Emergency Department Pediatric Readiness: A Trauma Center Quality Improvement Initiative.

BACKGROUND: Most pediatric patients present to general emergency departments, yet maintaining pediatric equipment, skilled staff, and resources remains a challenge for many hospitals. Pediatric readiness assessment is now a requirement for trauma center verification. OBJECTIVE: This study aims to assess the impact of a quality improvement initiative to improve emergency department pediatric readiness. METHODS: A pre- and poststudy design was used to evaluate a quality improvement initiative to improve the National Pediatric Readiness assessment survey results conducted at a Southwestern United States adult Level I trauma center from September 2022 to April 2023. The multicomponent initiative included implementing a pediatric emergency care coordinator, pediatric-specific policies and procedures, identifying pediatric-specific quality and performance indicators, and educating pediatric-specific staff. Study inclusion criteria were all patients younger than 18 years who presented to the emergency department. The primary outcome measure was the improvement in the weighted Pediatric Readiness Score. Secondary outcomes were throughput, nursing documentation of vital signs, and pain scores. RESULTS: A total of N = 2,356 patients met inclusion, of which n = 1,158 (49.2%) were in the preintervention group and n = 1,198 (50.8%) postintervention group. The weighted Pediatric Readiness Score improved by 45.4%. Transfers to a pediatric hospital increased from 4.1% to 8.6% (p = .016). Blood pressure documentation improved slightly from 88.3% to 88.6%. Pain score documentation decreased from 83.9% to 63.1% (p = .008). Pain medication and administration improved from 19.8% to 26.7% (p = .046). CONCLUSION: We found that participation in the quality improvement initiative was associated with emergency department pediatric readiness improvements.

New Zealand patients have a higher melanoma burden in sentinel nodes and completion lymphadenectomy than patients in MSLT-II.

New Zealand has the highest rate of melanoma-related mortality in the world. Access to immunotherapy and radiology is limited and surgical treatment of regional disease remains important. A recent pilot study of a single health district observed a higher nodal melanoma burden than was reported in the second Multicentre Selective Lymphadenectomy Trial (MSLT-II). In this study, a series of regional censuses were undertaken covering the 10 years immediately prior to the publication of MSLT-II. The study population was seven District Health Boards covering 62.2% of the population of New Zealand across a 10-year period preceding MSLT-II. The primary outcomes measured were the size of sentinel lymph node metastases and non-sentinel node (NSN) positivity on completion lymph node dissection (CLND) for patients with a positive sentinel lymph node biopsy (SLNB). In the 2323 SLNB identified, the mean sentinel lymph node metastatic deposit size was larger compared to MSLT-II (2.55 vs. 1.07/1.11 mm). A greater proportion of New Zealand patients (44.2%) had metastatic deposits larger than 1 mm compared to MSLT-II (33.2/34.5%) and the rate of non-sentinel node involvement on CLND was also higher (22.2% vs. 11.5%). These findings indicate that New Zealand is a high-risk population for nodal melanoma metastases. Due to these differences, the conclusions of MSLT-II may not be able to be applied to melanoma patients in the 7 regions studied in New Zealand.

Taste Perceptions of Common Pediatric Antibiotic Suspensions and Associated Prescribing Patterns in Medical Residents.

OBJECTIVE: Palatability of medication is an important factor for adherence, especially in pediatric populations that tend to use oral suspensions for antibiotic therapy. Our study is the first to evaluate the impact of taste on prescribing patterns of antibiotic suspensions. The objective was to determine if taste testing common antibiotic suspensions altered prescribing patterns of medical residents, through data extracted from the electronic health record. METHODS: After assessing 5 "primer" tastes (sweet, salty, bitter, sour, umami [savory]), residents were randomized to sample 6 antibiotic suspensions to rate their taste perception. A 12-month retrospective and prospective analysis of outpatient prescribing practices of the residents followed, and the results were compared to the resident cohort randomized to no taste test. RESULTS: The 43 residents prescribed 207 liquid antibiotic prescriptions for 176 patients, with no difference in patient characteristics between residents in the taste test versus non-taste test group. Although amoxicillin was most preferable and amoxicillin-clavulanate least, the only significant finding was a greater prescribing rate of cefdinir among those who had tasted it and an inverse relationship between cephalexin taste preference and percentage prescribing amoxicillin in the taste group. Residents who tasted were poor in identifying primer tastes, but this did not impact prescribing patterns. CONCLUSIONS: Among 6 commonly prescribed antibiotic suspensions, amoxicillin remains a highly preferred taste among prescribers. Interestingly, after the taste test there was a significantly greater prescribing rate of cefdinir among those who had tasted it and somewhat lower prescribing rate for amoxicillin-clavulanate.

