Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia.

OBJECTIVES: Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children. METHODS: Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included. RESULTS: Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children. CONCLUSIONS: Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.

Screening for Youth Firearm Violence Exposure in Primary Care.

Introduction: The aim of this study was to assess a modified gun violence exposure tool at a pediatric clinic on the West Side of Chicago to identify youth at high risk of future gun violence. Methods: A modified version of the SaFETy gun violence exposure tool, studied in a community pediatric primary care setting, was implemented from June to August 2021. Patients and pediatric clinicians were surveyed after pilot. Results: Of 508 eligible patients, 341 youth (67.1%) completed the SaFETy tool. None had a SaFETy score ≥6, the threshold for immediate referral. Over a quarter (26.4%) of youth had scores of 1-5, and of those, 7.8% were referred at the clinician's discretion. Youth (n=84) participants randomly selected to complete an anonymous survey provided feedback about the SaFETY tool, reporting that the questions were easy to understand (92%). All 6 pediatric clinicians surveyed agreed that the tool helped to identify youth exposed to gun violence. Conclusions: Screening for gun violence exposure among youth is logistically feasible in the pediatric outpatient setting. A more sensitive validated tool to stratify low-/medium-risk patients in the primary care setting is needed.

Development and Evaluation of a Wearable Simulator System.

Background: Peer physical examination is a clinical teaching-learning approach used for decades because of the convenient sample of peers for practicing. However, this approach has limitations when learning to assess abnormalities and threatens psychologically safe learning. A wearable simulator system was designed for learning physical examination skills to minimize ethical and learning challenges. Sample: The sample consisted of fifty prelicensure nursing students and ten faculty in an upper Midwest university. Method: The wearable simulator was constructed into a vest with RFID tags and ribcage landmarks. An observational, evaluative design was used for participants to rate seven categories during a one-hour evaluation session of the wearable simulator worn by a standardized patient trained to portray an individual with pneumonia. Results: Satisfaction was rated highly among participants. More than 80% of student participants indicated the wearable simulator promotes privacy and reduces embarrassment. Conclusion: The wearable simulator system offers a promising teaching-learning alternative with scenario-specific auscultation and palpation feedback to provide a safe, repeatable, and consistent simulation experience.

Cross-sectional association of light sensor-measured time outdoors with physical activity and gross motor competency among U.S. preschool-aged children: the 2012 NHANES National Youth Fitness Survey.

BACKGROUND: Time spent outdoors (outdoor time) has been suggested to be beneficial for physical activity (PA) and healthy development among preschool-aged children. The aim of this study was to quantify PA level and gross motor competency associated with light sensor-measured daily outdoor time in a representative sample of U.S. children aged 3 to 5 years. METHODS: The study sample included 301 participants (149 girls) aged 3 to 5 years from the 2012 U.S. National Health and Examination Survey National Youth Fitness Survey. ActiGraph GT3X+ accelerometers with a built-in ambient light sensor were used to measure PA (expressed in monitor-independent movement summary [MIMS]) and outdoor time. The Test of Gross Motor Development-Second Edition (TGMD-2) was used to assess gross motor skills. Multivariable linear regression models were fit to predict daily and gross motor scores by daily outdoor time. RESULTS: Average daily outdoor time was 95 min (median of 84 min; interquartile range of 52 to 123 min). Means of daily outdoor time and daily MIMS were not significantly different between boys and girls. Among girls, every additional 10 min of daily outdoor time was associated with an additional 540 daily total MIMS (95% CI = 372, 708). Among boys, every additional 10 min of daily outdoor time was associated with an additional 296 daily total MIMS (95% CI = 131, 460). Every additional 10 min of daily outdoor time was associated with a 0.1-point (95% CI = 0.001, 0.130) higher object control standard score. Daily outdoor time was not associated with a locomotor standard score. CONCLUSIONS: In a representative sample of U.S. preschool-aged children, daily outdoor time was positively associated with daily PA. The contribution of outdoor time to PA was greater among girls than boys, suggesting that providing outdoor opportunities is critical for promoting PA, particularly among girls.

Projected Augmented Reality (P-AR) for Enhancing Nursing Education About Pressure Injury: A Pilot Evaluation Study.

