Academic Half Day Improves Resident Perception of Education Without Compromising Patient Safety

BACKGROUND

Residency programs are required to offer a didactic curriculum and protect resident time for education. Our institution implemented an academic half day (AHD) in the 2021-2022 academic year to address issues related to the standard noon conference series.

OBJECTIVE

Determine the impact of AHD implementation on education, patient safety, and workflow.

METHODS

This was a prospective, single-site educational intervention study. Pre- and post-implementation surveys and Accreditation Council for Graduate Medical Education (ACGME) surveys assessed changes in trainee and faculty attitudes and behaviors. Patient safety and workflow were evaluated by comparing the number of safety event reports, rapid response team activations, time to admission from the ED, and time of discharge on AHD days compared to other weekdays.

RESULTS

Survey response rates were: residents 68%/48%, fellows 42%/35%, and faculty 59%/29%. AHD was associated with a significant, positive change in resident attitudes and experiences and on ACGME survey items. On AHDs compared with other weekdays, there were no significant differences in safety event report rates (P = .98), nor in rapid response team activation rates (P = .99). There was not a clinically meaningful difference in median admission time from the ED on AHD weekdays (125 minutes) compared to other weekdays (130 minutes, P = .04). There was no significant difference in median discharge time on AHD vs other weekdays (P = .13).

CONCLUSIONS

This study suggests that there is no significant difference in patient safety or workflow with the implementation of AHD. This study supports prior studies that residents strongly prefer AHD. AHD may be a useful framework for resident education without compromising patient care.

A Proposed Pediatric Clinical Cardiovascular Health Reference Standard

INTRODUCTION

Clinical cardiovascular health is a construct that includes 4 health factors-systolic and diastolic blood pressure, fasting glucose, total cholesterol, and body mass index-which together provide an evidence-based, more holistic view of cardiovascular health risk in adults than each component separately. Currently, no pediatric version of this construct exists. This study sought to develop sex-specific charts of clinical cardiovascular health for age to describe current patterns of clinical cardiovascular health throughout childhood.

METHODS

Data were used from children and adolescents aged 8-19 years in six pooled childhood cohorts (19,261 participants, collected between 1972 and 2010) to create reference standards for fasting glucose and total cholesterol. Using the models for glucose and cholesterol as well as previously published reference standards for body mass index and blood pressure, clinical cardiovascular health charts were developed. All models were estimated using sex-specific random-effects linear regression, and modeling was performed during 2020-2022.

RESULTS

Models were created to generate charts with smoothed means, percentiles, and standard deviations of clinical cardiovascular health for each year of childhood. For example, a 10-year-old girl with a body mass index of 16 kg/m2 (30th percentile), blood pressure of 100/60 mm Hg (46th/50th), glucose of 80 mg/dL (31st), and total cholesterol of 160 mg/dL (46th) (lower implies better) would have a clinical cardiovascular health percentile of 62 (higher implies better).

CONCLUSIONS

Clinical cardiovascular health charts based on pediatric data offer a standardized approach to express clinical cardiovascular health as an age- and sex-standardized percentile for clinicians to assess cardiovascular health in childhood to consider preventive approaches at early ages and proactively optimize lifetime trajectories of cardiovascular health.

Analysis of brain edema in RHAPSODY

BACKGROUND

Cerebral edema is a secondary complication of acute ischemic stroke, but its time course and imaging markers are not fully understood. Recently, net water uptake (NWU) has been proposed as a novel marker of edema.

AIMS

Studying the RHAPSODY trial cohort, we sought to characterize the time course of edema and test the hypothesis that NWU provides distinct information when added to traditional markers of cerebral edema after stroke by examining its association with other markers.

METHODS

A total of 65 patients had measurable supratentorial ischemic lesions. Patients underwent head computed tomography (CT), brain magnetic resonance imaging (MRI) scans, or both at the baseline visit and after 2, 7, 30, and 90 days following enrollment. CT and MRI scans were used to measure four imaging markers of edema: midline shift (MLS), hemisphere volume ratio (HVR), cerebrospinal fluid (CSF) volume, and NWU using semi-quantitative threshold analysis. Trajectories of the markers were summarized, as available. Correlations of the markers of edema were computed and the markers compared by clinical outcome. Regression models were used to examine the effect of 3K3A-activated protein C (APC) treatment.

