A spectrum of indications exists for the implementation of neonatal tracheostomies, ranging from short-term airway control to congenital airway anomalies. The decision to initiate long-term mechanical ventilation is multifaceted and can be influenced by factors such as physician preferences, caregivers’ attitudes, and comorbidities. It is important to have an ethical framework in place to guide the treatment of preterm neonates who may require long term mechanical ventilation. This study examines physician perspectives on the ethics of neonatal tracheostomy, focusing on the treatment of infants with bronchopulmonary dysplasia. A mixed methods study, consisting of demographic information and 5 clinical vignettes centering on an infant with bronchopulmonary dysplasia, was sent to physicians with experience treating bronchopulmonary dysplasia patients. The respondents chose between 3 outcomes for each scenario: keep the patient intubated with hopes of future extubation, compassionately extubate, or override parental rights with a court order. The results indicate that there are mixed feelings regarding the redirecting care for neonates with bronchopulmonary dysplasia. For 3 out of 5 of the clinical scenarios, the majority of respondents opted to keep the patient intubated with plans of future extubation. The inclusion of comorbidities such as subglottic stenosis resulted in most respondents opting to compassionately extubate the patient. Ultimately, this study highlights the complexity of the decision-making process.
Background: Adults with an ambulatory disability are at higher risk of obesity and sequalae from obesity than aged-matched adults without disability. Research shows adults with an ambulatory disability are less likely to participate in the recommended 150 minutes of physical activity per week than non-disabledadults. Availability ofadaptive exercise could help increase physical activity participation in adults with ambulatory disability. Objective: This observational study examines the availability of adaptive exercise programs throughout the United States and determines how it relates to the population of adults with an ambulatory disability. Methods: Adaptive exercise sites (n=268) were identified via internet searches to form a comprehensive database. Population data were collected from the US Census Bureau. Statistical analysis (one-way ANOVA, Fisher’s LSD) was completed to determine the significance of adaptive exercise programing deficits among different regions of the United States. Results: A total of 268 adaptive exercise sites throughout the United States were identified and evaluated. On average, 8.13% ± 1.65% of each state’s population ≥ 18 years of age has an ambulatory disability. Each state had an average of 2.68 ± 3.81 sites per 100,000 people with an ambulatory disability. Conclusions: Areas within the United States with high populations of adults with ambulatory disability do not have sufficient availability of adaptive exercise programs.Increasing the availability of physical sports has a wide-range of impact – not only to reduce morbidity – but also to improve public health, foster social and community connections, and optimize mental health of vulnerable populations. This study found that the proportion of state population with an ambulatory disability and availability of adaptive exercise sites within each state were negatively correlated. Our research provides a novel understanding of the availability of adaptive exercise programs and the prevalence of ambulatory disability by geographic region. This work paves the way for more in-depth exploration of potential mismatches of need and resources within vulnerable populations.
Background Immunization rates among pediatric patients are declining, largely due to growing vaccine hesitancy among parents and guardians. Addressing public health concerns related to vaccines is critical to preventing a significant reduction in vaccination coverage. Objective This critical review examines the effectiveness of training physicians in communication strategies, such as motivational interviewing, on improving vaccine acceptance. Methods A systematic search was conducted in PubMed using MeSH terms “Training AND (Motivational Interviewing OR Online Systems) AND Vaccination Hesitancy NOT COVID-19.” The search yielded 26 results, from which 7 studies met the inclusion criteria for full-text review, focusing on training interventions aimed at addressing vaccine hesitancy among healthcare providers. Results The studies reviewed consistently reported that training programs focusing on motivational interviewing significantly improve physicians’ ability to communicate effectively with vaccine-hesitant parents. Providers trained in MI showed increased confidence, better patient engagement, and greater proficiency in addressing concerns, which contributed to higher vaccine acceptance rates among parents. Furthermore, the review identified that longer, repeated training sessions had a more sustained impact on providers’ skill retention and application. Conclusion Training healthcare providers in motivational interviewing and tailored communication strategies appears to be a valuable approach for addressing vaccine hesitancy. By equipping physicians with the necessary skills and confidence, these programs may help bridge the gap between parental concerns and scientific evidence, ultimately improving immunization rates among pediatric populations. Future research should focus on standardizing training formats and evaluating long-term outcomes to enhance the applicability and effectiveness of such interventions.
