Opportunities and Challenges for Augmented Reality in Family Caregiving: Qualitative Video Elicitation Study.

BACKGROUND: Although family caregivers play a critical role in care delivery, research has shown that they face significant physical, emotional, and informational challenges. One promising avenue to address some of caregivers' unmet needs is via the design of digital technologies that support caregivers' complex portfolio of responsibilities. Augmented reality (AR) applications, specifically, offer new affordances to aid caregivers as they perform care tasks in the home. OBJECTIVE: This study explored how AR might assist family caregivers with the delivery of home-based cancer care. The specific objectives were to shed light on challenges caregivers face where AR might help, investigate opportunities for AR to support caregivers, and understand the risks of AR exacerbating caregiver burdens. METHODS: We conducted a qualitative video elicitation study with clinicians and caregivers. We created 3 video elicitations that offer ways in which AR might support caregivers as they perform often high-stakes, unfamiliar, and anxiety-inducing tasks in postsurgical cancer care: wound care, drain care, and rehabilitative exercise. The elicitations show functional AR applications built using Unity Technologies software and Microsoft Hololens2. Using elicitations enabled us to avoid rediscovering known usability issues with current AR technologies, allowing us to focus on high-level, substantive feedback on potential future roles for AR in caregiving. Moreover, it enabled nonintrusive exploration of the inherently sensitive in-home cancer care context. RESULTS: We recruited 22 participants for our study: 15 clinicians (eg, oncologists and nurses) and 7 family caregivers. Our findings shed light on clinicians' and caregivers' perceptions of current information and communication challenges caregivers face as they perform important physical care tasks as part of cancer treatment plans. Most significant was the need to provide better and ongoing support for execution of caregiving tasks in situ, when and where the tasks need to be performed. Such support needs to be tailored to the specific needs of the patient, to the stress-impaired capacities of the caregiver, and to the time-constrained communication availability of clinicians. We uncover opportunities for AR technologies to potentially increase caregiver confidence and reduce anxiety by supporting the capture and review of images and videos and by improving communication with clinicians. However, our findings also suggest ways in which, if not deployed carefully, AR technologies might exacerbate caregivers' already significant burdens. CONCLUSIONS: These findings can inform both the design of future AR devices, software, and applications and the design of caregiver support interventions based on already available technology and processes. Our study suggests that AR technologies and the affordances they provide (eg, tailored support, enhanced monitoring and task accuracy, and improved communications) should be considered as a part of an integrated care journey involving multiple stakeholders, changing information needs, and different communication channels that blend in-person and internet-based synchronous and asynchronous care, illness, and recovery.

Growing stronger together: Sharing a story of culturally responsive evaluation with indigenous families and communities.

BACKGROUND: Gaps exist in understanding how to create and conduct culturally responsive evaluations. This information is particularly critical when working with evidence-based programs and when involving populations that have and continue to experience oppression and trauma. OBJECTIVE: We share our story of developing and carrying out a culturally responsive evaluation of an EBP, Strengthening Families Program (SFP), with Indigenous families. PARTICIPANTS AND SETTING: A collective storytelling approach was used based on reflections from the evaluation team and key implementation staff. METHODS: We used a collective storytelling approach, organizing the content around six previously identified principles of Indigenous research (Tsosie et al., 2022). RESULTS: Emerging themes, supported by quotes throughout, illustrate the importance of organizing the integration of culture into the evaluation through the six principles of Indigenous research: respect, relationship, relevance, reciprocity, responsibility, and representation. CONCLUSION: Working toward a culturally responsive evaluation allowed for the creation of more meaningful connections with Indigenous community partners and families. It also acknowledged insights that partners and families bring to the work and encouraged multi-directional learning to occur between evaluators, partners, and families.

Growing stronger together: Implementing the Strengthening Families Program with Indigenous communities.