RESULTS

Two measures of mass effect, MLS and HVR, could be measured on all imaging modalities, and had values available across all time points. Accordingly, mass effect reached a maximum level by day 7, normalized by day 30, and then reversed by day 90 for both measures. In the first 2 days after stroke, the change in CSF volume was associated with MLS (ρ = -0.57, p = 0.0001) and HVR (ρ = -0.66, p < 0.0001). In contrast, the change in NWU was not associated with the other imaging markers (all p ⩾ 0.49). While being directionally consistent, we did not observe a difference in the edema markers by clinical outcome. In addition, baseline stroke volume was associated with all markers (MLS (p < 0.001), HVR (p < 0.001), change in CSF volume (p = 0.003)) with the exception of NWU (p = 0.5). Exploratory analysis did not reveal a difference in cerebral edema markers by treatment arm.

CONCLUSIONS

Existing cerebral edema imaging markers potentially describe two distinct processes, including lesional water concentration (i.e. NWU) and mass effect (MLS, HVR, and CSF volume). These two types of imaging markers may represent distinct aspects of cerebral edema, which could be useful for future trials targeting this process.

The Fibromyalgia Transcutaneous Electrical Nerve Stimulation in Physical Therapy Study Protocol: A Multisite Embedded Pragmatic Trial

OBJECTIVES

Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological intervention that provides an electrical current through the skin to produce analgesia. The primary purpose of this study is to examine if the addition of TENS to routine physical therapy improves movement-evoked pain in individuals with fibromyalgia in a physical therapy clinical setting.

METHODS

Fibromyalgia TENS in Physical Therapy Study is a phase III embedded pragmatic clinical trial funded through the National Institutes of Health Helping to End Addiction Long-Term Initiative. This trial will utilize a randomized cluster design that includes more than 110 physical therapists in 24 to 30 physical therapy clinics within 6 health care systems and 7 states. Clinics will be randomized to TENS or No-TENS, stratified by health care system and clinic size. The plan is to enroll 600 participants, with all participants completing physical therapy as prescribed by their physical therapist. Participants at TENS clinics will utilize TENS for a minimum of 2-hour per day while at the physical therapy clinic and at home when active. The primary outcome is reduction in movement-evoked pain from baseline to day 60 on an 11-point numeric rating scale when participants sit and stand 5 times (Sit and Stand Test). Secondary outcomes include resting pain and fatigue, pain interference, fibromyalgia disease activity, movement-evoked fatigue, multidimensional assessment of fatigue, rapid assessment of physical activity, patient global impression of change, and common data elements shared across studies supported through the Helping to End Addiction Long-Term Initiative.

IMPACT

The findings from this study will provide effectiveness data on TENS for individuals with fibromyalgia for health care policymakers, clinicians, and insurers. Data from this study will also inform future pragmatic trials for nonpharmacological interventions and chronic musculoskeletal pain conditions.

Best Practices in Medical Documentation: A Curricular Module

OBJECTIVE

To create and validate a checklist for high-quality documentation and pilot a multi-modal, immersive educational module across multiple institutions. We hypothesized that this module would improve knowledge, skills, and attitudes in medical documentation.

METHODS

Module design was grounded in an established curriculum design framework. We conducted the study across 12 pediatric critical care fellowship programs between September 2017 and January 2018. Workshops were allotted 90 minutes for completion. We utilized a pre-/post- study design to determine the workshop's impact. Changes in knowledge were assessed through pre and post testing. Changes in skills were evaluated with a validated checklist for inclusion of key documentation elements. Changes in attitudes were determined through learner self-assessment RESULTS: 83 of 138 eligible fellows (60%) started the module and 62 of 83 (75%) completed data sets for analysis. Immediate post-testing demonstrated modest statistically significant improvement in knowledge, skills, and attitudes. The workshop was easily disseminated and deployed CONCLUSIONS: This study demonstrates that a multi-modal educational intervention can lead to improvement in medical documentation knowledge, skills, and attitudes in a cohort of PCCM fellows and be easily disseminated for use by other specialties and types of clinicians.