Background: In June 2022, the Dobbs v Jackson Women’s Health Organization ruling overturned the previously upheld constitutional right to abortion. The resulting impact on medical training and student decision-making remains uncertain. This study aims to assess the nationwide impact of the Dobbs decision on medical students’ geographic residency preferences, specialty selection, and level of concern regarding civil and criminal charges for physicians providing abortion and fertility care. Methods: An anonymous IRB-approved REDCap survey was distributed to American accredited medical schools across the United States and Israel between December 2022 and May 2023. Participants indicated specialty interests and geographic preferences for residency prior to and following the Dobbs decision. Students indicated their level of concern regarding legal charges for physicians providing abortion care across ten scenarios using a Likert scale. Results: A total of 2,384 medical students from 72 schools completed the survey. Students reported a change in geographical preference for residency programs after the Dobbs decision: increasing preference for abortion-protected states and decreasing preference for abortion-banned states (p < 0.0001). Interest in pursuing reproductive medicine (RM) specialties decreased after the Dobbs decision. Females and individuals interested in pursuing residency in abortion-protected states reported higher levels of legal concern (p < 0.01). Conclusion: Medical students’ perceptions of the Dobbs decision offer insights into career selection and geographic preferences among future physicians. These findings suggest that Dobbs may exacerbate geographic barriers to care as medical students become less willing to train in states with strict anti-abortion legislation.
Background: Adults with an ambulatory disability are at higher risk of obesity and sequalae from obesity than aged-matched adults without disability. Research shows adults with an ambulatory disability are less likely to participate in the recommended 150 minutes of physical activity per week than able-bodied adults. Access to adaptive exercise could help increase physical activity participation in adults with ambulatory disability. Objective: This observational study examines the accessibility of adaptive exercise programs throughout the United States and determines how it relates to the population of adults with an ambulatory disability. Methods: Adaptive exercise sites (n=268) were identified via internet searches to form a comprehensive database. Population data were collected from the US Census Bureau. Statistical analysis (one-way ANOVA, Fisher’s LSD) was completed to determine the significance of adaptive exercise programing deficits among different regions of the United States. Results: A total of 268 adaptive exercise sites throughout the United States were identified and evaluated. On average, 8.13% ± 1.65% of each state’s population ≥ 18 years of age has an ambulatory disability. Each state had an average of 2.68 ± 3.81 sites per 100,000 people with an ambulatory disability. Conclusions: Areas within the United States with high populations of adults with ambulatory disability do not have sufficient access to adaptive exercise. Physical activity is important for reducing morbidity in those with disability and thus it is important to increase accessibility. The proportion of state population with an ambulatory disability and availability of adaptive exercise sites within each state were found to be negatively correlated.
Introduction: This scoping review consolidates existing research on outpatient ethics committees (OECs). While inpatient or hospital ethics committees are well-researched and established, OECs are scarce in number and have received less attention from scholars, ethicists, and physicians, despite the increase in outpatient care utilization over the past two decades. Methods: We conducted a scoping review following the JBI Manual for Evidence Synthesis. Key information sources included MEDLINE PubMed, Embase, and Academic Search Complete. Gray literature searching was conducted through Web of Science Database, keyword searching in Google Scholar, and backward citation searching was utilized. Relevant articles were screened through the software Rayyan, and EndNote was used to manage references. Results: 38 papers were identified that analyzed OECs. Most commonly these papers either advocated for the creation of OECs (16/38) or offered suggestions for their formation (8/38). Of these 38 studies, 14 studies analyzed the outcomes of existing OECs, concluding that they benefit practitioners by facilitating timely ethical decision making, quality improvement, and easing the burden of individual decisions. Conclusion: Our review indicates that there is desire for, and benefits to, establishing OECs. The authors seem to agree that OECs empower staff, providers, and families during ethical decision-making. The authors note the benefit of a multidisciplinary approach to OECs by incorporating a diverse team of providers and staff. OECs can be utilized in ethics training, case study reviews, policy reviews, guideline development, and research. This review underscores the need for more support and exploration into OECs.