Low Rates of Clinician Monitoring for Second Generation Antipsychotic Medications in Community Pediatric Practice.

Second generation antipsychotic (SGA) medications are frequently prescribed to pediatric patients in the United States. This retrospective observational study sought to ascertain the extent of adherence to established pediatric SGA monitoring guidelines in community practice. The team used the electronic health record to determine clinician adherence to SGA monitoring guidelines at baseline, 12-week, and annual times relative to prescribing an SGA. At the time of their SGA prescription, 5.5% of pediatric patients had received all of the orders according to the monitoring guidelines. Annually, 2.5% of patients had received the necessary orders to completely adhere to monitoring guidelines; 42% of patients received no monitoring orders. Monitoring was more likely for children who had multiple types of providers and interacted with the healthcare system beyond a traditional office visit. This research informs healthcare providers about the gap between prescribing and monitoring for SGA medications in community practice for pediatric populations.

Most Second-Generation Antipsychotic Prescriptions in Community Practice Are Neither FDA-Approved nor Within Prescribing Guideline Recommendations.

OBJECTIVE: Second-generation antipsychotic (SGA) prescription use has become increasingly prevalent in the pediatric population, despite metabolic adverse effects. A significant number of SGA medications are prescribed for indications that are not approved by the FDA. This study aimed to quantify clinician adherence to the FDA and professional society indication, age, and dosing guidelines when prescribing SGA medications for pediatric patients. METHODS: We used electronic health record data from 3 health care systems. We analyzed outpatient encounters where a pediatric patient was prescribed an SGA during an 18-month time frame. Clinician prescribing patterns were compared to a therapeutic regimen table created using professional society guidelines and FDA medication labels. RESULTS: Most of the encounters listed an indication that was not documented as a recommended use (84.3%). Most prescriptions aligned with the generalized dose guidelines (93.8%) and age guidelines (94.9%). Clinicians were more likely to follow indication guidelines when prescribing risperidone, the highest adherence medication, compared with quetiapine, the lowest adherence medication (odds ratio [OR], 2.5; 95% CI, 1.1-6.0). Compared with prescriptions for younger children, clinicians were more likely to follow indication guidelines for children aged 13 to 15 years (OR, 2.8; 95% CI, 1.1-7.2) and 16 to 18 years (OR, 3.1; 95% CI, 1.2-8.1). CONCLUSION: Community clinicians overall demonstrated a low level of adherence to indication guidelines when prescribing SGA medications to pediatric populations, while maintaining higher adherence to age and dosing guidelines. Older children were more likely to receive an SGA prescription for recommended indications compared with younger children.

Melanoma with osseous or chondroid differentiation: a report of eight cases including SATB2 expression and mutation analysis.

Melanoma can present with osteocartilaginous differentiation, however few reports exist on this rare subtype. We present eight cases of melanoma with osteocartilaginous differentiation to highlight its clinical, pathological and molecular features. The cases showed no association with gender (5 males and 3 females) or age (range 23-84 years). Cases included both primary melanomas and distant metastases (6 and 2, respectively), with the majority arising from cutaneous sites (7/8) and the remaining case from a mucosal site. Tumour-infiltrating lymphocyte (TIL) score ranged from 0 to 3 (median 1), and 2/8 lesions had evidence of inflammatory changes or antecedent trauma. No recurrent mutations were found in the tumours by next generation sequencing, and the mutations observed were typical of melanoma rather than osteosarcomatous lesions. The majority of tumours stained positive for melanoma markers including S100, HMB45, Melan-A, SOX10 and MITF. Staining of the osteoblastic marker SATB2 varied from negative to widespread positive. We demonstrate that melanomas with osteocartilaginous differentiation are heterogeneous in presentation and are not typified by a recurrent mutation in cancer associated genes. Where uncertainty exists in diagnosing an osteocartilaginous lesion, a diagnosis of melanoma can be supported by the presence of genomic mutations typical of melanoma such as BRAF, NRAS and NF1, and IHC staining positive for S100, HMB45, Melan-A, SOX10 and MITF. SATB2 may be positive in these lesions and thus should not be used to rule out melanoma.