Association Between Neighborhood-Level Poverty and Incident Atrial Fibrillation: a Retrospective Cohort Study

BACKGROUND

Atrial fibrillation (AF) is a leading cause of cardiovascular morbidity and mortality. While neighborhood-level factors, such as poverty, have been related to prevalence of AF risk factors, the association between neighborhood poverty and incident AF has been limited.

OBJECTIVE

Using a large cohort from a health system serving the greater Chicago area, we sought to determine the association between neighborhood-level poverty and incident AF.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Adults, aged 30 to 80 years, without baseline cardiovascular disease from January 1, 2005, to December 31, 2018.

MAIN MEASURES

We geocoded and matched residential addresses of all eligible patients to census-level poverty estimates from the American Community Survey. Neighborhood-level poverty (low, intermediate, and high) was defined as the proportion of residents in the census tract living below the federal poverty threshold. We used generalized linear mixed effects models with a logit link function to examine the association between neighborhood poverty and incident AF, adjusting for patient demographic and clinical AF risk factors.

KEY RESULTS

Among 28,858 in the cohort, patients in the high poverty group were more often non-Hispanic Black or Hispanic and had higher rates of AF risk factors. Over 5 years of follow-up, 971 (3.4%) patients developed incident AF. Of these, 502 (51.7%) were in the low poverty, 327 (33.7%) in the intermediate poverty, and 142 (14.6%) in the high poverty group. The adjusted odds ratio (aOR) of AF was higher for the intermediate poverty compared with that for the low poverty group (aOR 1.23 [95% CI 1.01-1.48]). The point estimate for the aOR of AF incidence was similar, but not statistically significant, for the high poverty compared with the low poverty group (aOR 1.25 [95% CI 0.98-1.59]).

CONCLUSION

In adults without baseline cardiovascular disease managed in a large, integrated health system, intermediate neighborhood poverty was significantly associated with incident AF. Understanding neighborhood-level drivers of AF disparities will help achieve equitable care.

Enhancements in Ammonia and Methane from Agricultural Sources in the Northeastern Colorado Front Range Using Observations from a Small Research Aircraft

Quantifying ammonia (NH₃) to methane (CH₄) enhancement ratios from agricultural sources is important for understanding air pollution and nitrogen deposition. The northeastern Colorado Front Range is home to concentrated animal feeding operations (CAFOs) that produce large emissions of NH₃ and CH₄. Isolating enhancements of NH₃ and CH₄ in this region due to agriculture is complicated because CAFOs are often located within regions of oil and natural gas (O&NG) extraction that are a major source of CH₄ and other alkanes. Here, we utilize a small research aircraft to collect in situ 1 Hz measurements of gas-phase NH₃, CH₄, and ethane (C₂H₆) downwind of CAFOs during three flights conducted in November 2019. Enhancements in NH₃ and CH₄ are distinguishable up to 10 km downwind of CAFOs with the most concentrated portions of the plumes typically below 0.25 km AGL. We demonstrate that NH₃ and C₂H₆ can be jointly used to separate near-source enhancements in CH₄ from agriculture and O&NG. Molar enhancement ratios of NH₃ to CH₄ are quantified for individual CAFOs in this region, and they range from 0.8 to 2.7 ppbv ppbv^-1. A multivariate regression model produces enhancement ratios and quantitative regional source contributions that are consistent with prior studies.

Association between county-level risk groups and COVID-19 outcomes in the United States: a socioecological study

BACKGROUND

Geographic heterogeneity in COVID-19 outcomes in the United States is well-documented and has been linked with factors at the county level, including sociodemographic and health factors. Whether an integrated measure of place-based risk can classify counties at high risk for COVID-19 outcomes is not known.