Pyruvate kinase deficiency (PKD) is an autosomal recessive disorder and the most common cause of chronic hemolytic anemia secondary to red blood cell (RBC) enzyme defects. Treatment is mainly supportive including splenectomy and transfusions. Mitapivat, an oral allosteric activator of defective pyruvate kinase, was approved by the FDA in February 2022 for treatment of adults with PKD. However, because Mitapivat undergoes liver metabolism, patients must have stable liver profiles prior to initiation of therapy. We present a case of PKD complicated by hemophagocytic lymphohistiocytosis (HLH). We initiated steroid therapy for his HLH with the intent to subsequently start Mitapivat. We delayed initiation of Mitapivat therapy due to persistent hepatic dysfunction. After starting Mitapivat his liver function remained stable, and his blood transfusion dependence slightly decreased. This suggested that Mitapivat does not necessarily worsen liver dysfunction or iron overload, and that this should therefore not be a reason to delay treatment.
Drug-induced hyperpigmentation is responsible for up to 20% of acquired hyperpigmentation cases, especially among the elderly population. The pathogenesis varies depending on the medication involved and may include melanin accumulation, drug deposition, production of special pigments, and iron deposition. We report the case of an elderly, immunocompromised patient with a history significant for leukemia presenting with black-blue hyperpigmentation of the upper and lower extremities, associated with iron deposition following levofloxacin exposure.
Objectives Trauma exposures and high rates of burnout are widespread among emergency department (ED) clinicians and patients. Trauma-informed care (TIC) education promotes resilience for patients and clinicians. However, there remains a scarcity of data on the impact of TIC on ED clinician outcomes. The objectives of this study were to evaluate post-COVID-19 pandemic professional quality of life among ED clinicians and to test if participation in a TIC education initiative among ED clinicians (1) improves professional quality of life and (2) decreases bias toward patients who misuse opioids. Methods This was a single center, prospective, parallel before-and-after pilot study conducted at a single academic medical center ED. All ED clinicians at our institution participated in a TIC education series and were given the option to participate in the education series in April-May 2023 or be waitlisted to participate in June-July 2023. The validated Professional Quality of Life (ProQOL) scale – V was used to assess compassion satisfaction, burnout, and secondary traumatic stress at baseline (March 2023) and again after the intervention group completed the TIC education (June 2023). The three-month change in the ProQOL subscale scores were compared between the two groups using repeated measures mixed-effects linear regression models. Results Of the 67 included clinicians, 56 selected to receive the TIC education early and 11 subjects selected to be waitlisted. Overall, no clinicians reported a high degree of burnout, secondary traumatic stress, or lack of compassion satisfaction. We did not find a statistically significant difference in the change in scores between the two groups. Conclusions We did not find the TIC education impacted ProQOL scores. This may be due to the low degree of burnout and secondary stress in our cohort.
Introduction: Post-surgical inflammation is a common adverse event that can have detrimental effects on the recovery phase for patients. Commonly associated with pain severity, inflammation can make the management of postoperative pain difficult. Of the multiple inflammatory molecules that can be found in an inflammatory response, interleukin 6 (IL-6) and C-reactive protein (CRP) are two of the most commonly assayed biomarkers of inflammation. Dexamethasone (DEX), with its anti-inflammatory properties, is thought to reduce IL-6 and CRP. It thus may reduce pain when administered perioperatively. In this review, we assessed the anti-inflammatory effects of DEX and the relationship of such effects in the management of postoperative pain. Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials using the following criteria: patients greater than or equal to eighteen years of age undergoing surgery. The intervention of interest is perioperative DEX administration and the control was normal saline or the absence of DEX administration. Primary outcomes included postoperative IL-6 and CRP levels, with a secondary outcome of postoperative pain scores. Utilizing the RevMan program, a meta-analysis was performed using a random effect model. Studies not able to be analyzed quantitatively were assessed through a narrative approach. Results: We identified a total of nine studies with 1048 subjects which fulfilled inclusion criteria. Only three of the nine studies were able to be quantitatively analyzed. Our analysis of these studies favored DEX administration for the reduction of postoperative inflammation with regard to IL-6 (SMD = -1.88; 95% CI -2.28 - 1.48; p < 0.01; Figure 3a), and near significant difference with regard to CRP (SMD = -0.93; 95% CI -1.91 - 0.04; p = 0.06; Figure 3b). DEX administration was also shown to significantly reduce postoperative pain (SMD = -1.34; 95% CI -2.12 - -0.56; p < 0.01; Figure 3c). Qualitative analysis for eight of the nine studies favored the administration of DEX for the reduction of inflammation as well as postoperative pain. The total dosage of DEX administered ranged from 6.6 to 40 mg. Regarding complications after DEX administration, all nine studies reported no significant increase in the incidence of serious adverse effects, including hyperglycemia, surgical site infections, or impaired wound healing. Conclusion: Dexamethasone is a commonly used medication for the management of postoperative nausea and vomiting. Additionally, administration of DEX perioperatively also appears to be efficacious in lowering inflammation and managing postoperative pain from various types of surgical procedures. Complications, including impaired wound healing, hyperglycemia, and surgical site infections, which have been reported in previous studies, have not been observed with significance with the administration of one or two doses of DEX as evidenced by the literature in this review. Further research may justify the utilization of DEX as a means to reduce postoperative inflammation and subsequent pain.
