Maternal Confidence and Emergency Department Utilization Among Infants.

OBJECTIVES: To determine if maternal confidence affects emergency department (ED) utilization in the first year of life. METHODS: This retrospective cohort study examined the Maternal Confidence Questionnaire responses from a longitudinal birth cohort study and ED visits for these subjects across all Inova hospitals from January 2012 to July 2017 for full-term children 12 months or younger at the time of visit. Using logistic regression, maternal confidence, maternal race/ethnicity, age, education, parity, and insurance were evaluated against Emergency Severity Index acuity levels and ED visit frequency. RESULTS: Of 2429 participants in the longitudinal study, 316 subjects visited the ED and met inclusion criteria. Medicaid status was the main factor associated with any ED visit. Low maternal confidence did not correlate with more frequent or nonurgent ED visits. Higher maternal confidence scores were seen in Hispanic or Latino mothers and mothers with parity greater than 1. Hispanic or Latino mothers were more likely to have Medicaid and more likely to bring their child to the ED. Mothers with college education had lower maternal confidence scores, were less likely to visit the ED, but had higher acuity level visits. CONCLUSIONS: Low maternal confidence did not correlate with frequent ED visits or nonurgent visits. Medicaid status was the main factor associated with any ED visit. Hispanic or Latino mothers had higher maternal confidence scores, were more likely to have Medicaid and more likely to bring their child to the ED.

Bronchiolitis: From Practice Guideline to Clinical Practice.

The American Academy of Pediatrics' clinical practice guideline in bronchiolitis was last updated in 2014 with recommendations to improve care for pediatric patients with bronchiolitis. As most treatments of bronchiolitis are supportive, the guideline minimizes the breadth of treatments previously used and cautions the use of tests and therapies that have a limited evidence base. Emergency physicians must be familiar with the guidelines in order to apply best practices appropriately.

Are pediatric concussion patients compliant with discharge instructions?

BACKGROUND: Concussions are commonly diagnosed in pediatric patients presenting to the emergency department (ED). The primary objective of this study was to evaluate compliance with ED discharge instructions for concussion management. METHODS: A prospective cohort study was conducted from November 2011 to November 2012 in a pediatric ED at a regional Level 1 trauma center, serving 35,000 pediatric patients per year. Subjects were aged 8 years to 17 years and were discharged from the ED with a diagnosis of concussion. Exclusion criteria included recent (past 3 months) diagnosis of head injury, hospital admission, intracranial injury, skull fracture, suspected nonaccidental trauma, or preexisting neurologic condition. Subjects were administered a baseline survey in the ED and were given standardized discharge instructions for concussion by the treating physician. Telephone follow-up surveys were conducted at 2 weeks and 4 weeks after ED visit. RESULTS: A total of 150 patients were enrolled. The majority (67%) of concussions were sports related. Among sports-related concussions, soccer (30%), football (11%), lacrosse (8%), and basketball (8%) injuries were most common. More than one third (39%) reported return to play (RTP) on the day of the injury. Physician follow-up was equivalent for sport and nonsport concussions (2 weeks, 58%; 4 weeks, 64%). Sports-related concussion patients were more likely to follow up with a trainer (2 weeks, 25% vs. 10%, p = 0.06; 4 weeks, 29% vs. 8%, p < 0.01). Of the patients who did RTP or normal activities at 2 weeks (44%), more than one third (35%) were symptomatic, and most (58%) did not receive medical clearance. Of the patients who had returned to activities at 4 weeks (64%), less than one quarter (23%) were symptomatic, and most (54%) received medical clearance. CONCLUSION: Pediatric patients discharged from the ED are mostly compliant with concussion instructions. However, a significant number of patients RTP on the day of injury, while experiencing symptoms or without medical clearance. LEVEL OF EVIDENCE: Care management, level IV. Epidemiologic study, level III.

Cardiovascular reactivity to and recovery from stressful tasks following a mindfulness analog in college students with a family history of hypertension.

OBJECTIVES: Ninety-seven (97) undergraduates with a family history of hypertension participated in a study that evaluated the effects of a brief mindfulness-induction on cardiovascular reactivity and recovery to two stressors. MATERIALS AND METHODS: Participants were randomized to either a mindfulness-induction or control condition and were then exposed to the cold pressor task (CPT) followed by the mirror-tracing task (MT). Blood pressure and heart rate were measured at baseline and postinduction, as well as during and immediately following each stressor. RESULTS: There were no group differences in reactivity to either stressor. Participants in the mindfulness-analog condition experienced significantly greater latency to systolic blood pressure recovery following the CPT and a tendency toward greater latency to diastolic blood pressure recovery, although these findings were not replicated with the MT task. CONCLUSIONS: These results are contrary to what was hypothesized and to the anecdotal evidence available regarding effects of comprehensive mindfulness interventions on reactivity. The findings are discussed with respect to purported mechanisms of mindfulness and learning theory.

Factors contributing to anxious driving behavior: the role of stress history and accident severity.