METHODS

We conducted an ecological nationwide analysis of 2,701 US counties from 1/21/20 to 2/17/21. County-level characteristics across multiple domains, including demographic, socioeconomic, healthcare access, physical environment, and health factor prevalence were harmonized and linked from a variety of sources. We performed latent class analysis to identify distinct groups of counties based on multiple sociodemographic, health, and environmental domains and examined the association with COVID-19 cases and deaths per 100,000 population.

RESULTS

Analysis of 25.9 million COVID-19 cases and 481,238 COVID-19 deaths revealed large between-county differences with widespread geographic dispersion, with the gap in cumulative cases and death rates between counties in the 90th and 10th percentile of 6,581 and 291 per 100,000, respectively. Counties from rural areas tended to cluster together compared with urban areas and were further stratified by social determinants of health factors that reflected high and low social vulnerability. Highest rates of cumulative COVID-19 cases (9,557 [2,520]) and deaths (210 [97]) per 100,000 occurred in the cluster comprised of rural disadvantaged counties.

CONCLUSIONS

County-level COVID-19 cases and deaths had substantial disparities with heterogeneous geographic spread across the US. The approach to county-level risk characterization used in this study has the potential to provide novel insights into communicable disease patterns and disparities at the local level.

Neighborhood Poverty and Incident Heart Failure: an Analysis of Electronic Health Records from 2005 to 2018

BACKGROUND

Neighborhood-level characteristics, such as poverty, have been associated with risk factors for heart failure (HF), including hypertension and diabetes mellitus. However, the independent association between neighborhood poverty and incident HF remains understudied.

OBJECTIVE

To evaluate the association between neighborhood poverty and incident HF using a "real-world" clinical cohort.

DESIGN

Retrospective cohort study of electronic health records from a large healthcare network. Individuals' residential addresses were geocoded at the census-tract level and categorized by poverty tertiles based on American Community Survey data (2007-2011).

PARTICIPANTS

Patients from Northwestern Medicine who were 30-80 years, free of cardiovascular disease at index visit (January 1, 2005-December 1, 2013), and followed for at least 5 years.

MAIN MEASURES

The association of neighborhood-level poverty tertile (low, intermediate, and high) and incident HF was analyzed using generalized linear mixed effect models adjusting for demographics (age, sex, race/ethnicity) and HF risk factors (body mass index, diabetes mellitus, hypertension, smoking status).

KEY RESULTS

Of 28,858 patients included, 75% were non-Hispanic (NH) White, 43% were men, 15% lived in a high-poverty neighborhood, and 522 (1.8%) were diagnosed with incident HF. High-poverty neighborhoods were associated with a 1.80 (1.35, 2.39) times higher risk of incident HF compared with low-poverty neighborhoods after adjustment for demographics and HF risk factors.

CONCLUSIONS

In a large healthcare network, incident HF was associated with neighborhood poverty independent of demographic and clinical risk factors. Neighborhood-level interventions may be needed to complement individual-level strategies to prevent and curb the growing burden of HF.

A fatal case report of antibody-dependent enhancement of dengue virus type 1 following remote Zika virus infection

BACKGROUND

Dengue virus (DENV) is endemic in many parts of the world. Antibody dependent enhancement (ADE) in DENV infections occurs when a person with primary immunity is infected by a second, different DENV strain. Antibodies to Zika virus (ZIKV), which emerged in the Western Hemisphere in 2015, are cross reactive with DENV and theoretically could provoke ADE in a DENV naïve individual.

CASE PRESENTATION

DENV infection was suspected in a child who had recently returned from a one-month stay in the Dominican Republic. The child presented with fever, vomiting, abdominal pain, and in hypovolemic shock. Volume and pressor resuscitation were unsuccessful, and the child died less than 24 h after hospitalization. Laboratory results suggested an early acute first DENV infection since serum, plasma, and spinal fluid had DENV1 detected by polymerase chain reaction (PCR), yet the serum lacked IgG antibodies to DENV nonstructural protein 1 (NS1) of all four DENV serotypes. This acute DENV infection occurred in the presence of a remote ZIKV infection as determined by antibodies to ZIKV NS1 envelope by multiplex microsphere immunoassay and an exceptionally high plaque reduction neutralization titer to ZIKV. ZIKV IgG avidity index was high, confirming a past infection. DENV1 RNA was detected in all ten organs and tissues examined by PCR. The severe and fatal complications reported here suggest that a remote ZIKV infection may provoke an exaggerated immune response leading to hypovolemic shock when primarily infected by DENV1.