PURPOSE: To describe results of a study evaluating a Projected Augmented Reality (P-AR) system for its potential to enhance nursing education about pressure injuries. DESIGN: Pilot evaluation survey. SUBJECTS AND SETTING: The sample comprised nursing students and faculty at a school of nursing in a large, Midwestern public university. A total of 32 participants, which included 27 students (30% BSN, 44% MN, and 26% DNP students; 81% female) and 5 faculty members (80% female) participated. METHODS: The P-AR system was prototyped using commercial-off-the-shelf components and software algorithms, applied to pressure injury nursing education content. After interaction with the P-AR system, participants completed a survey evaluating the following features of the P-AR system for potential: engagement, effectiveness, usefulness, user-friendliness, and realism, and users' overall impression and satisfaction with system features. Evaluation statements used a 5-level Likert-scale; open-ended questions about what was liked, disliked, or anything else offered opportunity for comments. RESULTS: Student and faculty median evaluation scores were 5 (strongly agree or very satisfied) and 4 (agree or satisfied) for nearly all evaluation and satisfaction statements. Students' satisfaction with "realism" received a median score of 3 (neutral). The P-AR system was refined to include realistic still and animated images. CONCLUSION: The P-AR system, an innovative technology using 3-dimensional dynamic images, was applied to nursing education content about pressure injury and was evaluated as having potential to enhance pressure injury teaching and learning. Education about complex processes of pressure injury development and management may benefit from using cutting-edge simulation technologies such as P-AR.

Views of wheelchair users and caregivers regarding a passive safety monitoring system for electric powered wheelchair operators with cognitive impairment.

The opinions of cognitively intact current wheelchair users and their professional caregivers were solicited to explore acceptability of the concept of a passive electric wheelchair-mounted movement monitor to track driving safety and cognitive impairment. Two focus groups of electric wheelchair users (N = 9), and two focus groups of staff caregivers (N = 8) were conducted at a congregate care facility. Participants also completed a questionnaire examining their perceptions of the concept. The results indicated most wheelchair users and staff caregivers were receptive to the idea of a passive safety monitoring system for wheelchairs to detect cognitive impairment. Three main and interrelated themes emerged regarding how the device could promote safety, how such a system might infringe upon the users' autonomy, and how and to whom the cognitive state information should be communicated. Legal, training, and marketing issues reflected similar concerns over balancing autonomy with safety issues. If successfully addressed, it appears there would be support for the device's use not only for older adults in institutional settings, but perhaps also among community living younger and older adults. A passive safety monitoring system for wheelchairs is acceptable to wheelchair users and can be successfully marketed if developers balance autonomy and safety concerns.

Clinical and technical factors associated with knee radiofrequency ablation outcomes: a multicenter analysis.

BACKGROUND: There has been a surge in interest in radiofrequency ablation (RFA) of the genicular nerves over the past decade, with wide variability in selection, technique and outcomes. The aim of this study is to determine factors associated with treatment outcome. METHODS: We retrospectively evaluated the effect of 23 demographic, clinical and technical variables on outcomes in 265 patients who underwent genicular nerve RFA for knee pain at 2 civilian and 1 military hospital. A primary outcome was designated as a > 30% decrease in average knee pain score lasting at least 3 months without cointerventions. RESULTS: The overall rate of a positive response was 61.1% (95% CI 55.2% to 67.0%). In univariable analysis, larger electrode size (p=0.01), repeated lesions (p=0.02), having>80% pain relief during the prognostic block (p=0.02), not being on opioids (p=0.04), having no coexisting psychiatric condition (p=0.02), having a lower baseline pain score (p=0.01) and having >3 nerves targeted (p=0.02) were associated with a positive outcome. In multivariate logistic analysis, being obese (OR 3.68, 95% CI 1.66 to 8.19, p=0.001), not using opioids (OR 0.35, 95% CI 0.16 to 0.77, p=0.009), not being depressed (OR 0.29, 95% CI 0.10 to 0.82, p=0.02), use of cooled RFA (OR 3.88, 95% CI 1.63 to 9.23, p=0.002) and performing multiple lesions at each neural target (OR 15.88, 95% CI 4.24 to 59.50, p<0.001) were associated with positive outcome. CONCLUSIONS: We identified multiple clinical and technical factors associated with treatment outcome, which should be considered when selecting patients for RFA treatment and in the design of clinical trials.

Critical Events Leading to Endotracheal Reintubation in the Postanesthesia Care Unit: A Retrospective Inquiry of Contributory Factors.