Although fear and travel avoidance among anxious drivers are well documented, relatively little is known about the behavior of anxious individuals who continue to drive. Previous research has identified three broad domains of anxious driving behavior: exaggerated safety/caution behaviors, anxiety-based performance deficits, and hostile/aggressive driving behaviors. In an effort to explicate factors associated with the development of anxious driving behavior, associations with objective accident severity, accident-related distress, and life stress history were explored among individuals reporting accident involvement (N=317). Interactive effects of accident distress and self-reported stress history were noted across all three domains of anxious driving behavior. Examination of these effects indicates unique associations between accident distress and anxious behavior only in those reporting more severe life stress. Consistent with contemporary models of anxiety, these data suggest stress history may serve as a general vulnerability factor for development of anxious driving behavior following accident involvement.

Management of psychosocial distress by oncologists.

OBJECTIVE: Little is known about the nature of psychosocial care delivered by oncologists. The goal of this study was to survey oncologists about their management of psychosocial distress, referencing the National Comprehensive Cancer Network guidelines. METHODS: A random sample of 1,000 oncologists were sent an e-mail requesting their participation in an online survey; nonrespondents were sent the survey through postal mail. Regression analyses were conducted to identify independent predictors of care. RESULTS: Forty-six percent (448 of 965) of oncologists responded. Practice locations included: community (63%), cancer center (25%), and hospital (7%). Respondents estimated that over one-third of their patients (mean+/-SD=38%+/-22%) experience psychosocial distress warranting intervention, although only 225 of 447 (50%) indicated having mental health services affiliated with their practice. Nearly half (212 of 447, 47%) reported only initiating a referral for psychosocial services, and 214 of 447 (48%) reported both making a referral and starting psychiatric medications, mainly selective serotonin reuptake inhibitors and benzodiazepines. CONCLUSIONS: Most oncologists delivered some level of psychosocial care, although only half had affiliated mental health services.

Screening for psychosocial distress: a national survey of oncologists.

Little is known about the dissemination and uptake of National Comprehensive Cancer Network (NCCN) guidelines for psychosocial distress in oncology practice. This study surveyed oncologists about their awareness of NCCN guidelines on psychosocial distress and their methods of screening patients for distress. In all, 1,000 oncologists practicing in the United States who were members of the American Society of Clinical Oncology were asked to complete an anonymous questionnaire. Predictors of routine screening for distress were identified using logistic regression. Overall, 46% (448/965) of the oncologists responded. Almost two thirds (63.4%) practiced in the community, 27.2% practiced in cancer centers, and 6.9% practiced in hospitals. Less than one-third (32.3%) reported being at least somewhat familiar with NCCN guidelines. Two-thirds (65.0%; 95% confidence interval, 60.6-69.4) reported screening patients for distress routinely, but only 14.3% used a screening instrument. Independent predictors for screening patients for distress included availability of mental health services, knowledge of NCCN guidelines, experience, lack of time, uncertainty about identifying distress, and female gender of the practitioner. NCCN guidelines for psychosocial distress do not appear to be widely disseminated. Whereas the majority of oncologists reported routinely screening patients for distress, only a small percentage followed the guidelines by using a screening instrument. Future efforts should focus on the dissemination and validation of the NCCN guidelines.

Stroke associated with Barth syndrome.

Barth syndrome is an inherited disorder characterized by dilated cardiomyopathy, neutropenia, growth retardation, and skeletal myopathy. We describe a case of acute stroke owing to Barth syndrome that required intra-arterial thrombolysis. This case suggests that cardiovascular complications can be observed in patients with Barth syndrome. Stroke prevention measures, including the use of antithrombotic agents, might be warranted.

Prevalence of traumatic injuries in drowning and near drowning in children and adolescents.

OBJECTIVE: To determine the prevalence of traumatic injuries in children involved in drowning and near-drowning accidents. DESIGN/METHODS: Ten-year retrospective medical chart review of patients at an urban tertiary care pediatric facility. Included patients had International Classification of Diseases, Ninth Revision, Clinical Modification codes for fatal/nonfatal drowning or E codes for fall into water, accidental drowning, and submersion. We recorded demographics, event characteristics, diagnostics, and outcome data. We used the chi(2) or the Fisher exact test to compare patients with and without injuries. RESULTS: One hundred forty-three patients met inclusion criteria. Of these, 95 (66.4%) were male. Median age was 3.8 years, and 30 (23.4%) of 128 had preexisting conditions. Site of drowning was the pool (70.6%), the bathtub (19.0%), or natural water (10.4%). The prevalence of traumatic injury was 4.9% (95% confidence interval, 0%-28%). The predominant mechanism of injury was diving, and all injuries were to the cervical spine. Patients with injury were more likely to be older (mean age, 13.5 vs 5.1 years; P<.001) and to have a history of diving (85.7% vs 2.2%; P<.001). The presence of injury was not associated with sex, preexisting condition, or site of drowning (P>.05). CONCLUSIONS: The prevalence of traumatic injury in drowning and near drowning is low. We identified only cervical spine injuries, and all but 1 patient had a clear history of diving. Use of specialized trauma evaluations may not be warranted for patients in drowning and near-drowning accidents without a clear history of traumatic mechanism.