CONCLUSION

We report the first known patient in the United States with a rapidly progressive and fatal case of travel-associated DENV in which prior exposure to ZIKV likely played a role in triggering an ADE phenomenon. This association of prior ZIKV immunity and subsequent new dengue infection is a worrisome phenomenon and an important contribution to the body of knowledge on immunity to flaviviruses.

Racial/ethnic minority and neighborhood disadvantage leads to disproportionate mortality burden and years of potential life lost due to COVID-19 in Chicago, Illinois

Epidemiological studies have highlighted the disparate impact of coronavirus disease 2019 (COVID-19) on racial and ethnic minority and socioeconomically disadvantaged populations, but data at the neighborhood-level is sparse. The objective of this study was to investigate the disparate impact of COVID-19 on disadvantaged neighborhoods and racial/ethnic minorities in Chicago, Illinois. Using data from the Cook County Medical Examiner, we conducted a neighborhood-level analysis of COVID-19 decedents in Chicago and quantified age-standardized years of potential life lost (YPLL) due to COVID-19 among demographic subgroups and neighborhoods with geospatial clustering of high and low rates of COVID-19 mortality. We show that age-standardized YPLL was markedly higher among the non-Hispanic (NH) Black (559 years per 100,000 population) and the Hispanic (811) compared with NH white decedents (312). We demonstrate that geomapping using residential address data at the individual-level identifies hot-spots of COVID-19 mortality in neighborhoods on the Northeast, West, and South areas of Chicago that reflect a legacy of residential segregation and persistence of inequality in education, income, and access to healthcare. Our results may contribute to ongoing public health and community-engaged efforts to prevent the spread of infection and mitigate the disproportionate loss of life among these communities due to COVID-19 as well as highlight the urgent need to broadly target neighborhood disadvantage as a cause of pervasive racial inequalities in life and health.

Aluminum phosphide poisoning: Successful recovery of multiorgan failure in a pediatric patient

Aluminum phosphide (AlP) is an insecticide and rodenticide that produces phosphine gas when exposed to moisture. Exposure to AIP has been described as through inhalation and ingestion routes and is typically either accidental or a suicidal attempt. The result is potential multiorgan toxicity involving the heart, kidneys, lungs, and liver, with an overall mortality related to exposure reported from 30% to 77%. The initial symptoms are nonspecific and can include epigastric pain, vomiting, diarrhea, dizziness, and dyspnea. Patients rapidly experience multisystem organ failure, cardiovascular collapse, and, finally, death. We report the case of a 3 year old girl with AlP poisoning who developed cardiogenic shock, ventricular arrhythmias, respiratory failure, liver injury, and significant acute kidney injury (AKI). She was successfully supported with veno-arterial extracorporeal membrane oxygenation (ECMO) for 16 days, treated with lidocaine and magnesium sulfate for ventricular arrhythmias, and received continuous renal replacement therapy (CRRT) and hemodialysis for 24 days for metabolic acidosis secondary to AKI. Despite her severe clinical presentation, she had complete normalization of her end-organ dysfunction with no neurological sequelae. This case demonstrates the high index of suspicion required for AlP poisoning given the potential for rapid progression and severe multiorgan toxicity. The authors recommend prompt referral to a tertiary care center with ECMO and CRRT capability in cases of suspected or documented AlP poisoning.

Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment

INTRODUCTION

Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion.

METHODS

We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential.

RESULTS

Five hundred and eighteen subjects completed the survey. Of 59 items, only one item ("displays honesty and integrity") was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills.

