounded theory analysis was used until thematic saturation was reached. Findings were triangulated, with experts in the field and a subset of informants themselves, to ensure data reliability.

RESULTS

Among 25 infant-mother dyads, 36% of infants required pharmacologic treatment, 72% of mothers initiated breastfeeding, and 40% continued until discharge. We identified the following themes: (1) information drives maternal feeding choice; (2) the hospital environment is both a source of support and tension for mothers exerting autonomy in the care of their infants; (3) opioid withdrawal symptoms negatively impact breastfeeding; (4) internal and external stigma negatively impact mothers' self-efficacy; (5) mothers' histories of abuse and trauma affect their feeding choice and bonding; (6) mothers' recovery makes caring for their infants emotionally and logistically challenging; and (7) having an infant is a source of resilience and provides a sense of purpose for mothers on their path of recovery.

CONCLUSIONS

Future interventions aimed at increasing breastfeeding and rooming-in during the birth hospitalization should focus on education regarding the benefits of breastfeeding and rooming-in, supporting mothers' autonomy in caring for their infants, minimizing stigma, and maximizing resilience.

Impact of Parental Presence at Infants' Bedside on Neonatal Abstinence Syndrome

BACKGROUND

Despite increased incidence of neonatal abstinence syndrome (NAS) over the past decade, minimal data exist on benefits of parental presence at the bedside on NAS outcomes.

OBJECTIVE

To examine the association between rates of parental presence and NAS outcomes.

METHODS

This was a retrospective, single-center cohort study of infants treated pharmacologically for NAS using a rooming-in model of care. Parental presence was documented every 4 hours with nursing cares. We obtained demographic data for mothers and infants and assessed covariates confounding NAS severity and time spent at the bedside. Outcomes included length of stay (LOS) at the hospital, extent of pharmacotherapy, and mean Finnegan withdrawal score. Multiple linear regression modeling assessed the association of parental presence with outcomes.

RESULTS

For the 86 mother-infant dyads, the mean parental presence during scoring was on average 54.4% (95% confidence interval [CI], 48.8%-60.7%) of the infant's hospitalization. Maximum (100%) parental presence was associated with a 9 day shorter LOS (r = -0.31; 95% CI, -0.48 to -0.10; P < .01), 8 fewer days of infant opioid therapy (r = -0.34; 95% CI, -0.52 to -0.15; P < .001), and 1 point lower mean Finnegan score (r = -0.35; 95% CI, -0.52 to -0.15; P < .01). After adjusting for breastfeeding, parental presence remained significantly associated with reduced NAS score and opioid treatment days.

CONCLUSIONS

More parental time spent at the infant's bedside was associated with decreased NAS severity. This has important implications for clinical practice guidelines for NAS.

Abstract B87: The effect of imaging on clinical management of breast pain

Breast pain is a common complaint to both primary care and breast specialists. Current literature recommends imaging for women with breast pain to provide reassurance of benign etiology. The current study sought to determine if imaging is a valuable tool in providing reassurance for women with breast pain, through measuring the association between initial imaging in the evaluation of women with breast pain and subsequent clinical services utilization

From 2006–2009, 916 women were referred to an urban, Safety Net, diagnostic breast health practice for breast pain. We compared the subsequent clinical utilization of women who had imaging ordered at their initial visit to women who did not have imaging ordered. Clinical utilization was defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within the 12 months following the initial provider visit. The study population was stratified based on the presence or absence of clinical breast exam findings.

Sixty-percent of women referred for breast pain were age 40 or younger, 87% were from racial/ethnic minority groups, 45% were non-English speaking, and 73% had public or no health insurance. Twenty five percent of women had imaging ordered at initial provider visit for breast pain. Minority and non-English speaking women were less likely to receive initial imaging. Of those who received initial imaging, 75% had radiographic findings which required no additional follow-up, yet 98% returned for additional evaluation. In adjusted analyses, women with imaging ordered at initial provider visit had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). When the study population was stratified by clinical breast exam results, the risk-adjusted association between initial imaging and subsequent clinical services utilization remained. Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0) than women who did not initial imaging. Six cancers were diagnosed in the study population; yet imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification.

Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase diagnostic certainty in ruling out malignancy.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B87.