BACKGROUND: Child welfare agencies commonly seek to use evidence-based programs (EBPs) for their demonstrated results. Challenges remain in adapting programs to fit for Indigenous populations. We suggest that relationality holds promise as a guide in the implementation of EBPs with Indigenous families and children. OBJECTIVE: We provide the story of a culturally integrated implementation of the EBP, Strengthening Families Program (SFP), with Indigenous families. PARTICIPANTS AND SETTING: Insights from the staff who implemented SFP, project leadership and a community steering committee were brought together to create the collective implementation story. METHODS: A relational approach was used in thematic analysis with a focus on the three Rs - responsibility, respect, and reciprocity- that support Indigenous knowledge organization. RESULTS: Findings offer insight into cultural integrations in the implementation of SFP. The program centered Indigenous and community identities through meals, gifts, parenting practice examples and discussions tailored by each group of families and staff. Practices related to responsibility, respect and reciprocity each proved to be essential concepts in the relationship building among caregivers, children, SFP staff, project leadership, and community supporters that led to program success. CONCLUSION: Cultural integration created a space that reflected Indigenous knowledge relationality. It respected the uniqueness among groups of families who participated in the evidence-based SFP. Our story supports the importance of having Indigenous staff and group leaders to guide cultural integration in relationship with tribal communities.

Enacting Mana Maori Motuhake during COVID-19 in Aotearoa (New Zealand): "We Weren't Waiting to Be Told What to Do".

Maori, the Indigenous people of Aotearoa (New Zealand), were at the centre of their country's internationally praised COVID-19 response. This paper, which presents the results of qualitative research conducted with 27 Maori health leaders exploring issues impacting the effective delivery of primary health care services to Maori, reports this response. Against a backdrop of dominant system services closing their doors or reducing capacity, iwi, hapu and ropu Maori ('tribal' collectives and Maori groups) immediately collectivised, to deliver culturally embedded, comprehensive COVID-19 responses that served the entire community. The results show how the exceptional and unprecedented circumstances of COVID-19 provided a unique opportunity for iwi, hapu and ropu Maori to authentically activate mana motuhake; self-determination and control over one's destiny. Underpinned by foundational principles of transformative Kaupapa Maori theory, Maori-led COVID-19 responses tangibly demonstrated the outcomes able to be achieved for everyone in Aotearoa when the wider, dominant system was forced to step aside, to be replaced instead with self-determining, collective, Indigenous leadership.

Predicting hospital readmission risk: A prospective observational study to compare primary care providers' assessments with the LACE readmission risk index.

PURPOSE: This study aims to determine if the primary care provider (PCP) assessment of readmission risk is comparable to the validated LACE tool at predicting readmission to hospital. METHODS: A prospective observational study of recently discharged adult patients clustered by PCPs in the primary care setting. Physician readmission risk assessment was determined via a questionnaire after the PCP reviewed the hospital discharge summary. LACE scores were calculated using administrative data and the discharge summary. The sensitivity and specificity of the physician assessment and the LACE tool in predicting readmission risk, agreement between the 2 assessments and the area under receiver operating characteristic (AUROC) curves were calculated. RESULTS: 217 patient readmission encounters were included in this study from September 2017 till June 2018. The rate of readmission within 30 days was 14.7%, and 217 discharge summaries were used for analysis. The weighted kappa coefficient was 0.41 (95% CI: 0.30-0.51) demonstrating a moderate level of agreement. Sensitivity of physician assessment was 0.31 (95% CI: 0.22-0.40) and specificity was 0.80 (95% CI: 0.77-0.83). The sensitivity of the LACE assessment was 0.42 (95% CI: 0.25-0.59) and specificity was 0.79 (95% CI: 0.73-0.85). The AUROC for the LACE readmission risk was 0.65 (95% C.I. 0.55-0.76) demonstrating modest predictive power and was 0.57 (95% C.I. 0.46-0.68) for physician assessment, demonstrating low predictive power. CONCLUSION: The LACE index shows moderate discriminatory power in identifying high-risk patients for readmission when compared to the PCP's assessment. If this score can be provided to the PCP, it may help identify patients who requires more intensive follow-up after discharge.