CONCLUSIONS

Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

The AAP Resilience in the Face of Grief and Loss Curriculum

A career in pediatrics can bring great joy and satisfaction. It can also be challenging and lead some providers to manifest burnout and depression. A curriculum designed to help pediatric health providers acquire resilience and adaptive skills may be a key element in transforming times of anxiety and grief into rewarding professional experiences. The need for this curriculum was identified by the American Academy of Pediatrics Section on Medical Students, Residents and Fellowship Trainees. A working group of educators developed this curriculum to address the professional attitudes, knowledge, and skills essential to thrive despite the many stressors inevitable in clinical care. Fourteen modules incorporating adult learning theory were developed. The first 2 sections of the curriculum address the knowledge and skills to approach disclosure of life-altering diagnoses, and the second 2 sections focus on the provider's responses to difficult patient care experiences and their needs to develop strategies to maintain their own well-being. This curriculum addresses the intellectual and emotional characteristics patient care medical professionals need to provide high-quality, compassionate care while also addressing active and intentional ways to maintain personal wellness and resilience.

Pediatric residents' clinical and educational experiences with end-of-life care

OBJECTIVE

The objective of this study was to document the frequency of pediatric resident experiences with end-of-life care for children and the educational context for these experiences, as well as to determine whether residents deem their preparatory training adequate.

METHODS

An Internet-based survey was distributed to all categorical pediatric residents at the Johns Hopkins Children's Center. Survey items asked residents to (1) quantify their experiences with specific responsibilities associated with the death of a pediatric patient, (2) identify their educational experiences, and (3) respond to Likert scale statements of, "I feel adequately trained to... ." The responsibilities were discussion of withdrawal/limitation of life-sustaining therapy, symptom management, declaration of death, discussion of autopsy, completion of a death certificate, seeking self-support, and follow-up with families.

RESULTS

Forty (50%) of 80 residents completed the survey. Residents had been present for a mean (+/- SD) of 4.7 (+/- 3.0) patient deaths. More than 50% of residents had participated in discussions of withdrawal/limitation of life-sustaining therapy, symptom management, completing a death certificate, and seeking personal support; however, <50% of residents had been taught how to hold discussions of withdrawal/limitation of life-sustaining therapy, declare death, discuss autopsy, complete a death certificate, and have follow-up with families. Residents did not feel adequately trained in any of these areas.

CONCLUSION

Pediatric residents have limited experience with pediatric end-of-life care and highly varied educational experiences and do not feel adequately trained to fulfill the responsibilities associated with providing end-of-life care for children. Overall, this perception does not improve with increased level of training. This study identifies several target areas for curricular intervention that may ultimately improve the end-of-life experience for our pediatric patients and their families and the young physicians who care for them.

Gastrointestinal blood loss associated with running a marathon

Gastrointestinal bleeding has been observed in long-distance runners. We prospectively studied participants of the Eighth Annual Marine Corps Marathon to determine the incidence of gastrointestinal blood loss associated with long-distance running. Of 600 runners contacted, 125 (21%) returned a questionnaire as well as pre- and postmarathon stool specimens. Stool specimens converted from Hemoccult negative to positive in 29/125 (23%) of the participants, indicating that running the marathon was associated with gastrointestinal blood loss (P less than 0.001). The incidence of this conversion (negative to positive) was significant for both males (N = 68, P less than 0.001) and females (N = 57, P less than 0.05). Gastrointestinal bleeding appeared to be independent of age, race time, abdominal symptoms, and the recent ingestion of aspirin, vitamin C, or steak.

Functional Injury of Vein Graft Endothelium

The cause of endothelial injury during vein harvesting and preservation is complex. Hypothermia is thought necessary to preserve cell viability but has been implicated in morphologic injury to the endothelium. This study explored the effect of temperature on preserving endothelial function using prostacyclin production as a metabolic marker. Canine veins were atraumatically excised and matched segments were stored at three temperatures using either nutrient medium or heparinized saline. After storage, endogenous production of prostacyclin by the luminal surface of each vein was collected in a closed perfusion system at 37 degrees C and assayed by radioimmunoassay. Optimal prostacyclin production was observed in veins stored in tissue culture medium at normothermia. Preservation of normal endothelial function may require revision of traditional vein graft-harvesting techniques.