Abstract A26: Caseload for patient navigation: What is keeping navigators busy?

Patient navigation is an innovative type of care management designed to reduce cancer disparities. As many sites adopt this model of care, a frequent query is how to assess appropriate caseload for these new positions. While data on the effectiveness of patient navigation interventions appears promising, there is a lack of methods to assess appropriate caseload for optimal effect of navigator intervention. Boston University and its affiliated Community Health Centers (CHCs) is one of nine sites participating in the NCI CRCHD National Cancer Institute Patient Navigation Research Program (PNRP), which aims to evaluate whether navigation improves cancer outcomes.

The purpose of this study is to develop and describe the caseload across six CHCs participating in the Boston PNRP. Navigators target female patients with abnormal breast or cervical cancer screening. Review of the literature identified several concepts to consider in assessing caseload. We examined the following four factors at each navigation site: (1) absolute number of cases navigated, (2) total patient days in navigation, (3) total time spent navigating, and (4) total documented patient-navigator encounters.

Eligible participants were women over 18 with an abnormal mammogram or Pap test at the participating CHCs from 7/1/2007 through 6/31/2008. Patients were navigated until their screening abnormality was resolved with a definitive diagnosis (cancer or noncancer) or until the end of cancer treatment.

Across the six CHCs, the median number of patients navigated was 145 (range: 19-216). The median number of encounters per patient at each of the CHCs was 5 (range: 3-11). The median time spent navigating per patient was 135 minutes (range: 77-240). The median number of days in navigation per patient was 56 (range: 73-142). The number of active patients a navigator was tracking, on average, ranged from 7 to 53 patients per day (median: 38).

We conclude that measuring caseload is more complex than counting heads. The four descriptions of caseload provide different representations of navigator workload that vary among the six CHCs. Patient characteristics (age, race/ethnicity, language, insurance) were not associated with these measures of caseload. Due to the different constructs assessed in each measure, a single caseload score may not adequately reflect navigator workload. Next research steps will involve assessing the predictive ability of these constructs on outcomes to help determine an appropriate navigator caseload.

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A26.

Assessing youth risk behavior in a clinical trial setting: lessons from the infant health and development program

PURPOSE

The purpose of this article was to describe the use of the Youth Risk Behavior Surveillance System (YRBSS) with known 17-18-year-old patients in follow-up of a multisite randomized clinical trial, and to develop a new scoring algorithm indicating the degree of risk-taking behavior for between-group analyses.

METHODS

Seventy-five questions from the YRBSS were incorporated into the study questionnaire, with the development of safety plans to guide the disposition of participants. The YRBSS questions were grouped into two categories (with three subdomains each) named problem behaviors (conduct problems, sexual behavior, and suicide/hopelessness) and substance use (cigarettes, alcohol, and marijuana use), with scores for each subdomain indicating high, moderate, and low risk.

RESULTS

Of the 677 participants, the safety plan was activated 215 times for 199 (29.4%) of participants. Risk behaviors included binge drinking (149), alcohol/substance use and driving (41), depression (22), hopelessness (37), and suicidal ideation (13; all in the past). No emergency room evaluations were required. The subdomain scaling was analyzed by demographic characteristics, and findings were consistent with the literature; for example, higher rates of conduct problems in males, more suicidal ideation in females, greater sexual risk in African Americans, more substance use in males and whites, and more alcohol use in youth with mothers with higher levels of education.

CONCLUSIONS

YRBSS can be administered in a research setting with appropriate safety precautions. These results should provide a useful guide to the application of the YRBSS to other adolescent populations in the future.

Activation of the stress protein response prevents the development of pulmonary edema by inhibiting VEGF cell signaling in a model of lung ischemia-reperfusion injury in rats