The tracheal reintubation of a surgical patient in the postanesthesia care unit (PACU) is a critical event that increases patient morbidity and mortality, cost, and staff demands. We performed a descriptive retrospective cohort study to identify the incidence of reintubation after planned extubation (RAP) in the PACU from 2010 to 2017. The incidence of RAP was 0.00083% (89/107,845) for the entire study period, an incidence range from 0.00014% to 0.00172% (1/7,407 to 26/15,139) with a steady decline from 2011 to 2017. A post hoc application of published prediction tools demonstrated that most RAP cases could be predicted preoperatively when the RAP predictive risk index (described in 2013) was applied to patients over the age of 64 years. Preoperative attention to increased risk of RAP decreases the incidence of RAP. Neuromuscular blockade (NMB) must be monitored, and reversal must be ensured. Attempting to reverse moderate to deep NMB with increased dosing of neostigmine should be avoided, and NMB reversal with sugammadex should be used in these cases and when residual weakness is observed. Hypothermia must be avoided, and a multimodal pain management regimen must be adopted.

Assessing and Mobilizing Faith Organizations to Implement Childhood Obesity Prevention Advocacy Strategies.

Childhood obesity remains a public health problem requiring mobilization across diverse social and political sectors. The faith-based sector can contribute to obesity prevention advocacy when existing resources are supported and leveraged. This article describes an advocacy resource assessment conducted in six Chicago faith organizations. Key administrators and congregation members were surveyed to identify organizational resources that could be mobilized for childhood obesity prevention advocacy. Survey data were analyzed using SPSS and Excel. Descriptive statistics were calculated for each organization and for all combined. Organizational resources for advocacy were identified, with varying degrees of resources within organizations. Congregation members and faith leaders expressed interest in advocacy training and activities but acknowledged competing organizational priorities. Participating organizations received a stipend to pursue recommended action items based on their assessment. Faith organizations have unique resources and human capital and can be key partners in childhood obesity prevention. Conducting an assessment prior to planning interventions and advocacy approaches can strengthen partnerships, leverage assets among partners, and ensure efforts are relevant and beneficial for faith organizations. It may also be strategic to incorporate funding in grant budgets in order to empower faith organizations to act on findings from the assessment process.

Society of Behavioral Medicine position statement: early care and education (ECE) policies can impact obesity prevention among preschool-aged children.

The Society of Behavioral Medicine (SBM) urges policymakers to help prevent childhood obesity by improving state regulations for early care and education (ECE) settings related to child nutrition, physical activity, and screen time. More than three quarters of preschool-aged children in the USA attend ECE settings, and many spend up to 40 h per week under ECE care. ECE settings provide meals and snacks, as well as opportunities for increasing daily physical activity and reducing sedentary screen time. However, many states' current policies do not adequately address these important elements of obesity prevention. A growing number of cities and states, child health organizations, medical and early childhood associations, and academic researchers are beginning to identify specific elements of policy and regulations that could transform ECE settings into environments that contribute to obesity prevention. Let's Move! Child Care recommends a set of straightforward regulations addressing nutrition, physical activity, and screen time in ECE settings. These emerging models provide local and state leaders with concrete steps to implement obesity prevention initiatives. We provide a set of recommendations based upon these models that will help state and local policymakers to improve current policies in ECE settings.

The Relationship Between the Social Environment and Lifestyle-Related Physical Activity in a Low-Income African American Inner-City Southern Neighborhood.

The social ecological model was used to examine individual, interpersonal, and neighborhood characteristics related to lifestyle-related physical activity (PA) in a low-income African American (AA) population in New Orleans, Louisiana. Interviewers administered surveys to randomly-sampled household participants from three low-income, AA neighborhoods in New Orleans, Louisiana. Questions included the social and physical environment, physical activity, interpersonal factors, demographics, height and weight. Logistic regression multivariable models were built predicting whether the respondent met PA guidelines, controlling for neighborhood. Females were less as likely to engage in lifestyle-related PA compared to males (OR 0.46, CI 0.30-0.70). Support specific for PA was correlated with engaging in lifestyle-related PA (OR 1.45, CI 1.14-1.83). The individual and social environment should be considered for increasing PA in AA. Interventions targeting the AA population could consider ways of enhancing social support for PA.

Working with community partners to implement and evaluate the Chicago Park District's 100% Healthier Snack Vending Initiative.