Determining the impact of an interprofessional simulation focused on social determinants of health among pharmacy students.

INTRODUCTION: The purpose of this study was to determine the impact on pharmacy students' self-perception of knowledge, skills, collaborative behavior, and satisfaction after participating in an interprofessional (IP) simulation focused on social determinants of health (SDOH) and substance use. METHODS: Pharmacy students completed a voluntary questionnaire after participating in an IP simulation focused on SDOH and substance use where they collaborated with social work (SW) students. Questions assessed the students' understanding and knowledge of SDOH and students' confidence in asking patients about their substance use, willingness to refer patients to SW, and satisfaction with the simulation. The data were analyzed using a Wilcoxon signed-rank test. RESULTS: Results of pharmacy students' (N = 68) self-reported knowledge of SDOH and skills addressing and counseling on SDOH were improved following an IP simulation. No statistically significant change was observed in students' confidence when asking about or advising a patient on their substance use. There was a positive, significant change in how likely pharmacy students would refer patients to SW (P < .001) in their future practice. CONCLUSIONS: This simulation proved to be an effective way to improve pharmacy students' self-reported knowledge of SDOH and skills for assessing and counseling on resources for SDOH. The simulation was effective in exposing pharmacy students to the role of social workers on the team and how they address SDOH and substance use issues.

Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada.

Background: Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections. Methods: A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects. Results: Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase. Conclusions: PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.

Historique: Des programmes de gestion antimicrobienne (PGA) communautaires efficaces doivent exister, parce que 90 % des antimicrobiens sont prescrits dans la communauté. Des chercheurs ont évalué un PGA en première ligne (PGA-PL) afin d'en déterminer l'efficacité à réduire les prescriptions d'antibiotiques pour six infections courantes. Méthodologie: Les chercheurs ont évalué un programme de formation polyvalent au moyen d'une méthodologie avant-après dans quatre cliniques de soins de première ligne entre 2015 et 2017. Le résultat clinique primaire était la différence entre les cliniques de contrôle et d'intervention pour ce qui est du total de prescriptions antibiotiques contre six infections courantes avant et après l'intervention. Les résultats cliniques secondaires incluaient des modifications à l'utilisation des antibiotiques propres au trouble de santé, le report des prescriptions d'antibiotiques, des prescriptions de plus de sept jours, l'utilisation des antibiotiques recommandés et les visites à l'urgence ou les hospitalisations dans les 30 jours. Les chercheurs ont utilisé des méthodes multimodèles tenant compte de la démographie, du mélange de cas et du regroupement par médecin pour évaluer l'effet des traitements. Résultats: Les prescriptions totales d'antibiotiques dans les cliniques de contrôle et d'intervention ne différaient pas (différences des différences = 1,7 %; IC à 95 %, ­12,5 % à 15,9 %), ni l'utilisation de prescriptions reportées (­5,2 %; IC à 95 %, ­24,2 % à 13,8 %). Les prescriptions de plus de sept jours étaient très peu courantes (­21,3 %; IC à 95 %, ­42,5 % à ­0,1 %). Cependant, seulement 781 des 1 777 rencontres (44,0 %) avaient eu lieu avec des dispensateurs qui avaient suivi la formation sur le PGA. Lorsque les dispensateurs avaient suivi la formation, les reports de prescriptions augmentaient de 17,7 % (p = 0,06) et les prescriptions de plus de sept jours diminuaient (­27 %; IC à 95 %, ­48,3 % à ­5,6 %). Les visites subséquentes à l'urgence et les hospitalisations n'ont pas augmenté. Conclusions: L'efficacité du PGA-PL pour l'utilisation d'antibiotiques était variable. Les dispensateurs de soins de première ligne qui y avaient participé préparaient des prescriptions de moins longue durée et reportaient davantage leurs prescriptions.

Clinical and dermoscopic features of Fibroepithelioma of Pinkus: case series with an emphasis on hypopigmented to pink lines intersecting at acute angles.