An exploration of perceived neonatal nurse practitioner authority in a restricted practice setting.

BACKGROUND: Perceptions of autonomy in practice affect Neonatal Nurse Practitioner (NNP) job satisfaction, retention, and motivation to pursue NNP roles. However, Novice to Expert theory describes the processes for transitioning to nurse practitioner roles are not in relationship with NNP practice autonomy. PURPOSE: Relationships between Advanced Practice Registered Nurse (APRN) practice authority, state restrictions, APRN volume, and health care access exist. However, do APRN perceptions of autonomy relate to motivation to pursue practice authority? This study provides an exploration of perceptions of NNP practice autonomy in this context. METHODOLOGY: Semistructured interviews conducted with NNPs and neonatologists practicing in a restricted setting explored perceptions of practice expertise and autonomy, based on Patricia Benner's Novice to Expert theoretical framework. Laddered methodology organized survey questions, and the Framework Method was used for analysis of results. RESULTS: The majority of eligible NNPs (n = 12, 67%) and neonatologists (n = 8, 67%) agreed to study participation. Identified themes were grouped into larger concepts, including "NNP practice authority," "NNP expertise," and "NNP autonomy." For example, "NNP expertise" included the theme "determining NNP expertise" and associated factors included "procedural skills," "years and acuity of practice level," and "confidence in management plan and emergent situations." CONCLUSIONS: Both neonatologists and NNPs perceived neonatologists as a practice authority with support for NNP autonomy. Factors indicating NNP expertise correlated with domains in Benner Novice to Expert theory. IMPLICATIONS: These findings support previous work concerning the evolution of expertise and transition to practice. More inquiry to understand perspectives of APRNs in restricted practice settings is indicated.

An Interdisciplinary Approach to Reducing Errors in Extracted Electronic Health Record Data for Research.

Erroneous electronic health record (EHR) data capture is a barrier to preserving data integrity. We assessed the impact of an interdisciplinary process in minimizing EHR data loss from prescription orders. We implemented a three-step approach to reduce data loss due to missing medication doses: Step 1-A data analyst updated the request code to optimize data capture; Step 2-A pharmacist and physician identified variations in EHR prescription workflows; and Step 3-The clinician team determined daily doses for patients with multiple prescriptions in the same encounter. The initial report contained 1421 prescriptions, with 377 (26.5 percent) missing dosages. Missing dosages reduced to 361 (26.3 percent) prescriptions following Step 1, and twenty-three (1.7 percent) records after Step 2. After Step 3, 1210 prescriptions remained, including 16 (1.3 percent) prescriptions missing doses. Prescription data is susceptible to missing values due to multiple data capture workflows. Our approach minimized data loss, improving its validity in retrospective research.

Attitudes of Michigan Female College Students About Pharmacists Prescribing Birth Control in a Community Pharmacy.

In the United States, the overall unintended pregnancy rate is about 45%. Women between 20-24 years old account for 59% of the unintended pregnancies. Continuous birth control use is related to decreasing unintended pregnancies. Therefore, we assessed female college students' opinions about pharmacists prescribing birth control in a community pharmacy using an intersectionality framework. A survey with 49 items about provider attributes, pharmacy services use and evaluation, advantages and barriers of pharmacists prescribing birth control, sexual and reproductive history, and demographics was distributed by survey link and QR code. Recruitment was done by investigators and students (snowballing technique) via emails, social media posts, and direct student contact. Respondents (n = 859) were 23.0 ± 4.9 years old, 83% white, 64% healthcare students, 32% student pharmacists, 69% sexually active, 68% with at least one episode of unprotected intercourse within a year, and 29% never using condoms. Forty-six percent of students were extremely likely and 26% moderately likely to get birth control from a pharmacist because it would be easier to adhere to birth control, could prevent unintended pregnancies, would be more convenient, and require less time. Concerns included the lack of Pap screenings and prescriptions written for the wrong birth control. Within most student characteristics or attitudes assessed, at least 70% of the students would use this service. Based on student opinions, female college students would use pharmacists prescribing birth control services.