BACKGROUND: The objective of this case study was to evaluate the acceptability, sales impact, and implementation barriers for the Chicago Park District's 100% Healthier Snack Vending Initiative to strengthen and support future healthful vending efforts. COMMUNITY CONTEXT: The Chicago Park District is the largest municipal park system in the United States, serving almost 200,000 children annually through after-school and summer programs. Chicago is one of the first US cities to improve park food environments through more healthful snack vending. METHODS: A community-based participatory evaluation engaged community and academic partners, who shared in all aspects of the research. From spring 2011 to fall 2012, we collected data through observation, surveys, and interviews on staff and patron acceptance of snack vending items, purchasing behaviors, and machine operations at a sample of 10 Chicago parks. A new snack vending contract included nutrition standards for serving sizes, calories, sugar, fat, and sodium for all items. Fifteen months of snack vending sales data were collected from all 98 snack vending machines in park field houses. OUTCOMES: Staff (100%) and patrons (88%) reacted positively to the initiative. Average monthly per-machine sales increased during 15 months ($84 to $371). Vendor compliance issues included stocking noncompliant items and delayed restocking. INTERPRETATION: The initiative resulted in improved park food environments. Diverse partner engagement, participatory evaluation, and early attention to compliance can be important supports for healthful vending initiatives. Consumer acceptance and increasing revenues can help to counter fears of revenue loss that can pose barriers to adoption.

Engaging Chicago hospitals in the baby-friendly hospital initiative.

Breastfeeding is now widely recognized as a vital obesity prevention strategy and hospitals play a primary role in promoting, supporting and helping mothers to initiate and maintain breastfeeding. The Baby-Friendly Hospital Initiative (BFHI) provides an evidence-based model that hospitals can use to plan and implement breastfeeding quality improvement (QI) projects. Funding under Communities Putting Prevention to Work (CPPW), administered by the CDC, brought together key Chicago partners to provide individualized support and technical assistance with breastfeeding QI projects to the 19 maternity hospitals in Chicago. A community organizing approach was taken to mobilize hospital interest in breastfeeding QI projects, leading to successes, e.g. 12/19 (63 %) Chicago hospitals registered with Baby-Friendly USA, Inc. (BFUSA) to pursue official Baby-Friendly designation. Key factors that fostered this success included: involving all levels of hospital staff, financial incentives, and ongoing tailored technical assistance. To assist other communities in similar work, this article discusses the approach the project took to mobilize hospitals to improve breastfeeding support practices based on the BFHI, as well as successes and lessons learned.

Endoscopic endonasal anatomy of the nasopharynx in a cadaver model.

BACKGROUND: Nasopharyngectomy is an accepted treatment for recurrent nasopharyngeal carcinoma following radiation with or without chemotherapy. Traditionally, the nasopharynx has been approached through relatively invasive "open" techniques including transpalatal, maxillary swing, and trans-mandibular-pterygoid approaches. Contemporary management has included the use of endoscopic techniques to exenterate tumors in this location. The purpose of the present study is to describe the endoscopic anatomy of this region through cadaveric dissection and to characterize the technical limitations of the approach. METHODS: Five fresh cadaveric heads were dissected to study the endoscopic anatomy of the nasopharynx and associated structures. RESULTS: Endoscopic dissection of the nasopharynx was completed in all 5 specimens. Nasopharyngeal anatomy including the buccopharyngeal fascia, pharyngobasilar fascia, superior constrictor, longus capitus, longus coli, fossa of Rosenmuller, basisphenoid, auditory torus, and internal carotid artery were characterized. CONCLUSION: Surgical access to the nasopharynx has posed significant challenges in the treatment of recurrent or persistent nasopharyngeal carcinoma. This study demonstrated that endoscopic dissection of this region is feasible and has the potential to completely exenterate these lesions.

First constraints on the running of non-Gaussianity.

We use data from the Wilkinson Microwave Anisotropy probe temperature maps to constrain a scale-dependent generalization of the popular "local" model for primordial non-Gaussianity. In the model where the parameter f(NL) is allowed to run with scale k, f(NL)(k) = f*(NL) (k/k(piv))(n)(fNL), we constrain the running to be n(f)(NL) = 0.30(-1.2)(+1.9) at 95% confidence, marginalized over the amplitude f*(NL). The constraints depend somewhat on the prior probabilities assigned to the two parameters. In the near future, constraints from a combination of Planck and large-scale structure surveys are expected to improve this limit by about an order of magnitude and usefully constrain classes of inflationary models.

Effect of changes to the neighborhood built environment on physical activity in a low-income African American neighborhood.

INTRODUCTION: Obesity is a public health problem that is due in part to low levels of physical activity. Physical activity levels are influenced by the built environment. We examined how changes in the built environment affected residents' physical activity levels in a low-income, primarily African American neighborhood in New Orleans. METHODS: We built a 6-block walking path and installed a school playground in an intervention neighborhood. We measured physical activity levels in this neighborhood and in 2 matched comparison neighborhoods by self-report, using door-to-door surveys, and by direct observations of neighborhood residents outside before (2006) and after (2008) the interventions. We used Pearson χ² tests of independence to assess bivariate associations and logistic regression models to assess the effect of the interventions. RESULTS: Neighborhoods were comparable at baseline in demographic composition, choice of physical activity locations, and percentage of residents who participated in physical activity. Self-reported physical activity increased over time in most neighborhoods. The proportion of residents observed who were active increased significantly in the section of the intervention neighborhood with the path compared with comparison neighborhoods. Among residents who were observed engaging in physical activity, 41% were moderately to vigorously active in the section of the intervention neighborhood with the path compared with 24% and 38% in the comparison neighborhoods at the postintervention measurement (P < .001). CONCLUSION: Changes to the built environment may increase neighborhood physical activity in low-income, African American neighborhoods.