Background: Adverse childhood experiences (ACEs) have shown to have a negative impact on health outcomes. There is evidence of how negative childhood events adversely affect self-esteem in adulthood. Not only do ACEs have an impact on one's own life, but maternal ACEs have shown to have consequences on infants’ development as well, indicating a negative intergenerational impact. Objectives: To analyze the relationship between maternal ACEs on infant outcomes, breastfeeding adherence, and maternal self-perception Design/Methods: Between 2020 and 2023, 120 mother-infant pairs from a New Jersey urban hospital were approached between their 2nd trimester and the 2-month well visit. Mothers completed the ACE Questionnaire and the 7 C’s Tool survey for maternal resilience. Infant developmental milestones were collected from 2-,4-,6- and 12-month well-visits. Chi-square, Mann Whitney U, and independent t-tests were used to examine ACEs, maternal race and resilience, breastfeeding adherence, and infant developmental milestones. Results: A total of 51% (N=59) of mothers were categorized as having high ACE scores (2+). Higher scores from the 7 C’s Tool survey reflected lower resilience. There was a significant association between maternal ACE scores and higher 7 C’s Tool survey scores, linking lower maternal resilience with higher maternal ACE exposure (p< 0.001) There was found to be no significant relationship between ACE scores, race, and breastfeeding, and infant weights and head circumferences. Additionally, there was no significant relationship between resilience scores, race, breastfeeding, and infant weights and head circumferences. Though not statistically significant, black and Hispanic mothers represented a larger percentage of mothers with high ACEs scores while white mothers represented a lower percentage. Black mothers also represented a higher percentage of mothers categorized as high 7 C’s Tool Survey scores, reflecting lower resilience against adversity. Conclusions: The data shows evidence for a significant impact of ACEs affecting mothers’ self-perception and self-determined resiliency. Future research should focus on determining the relationship between maternal race, ACEs, and their impact on both maternal and infant health outcomes.
amed. Investigation of published recommendations for handling these situations can give victims, peers, and institutions the tools necessary to prepare, protect, and support providers through these challenging encounters. Methods: This paper is a literature review. For inclusion in this review, studies must have met the criteria of providing recommendations for healthcare providers or institutions on how to deal with racist patients. Excluded articles did not include recommendations on how to handle such situations or did not otherwise meet inclusion criteria. PubMed Medline was searched in January 2022 using a combination of the following keywords and associated MeSH terms: “Racism” AND “Physician-Patient relations”. The resulted articles then underwent forward and backward citation searching. A total of 44 articles were included after evaluation of 272 articles via this process. Results: For the affected individual, recommended responses include addressing the comment firmly and directly in real time, setting boundaries and behavior expectation, reporting the incident to supervisors and to the hospital, and seeking support from peers and/or professionals. At the peer level, core practices are supporting the victim, addressing the patient if necessary, debriefing with the victim and team, and checking-in with the victim in the following days. At the institution level, core practices are enacting reporting system and tracking incidents, developing specific policies and procedures about biased patients, and training staff with focused antibias and antidiscrimination sessions. Discussion: There are steps to be taken at every level to create a supportive and inclusive practice that protects providers against racist patients. One limitation of this study was that it was not a systematic review so there may be other recommendations published that are not reflected here.