Lung endothelial damage is a characteristic morphological feature of ischemia-reperfusion (I/R) injury, although the molecular steps involved in the loss of endothelial integrity are still poorly understood. We tested the hypothesis that the activation of vascular endothelial growth factor (VEGF) cell signaling would be responsible for the increase in lung vascular permeability seen early after the onset of I/R in rats. Furthermore, we hypothesized that the I/R-induced pulmonary edema would be significantly attenuated in rats by the activation of the stress protein response. Pretreatment with Ad Flk-1, an adenovirus encoding for the soluble VEGF receptor type II, prevented I/R-mediated increase in lung vascular permeability in rats. Furthermore, the I/R-induced lung injury was significantly decreased by prior activation of the stress protein response with geldanamycin or pyrrolidine dithiocarbamate. In vitro studies demonstrated that VEGF caused an increase in protein permeability across primary cultures of bovine macro- and microvascular lung endothelial cell monolayers that were associated with a phosphorylation of VE- and E-cadherin and the formation of actin stress fibers. Activation of the stress protein response prevented the VEGF-mediated changes in protein permeability across these cell monolayers and reduced the phosphorylation of VE-and E-cadherins, as well as the formation of actin stress fibers in these cells.

Total hip arthroplasty for arthrodesed hips

The benefits of converting an ankylosed or arthrodesed hip to total hip arthroplasty have been reported in the literature as have the technical difficulties associated with this procedure. This review, however, outlines the experience of a single surgeon (WJMB) at a single institution using uncemented prostheses. Between November 1991 and June 1996, 5 arthrodesed hips underwent uncemented total hip arthroplasty in 4 males and 1 female. Clinical and radiological follow-up review was for at least three years in all patients. In general, patients were satisfied with the outcome of their surgery with Harris Hip scores improving from an average of 62 preoperatively to an average of 72 postoperatively. The surgical outcome in these difficult cases was not as satisfactory as for routine total hip arthroplasty. Meticulous preoperative planning is required to aim toward leg length restoration and restoration of the abductor moment arm. A modular prosthesis allows versatility at surgery.

Serum levels of Hsp 72 measured early after trauma correlate with survival

BACKGROUND

Experimental studies have shown that hemorrhagic shock is associated with the expression of inducible heat proteins, especially heat shock protein (Hsp) 72, in liver, brain, heart, and kidney. Moreover, induction of Hsp 72 by various stressors before the onset of shock has been associated with the attenuation of organ injury caused by hemorrhage. However, it is not known whether Hsp 72 is expressed after severe trauma in humans. The purpose of this study was therefore to determine whether Hsp 72 could be detected in the serum of patients early after severe trauma and whether serum levels of Hsp 72 might correlate with survival of trauma patients or the severity of the postinjury inflammatory response.

METHODS

Clinical data were collected prospectively over a 3-year period for trauma patients mechanically ventilated for more than 2 days who met the following inclusion criteria: Injury Severity Score > or = 16, and age > 18 years. Physiologic data for quantitative assessment of organ dysfunction were collected for each patient. Hsp 72 and nitrate and nitrite levels were measured in the serum of trauma patients collected at or 12 to 48 hours after the admission to the emergency department.

RESULTS

Sixty-seven patients with severe trauma were enrolled in the study. Hsp 72 was detected in the serum of all trauma patients. All patients with high initial serum levels of Hsp 72 (serum levels > 15 ng/mL) survived, whereas 29% of the patients with low Hsp 72 serum levels died from their traumatic injuries (p = 0.01). The overall mortality was 21%, occurring within 5 to 7 days. Patients who died were older (mean age, 54 +/- 15 years) than those who survived (mean age, 36 +/- 15 years) (p < 0.0.05). The cause of death was attributable to head injury in 79%, although the severity of head injury (Abbreviated Injury Scale score) was not statistically different between survivors with high serum values of Hsp 72 and patients who died. There was no correlation between the initial serum Hsp 72 values and the severity of organ dysfunction or clinical indicators of the inflammatory response.

CONCLUSION

Hsp 72 can be detected in the serum of severely traumatized patients within 30 minutes after injury. Elevated initial serum levels of Hsp 72 (serum levels > 15 ng/mL) are associated with survival after severe trauma, but are not related to the incidence or severity of the postinjury inflammatory response or organ dysfunction.