Role of rhinitis in laryngitis: another dimension of the unified airway.

OBJECTIVES: We evaluated the prevalence of dysphonia and secondary laryngeal symptoms among patients with allergic rhinitis (AR), nonallergic rhinitis (NAR), and no rhinitis symptoms (controls). METHODS: Patients with rhinitis symptoms with positive and negative allergy tests were recruited from allergy clinics, and patients without rhinitis symptoms were recruited from an orthopedic clinic. All groups completed the Voice-Related Quality of Life survey (VRQOL),the mini-Rhinoconjunctivitis Quality of Life Questionnaire (mini-RQLQ), and the Reflux Symptom Index (RSI). RESULTS: Completing the study were 134 patients with AR, 54 patients with NAR, and 62 controls. Both AR and NAR patients had an increased prevalence of dysphonia compared to controls (32.8% and 26.9% versus 8.1%, respectively; p = 0.001). When we controlled for confounding variables such as asthma, inhaled steroid use, and gastroesophageal reflux, patients with either AR or NAR had higher odds of dysphonia (odds ratio, 4.22; 95% confidence interval, 1.03 to 17.32). Patients with worse mini-RQLQ scores had lower VRQOL scores and higher RSI scores (Spearman correlation of -0.47 and p < 0.001 and Spearman correlation of 0.6 and p <0.001, respectively). CONCLUSIONS: Patients with rhinitis (AR or NAR) had a higher prevalence of dysphonia than did controls. Patients with worse rhinitis symptoms had worse voice-related quality of life and more severe chronic laryngeal symptoms.

Outcomes of the 5-4-3-2-1 Go! Childhood obesity community trial.

OBJECTIVES: To determine effects of the 5-4-3-2-1 Go! community social marketing campaign on obesity risk factors. METHODS: We randomly assigned 524 parents of 3- to 7-year-old children to receive 5-4-3-2-1 Go! counseling or not. We surveyed parents about 5-4-3-2-1 Go! behaviors and perceptions of children's behaviors at baseline and one year later. We conducted multivariable logistic regression for each outcome. RESULTS: Parents who received counseling consumed more fruits and vegetables at follow-up (OR 1.749, [95% CI: 1.01-3.059]). Parental exposure to messaging at children's school events was associated with higher water consumption (6.879, [1.954-24.212]). CONCLUSIONS: 5-4-3-2-1 Go! is a promising intervention.

Prostatic involution after intraprostatic injection of cobra toxin.

PURPOSE: We evaluated the comparative effects of intraprostatic injection of cobra cardiotoxin D and botulinum toxin type A on prostate structure in the rat model. MATERIALS AND METHODS: A total of 18 Sprague-Dawley® rats weighing 500 to 600 gm received a single 0.1 ml injection of saline (6), botulinum toxin type A (6) or the cardiotoxin D (6) component of cobra (Naja naja atra) toxin in the right and left ventral lobes of the prostate. At 14 days the rats were sacrificed. The prostate glands were harvested, weighed and processed for immunohistochemical and morphological studies. RESULTS: Prostate glands injected with cardiotoxin D showed significantly decreased weight compared to that of prostates injected with botulinum toxin type A and the saline control. Prostatic atrophy in the glandular component with flattening of the epithelial lining was seen histologically in rats that received botulinum toxin and cardiotoxin D. Each group injected with cardiotoxin D and botulinum toxin showed a significant increase in the number of apoptotic cells compared with controls while only the botulinum toxin group showed a significant increase in the number of proliferating cells. Only rats injected with botulinum toxin had body weight loss. CONCLUSIONS: Our study shows that intraprostatic injection of cobra cardiotoxin D induces prostatic atrophy and leads to a decrease in prostatic weight greater than that of intraprostatic injection of botulinum toxin type A. No systemic effects, such as decreased body weight, were noted after cardiotoxin D injection. Further studies are warranted but the statistically significant decrease in the number of proliferating cells implies a prolonged effect of cardiotoxin D.