Background: In the United States, laws and policies are proposed and passed daily that either protect or restrict transgender patients’ access to care. The objective of this study is to review the existing body of literature on the effect of state-level policy on transgender patients’ overall health. Methods: Primary literature was identified through PubMed and the National Institutes of Health. Search terms included keywords related to the following concepts: LGBTQ terms, differentiating terms, regional terms, and health outcome terms. Inclusion criteria: Quantifiable studies conducted on the American LGBTQ and Transgender population from January 2015 to April 2023. Exclusion criteria: Studies not conducted in English, on the American population, and not relevant to the research question. Results were individually discussed and then synthesized using a narrative approach. Results: A total of 6 studies were identified for review. The difference in rates of suicidality, suicide attempt, depression, and anxiety between Democratic and Republican states was statistically significant (p Conclusion: Republican-run states, on average, had policies in place restricting access and treatment for transgender patients which is correlated with worse health outcomes. Advocacy is greatly needed to help protect this at-risk population and further research is needed to better understand how state-level barriers impact transgender patients across the US.
INTRODUCTION Acute ankle sprains account for nearly 2% of visits to the pediatric emergency department (PED). The Ottawa Ankle Rules (OAR) were developed as a safe and effective clinical decision-making tool for detecting the need for radiographs in adults with acute ankle pain. OAR state radiographs are required with at least one of the following: 1. Inability to bear weight immediately following the injury and for four steps in the ED 2. Bony tenderness at the posterior edge of the lateral or medial malleolus OBJECTIVE Few prospective cohort studies have attempted to assess OAR pediatric populations. This study investigates the validity and documentation of OAR within a single academic institution’s PED. METHODS This retrospective chart review included previously healthy patients aged 2-19 years who presented to the PED with a traumatic ankle injury between 2019 and 2021. Exclusion criteria were met with documented parental insistence for imaging studies. We compared calculated OAR predictive values to those in literature using Chi-squared tests and WINPEPI. RESULTS A total of 295 subjects were included. When only considering clinically significant fractures in the data analysis, 247 patients received X-rays and 42 clinically significant fractures were found. OAR were 100% sensitive (95% confidence interval 93.1–100.0), 12.2% specific (95% CI 8.2–17.2), with a positive predictive value (PPV) of 18.9% (95% CI 16.6–26.5), and negative predictive value (NPV) of 100% (95% CI 88.7–100.0). When comparing this study’s findings to those with similar design protocol, specificity was lower (p<0.05) and there was no significant difference in sensitivity, PPV, or NPV. CONCLUSION Implementing the highly sensitive OAR yielded zero missed fractures. Their poor specificity results in unnecessary radiation exposure, which also increases expense and wait time. Excess imaging may be attributed to ambiguous OAR criteria, their dependence on pediatric cooperation, and parental expectations for imaging studies.
Introduction: Adverse Childhood Experiences (ACEs) are traumatic events that occurred to an individual during ages 0-17 years. The 1998 Adverse Childhood Experiences (ACE) suggested higher ACE scores contributed to negative future health outcomes. The tool is now used to screen at-risk populations for the development of chronic health conditions. Protective factors, such as resilience, were later studied and found to offset the negative health impacts of traumatic childhood events. The 7Cs questionnaire was a tool developed to measure resilience in adolescents and demonstrated better health outcomes despite the presence of higher ACE scores. This pilot study evaluated whether higher maternal ACEs would result in more frequent pediatric ED visits and less vaccination adherence and whether higher 7Cs would be protective. Methods: This IRB approved study recruited pregnant women and new mothers in a tertiary NJ urban hospital, between their second trimester and their child’s one month well visit at the pediatric clinic. All subjects completed the Adverse Childhood Events (ACEs) survey, 7Cs resilience tool, and a Maternal Health questionnaire at the time of recruitment. A review of children’s electronic medical records was conducted at 2-, 4-, 6-, and 12-months to evaluate pediatric outcomes, adherence to AAP recommended vaccine schedule and emergency department visits. Results: Total of 34 women were enrolled, their and their children’s medical and demographic data collected. There was no difference in higher ACE scores and number of ED visits for the babies (OR 0.9645 [CI 0.7643 - 1.2172]), with no effect seen with higher resilience scores and number of ED visits (OR 0.8477 [0.6192 – 1.1604]). Increase in ACE scores resulted in reduction in vaccination adherence (OR 0.3555 [CI 0.1417 – 0.8923]). Increase in resilience scores decreased vaccination adherence by 44% (OR 0.5578 [CI 0.4164 - 0.7471]). Conclusion: There was no significant relationship between ACE or resilience scores and pediatric ED visits. A higher ACE score and lower levels of resilience were associated with decreased child vaccine adherence rate. ACE scores relate to higher traumatic childhoods, suggest poorer outcomes in offspring. Women with higher ACE scores could benefit from closer interventions and resources from obstetricians, and closer follow up of their children by the pediatricians.