Complete resection of colorectal cancer with ovarian metastases combined with chemotherapy is associated with improved survival.

BACKGROUND: Ovarian metastases (OM) from colorectal cancer (CRC) are uncommon, and data about optimal management are lacking. The aim of this study was to examine the management and outcomes of patients with OM from CRC. METHODS: A retrospective review of records of patients with a histopathological diagnosis of OM from CRC who were treated at Christchurch Hospital between 1 January 2000 and 31 December 2016. Data related to presentation, clinicopathological characteristics, treatment and outcomes were recorded. The primary outcomes were overall survival and disease-free survival. RESULTS: Thirty-one patients were identified (median age 55 years, range 28-77), with a median follow-up of 23 months (range 3-84 months). Abdominal pain was the most common presenting symptom (22 patients). Synchronous OM occurred in 22 patients, 14 patients had bilateral ovarian involvement. Twenty-one patients received adjuvant chemotherapy. R0 resection was achieved in 14 patients. For all patients the 5-year disease-free and overall survival were 11% and 12%, respectively, while 5-year overall survival for R0 resections was 30%. Improved median survival was associated with negative colon resection margins (26.7 months versus 7.8 months, P = 0.03), R0 resection (30.5 months versus 23.5 months, P = 0.04), and use of adjuvant chemotherapy (28.8 months versus 8.2 months, P < 0.0001); however, on multivariate analysis adjuvant chemotherapy was the only independent factor associated with improved prognosis (P = 0.01). CONCLUSIONS: OM from CRC are uncommon and carry a poor prognosis. Improved survival was associated with complete surgical resection of the primary tumour and metastatic disease in combination with systemic chemotherapy.

The role of the thalamus in ADHD symptomatology and treatment.

Attention-deficit hyperactivity disorder (ADHD) is a chronic disorder with symptoms of inattention and impulsivity that partially remit with age. A review of longitudinal studies of children and adolescents with ADHD showed that the majority will have continued cognitive and functional impairments into adulthood. The thalamus likely plays a prominent role in ADHD symptomatology, based on evidence that the thalamus generates waking-state electroencephalography (EEG) rhythms along with extensive thalamic neural circuitry connections with cortical and subcortical areas. Research demonstrates a specific abnormality in the thalamic pulvinar nucleus in ADHD populations. The thalamus can also play a role in ADHD treatment, based on solid evidence that both animals and humans can learn to self-regulate EEG oscillations. Given the underarousal and sleep disturbance commonly seen in ADHD, along with data that indicate an increased dosage of ADHD medication may improve behavioral control at a cost of lowered cognitive functioning, further investigation of the role for self-regulation through EEG training is warranted.

Beyond DSM: the role of auditory processing in attention and its disorders.

This article reviews and synthesizes recent research regarding auditory processing, attention, and their roles in generating both adaptive and maladaptive behavioral responses. Research in these areas is beginning to converge on the role of polymorphisms associated with catecholamine metabolism and transport, particularly the neurotransmitter dopamine. The synthesis offered in this article appears to be the first to argue that genetic differences in dopamine metabolism may be the common factor in four disparate disorders that are often observed to be comorbid, i.e., attention-deficit hyperactivity disorder, auditory processing disorders, developmental language disorders, and reading disorders.

Auditory pathways and processes: implications for neuropsychological assessment and diagnosis of children and adolescents.

Neuroscience research on auditory processing pathways and their behavioral and electrophysiological correlates has taken place largely outside the field of clinical neuropsychology. Deviations and disruptions in auditory pathways in children and adolescents result in a well-documented range of developmental and learning impairments frequently referred for neuropsychological evaluation. This review is an introduction to research from the last decade. It describes auditory cortical and subcortical pathways and processes and relates recent research to specific conditions and questions neuropsychologists commonly encounter. Auditory processing disorders' comorbidity with ADHD and language-based disorders and research addressing the challenges of assessment and differential diagnosis are discussed.