Studies on immunity in anthrax. XI. Control of cellular permeability by bicarbonate ion in relation to protective antigen elaboration

Puziss, Milton (Fort Detrick, Frederick, Md.) and Mary B. Howard. Studies on immunity in anthrax. XI. Control of cellular permeability by bicarbonate ion in relation to protective antigen elaboration. J. Bacteriol. 85:237-243. 1963.-No elaboration of Bacillus anthracis protective antigen was demonstrated after addition of bicarbonate to cultures incubated 42 hr in a bicarbonate-free medium. Antigen accumulation in culture filtrates was greater if the bicarbonate was added to these cultures early in the growth period. Cell-free extracts of washed cell suspensions, prepared by hand grinding or lysozyme treatment, had no demonstrable intracellular protective antigen. Sonic treatment released antigen in measurable amounts, but tended to destroy or degrade the labile antigen. Freezing and thawing disrupted the cells and liberated the antigen; protective antigen was shown to be of internal rather than of extracellular origin. Maximal intracellular antigen concentration occurred before the peak concentration was reached in the culture filtrates. Antigen also was found in cell extracts from bicarbonate-free culture media when none was present in the corresponding culture filtrates. A high level of internal protective antigen was present in cells grown in a bicarbonate-free medium maintained at a constantly alkaline pH; only a trace of antigen was present in the corresponding pH-adjusted culture filtrate. The hypothesis is presented that bicarbonate functions to control cellular permeability and release of antigen from the cells into the ambient medium.

Antibodies against the cystic fibrosis transmembrane regulator

Rabbit polyclonal antibodies have been raised against high-performance liquid chromatography purified synthetic peptides corresponding to two discrete regions of the cystic fibrosis transmembrane regulator (CFTR) protein: the R-domain (residues 785-796) and the extreme COOH-terminus (residues 1467-1480). Antibodies (Ab) to each of these peptides were affinity purified either by passage over a peptide-derivatized agarose matrix (Ab 785) to produce monospecific polyclonal antibodies or by protein A affinity chromatography to purify the immunoglobulin G1 fraction free of other serum proteins (Ab 1467). These antibodies recognize a candidate CFTR protein in the colonic cell line T84, as determined by Western blot analysis and by immunoprecipitation and labeling of the precipitate with [gamma-32P]ATP in the presence of protein kinase A. Both antibodies precipitated CFTR-related polypeptides from four mammalian cell types (HeLa, Bsc-40, HEp-2, and Chinese hamster ovary cells) transfected with the full-length CFTR cDNA clone using a vaccinia T7 protein expression system. Similar results were observed using a yeast CFTR expression system. In each case the Mr values of the bands observed were consistent with that expected for the CFTR protein. These antibodies should be useful probes for the immunocytochemical localization, immunoaffinity purification, and ultimately the functional characterization of the CFTR protein.

Induction of mutants of Staphylococcus aureus 100 with increased ability to produce enterotoxin A

As a result of serial exposures to a mutagenic agent, N-methyl-N'-nitro-N-nitrosoguanidine, the yield of enterotoxin A produced by the last mutant in the series was increased nearly 20-fold over the amount produced by the parent Staphylococcus aureus 100.

STUDIES ON IMMUNITY IN ANTHRAX XI

Puziss, Milton (Fort Detrick, Frederick, Md.) and Mary B. Howard . Studies on immunity in anthrax. XI. Control of cellular permeability by bicarbonate ion in relation to protective antigen elaboration. J. Bacteriol. 85: 237–243. 1963.—No elaboration of Bacillus anthracis protective antigen was demonstrated after addition of bicarbonate to cultures incubated 42 hr in a bicarbonate-free medium. Antigen accumulation in culture filtrates was greater if the bicarbonate was added to these cultures early in the growth period. Cell-free extracts of washed cell suspensions, prepared by hand grinding or lysozyme treatment, had no demonstrable intracellular protective antigen. Sonic treatment released antigen in measurable amounts, but tended to destroy or degrade the labile antigen. Freezing and thawing disrupted the cells and liberated the antigen; protective antigen was shown to be of internal rather than of extracellular origin. Maximal intracellular antigen concentration occurred before the peak concentration was reached in the culture filtrates. Antigen also was found in cell extracts from bicarbonate-free culture media when none was present in the corresponding culture filtrates. A high level of internal protective antigen was present in cells grown in a bicarbonate-free medium maintained at a constantly alkaline pH; only a trace of antigen was present in the corresponding pH-adjusted culture filtrate. The hypothesis is presented that bicarbonate functions to control cellular permeability and release of antigen from the cells into the ambient medium.