Fibroids are a common benign tumor located in the female reproductive tract and affect up to 10 percent of women, leading to challenges during cesarean section. Few cases of myomectomy at the time of cesarean section have been described and most describe uteri with only a few fibroids present. Our case describes a 39 year old G1P0101female with extensive fibroids including large fibroids located at the lower uterine segment. This patient underwent cesarean section and myomectomy at 27 weeks and five days gestation with a fundal, vertical hysterotomy, extending from the anterior to posterior wall of uterus. This is the first case described in the literature of a cesarean section performed on a uterus with innumerable intramural fibroids and first case documented of a fundal, anterior to posterior hysterotomy.
A 48 year old male presented with neck pain and left arm pain that worsened with movement alongside left arm weakness, numbness, and tingling. The differential diagnosis for a patient with symptoms of a neck mass includes benign tumors like neurofibromas, malignant tumors like chordomas, and non-neoplastic conditions like cervical spondylitis. A magnetic resonance imaging (MRI) study of the cervical spine with and without contrast identified a T1 hypointense, T2 hyperintense, heterogeneously enhancing prevertebral mass with parapharyngeal extension. A direct laryngoscopy with biopsy was performed and revealed a paraspinal tumor. The patient’s diagnosis of cervical chordoma was confirmed upon detection of Brachyury, a gene that encodes a transcription factor which promotes epithelial mesenchymal transition (EMT) in chordoma pathogenesis. Chordomas are slow-growing tumors located within the body’s midline and they are associated with poorer outcomes because of neurovascular encasement at time of presentation. Chordomas are rare, with an incidence of 1 in 1,000,000. Approximately 6% of chordomas are located in the cervical spine. They are typically treated with surgery followed by radiation therapy. The patient underwent anterior resection for the prevertebral mass in the C2-C6 section of the cervical spinal cord. Surgery achieved subtotal resection and involved removal of the spinous processes of C3-C5 and reconstruction of the cervical spine with implants. The patient will be starting proton beam radiotherapy for his adjuvant treatment. Although rare, it is important to keep chordomas in the differential diagnosis when evaluating a patient with a neck mass.
This case report illustrates a case of guttate psoriasis in a young adult and the logistical role dermatologists can play in patients acquiring their prescriptions and improving the quality of their care.
Background: Hypoxemic ischemic encephalopathy (HIE) is a major cause of morbidity and mortality in the neonatal population. Recent research has shown human adipose stem cells (hASCs) to have neuroprotective effects in animal models of HIE. This study tested the hypothesis that neurodevelopmental outcomes would be improved using hASC therapy in term neonatal HIE rat model. Methods: Seven day old rats underwent left carotid artery ligation followed by 8% oxygen for 120 minutes, or carotid isolation in shams. Forty-eight hours after surgery half of the rats received hASCs and half normal saline (NS) intravenously. Rota-rod and cylinder tests were used to assess skill learning, balance, coordination, and symmetry of limb use at 2, 4 and 6 weeks of life. Results: HIE rats treated with hASCs traveled further on Rota-rod (p=0.03) when compared to HIE with NS groups. Those in the HIE-hASC group had significant improvement in the usage of the affected limb at week 6 (p=0.03) compared to those with HIE and NS. Rats receiving hASCs post HIE had less cortical atrophy compared to those with HIE and NS. Conclusions: Rats with HIE treated with hASCs showed improvement in long-term neurodevelopmental aspects and decreased cortical atrophy compared to HIE control group.