Fibroepithelioma of Pinkus (FEP) is a subtype of basal cell carcinoma (BCC) that can clinically resemble intradermal nevi (IDN) and fibromas. We performed a retrospective review of consecutively biopsied lesions confirmed to be FEP on histopathology diagnosed from January 1, 2008 to April 8, 2019. Clinical (n = 48), contact non-polarized dermoscopy (NPD) (n = 44), and contact polarized dermoscopy (PD) (n = 22) images from 36 patients were reviewed. Mean age was 64.5 years (SD 15.1 years, range 24-86 years) at diagnosis of first FEP lesion. Most lesions were located on the torso (n = 28, 58.3%), followed by the lower extremity (n = 9, 18.8%). The most common differential diagnoses at the time of biopsy included BCC (n = 40) and nevus (other than IDN, n = 5). Clinically, FEP were pink (95.8%), scaly (66.7%) papules (77.1%) displaying disrupted skin markings (62.5%) and absence of hair follicles (87.5%). NPD revealed serpentine (97.7%), dotted (81.8%), or polymorphous vessels (86.4%), and hypopigmented to pink lines intersecting at acute angles (HPLA) (52.3%). PD demonstrated serpentine (95.5%), dotted (86.4%), or polymorphous vessels (81.8%), shiny white lines (50.0%), and HPLA (59.1%). Classic features of BCC such as arborizing vessels (n = 2), ulceration (n = 1), shiny white blotches and strands (n = 1), blue-gray ovoid nest (n = 1), and leaf-like areas (n = 1) were uncommon. FEP often presents as scaly, erythematous papules with disrupted skin markings and absence of hair follicles. Dermoscopy reveals polymorphous vessels with shiny white lines and HPLA.

Preparing Master of Social Work Students for Interprofessional Practice.

PURPOSE: This study aims to measure growth in interprofessional knowledge, skills, and values in MSW students from three universities who participated in a Behavioral Health Workforce Education and Training program focused on serving children, adolescents, and transition-age youth. METHODS: Students participated in an interprofessional field placement and specialized educational sessions that addressed interprofessional team-based care, engaging at-risk youth and families, and working with vulnerable populations. The Interprofessional Socialization and Valuing Scale (ISVS) was administered pre- and post-experience. RESULTS: Paired t-tests of the ISVS total score and each subscale showed statistically significant increases over time. Multiple regression models indicated only the pretest score was a significant predictor of the posttest score for the total or subscale of the ISVS. CONCLUSION: Social work programs that create interprofessional education and training opportunities can achieve positive outcomes in student attitudes toward interprofessional practice.

A Regional Survey on Residents' Preferences on Patient-Centered Medical Home Design in Rural Areas.

OBJECTIVES: This study aims to explore the rural residents' preferences on various aspects of the patient-centered medical home (PCMH) model and the associated physical environment features. BACKGROUND: The PCMH model has gained popularity as an innovative care model that intends to improve patient experience and outcomes while reducing costs. Yet few studies focused on patients' perspective, even less considered the needs of the rural communities. METHOD: Using a convenience sample, an exploratory survey was completed by 362 rural residents in the Midwestern region. Survey items were designed to gather information on both rural residents' preferences for five key PCMH attributes (comprehensive, patient-centered, coordinated, accessible, and quality) and of the physical environment that supports these attributes. Analyses were arranged along these key attributes. RESULTS: Results indicated that residents' demographics affect their preferences for spatial features for PCMH. The three most important environmental factors for PCMH for the rural residents are the privacy, extra chairs in the exam room for family, and space that supports information sharing and communication among patient, family, and healthcare staff. Through structural equation modeling analysis, residents' preferences on comprehensive care, patient-centered care, coordinated care, quality, and safety have shown to affect their preference for the space features. The open-ended survey shows that rural residents are mostly satisfied with their current healthcare environment in terms of supporting patient-centered care, while other aspects still have room for future improvement. CONCLUSIONS: Overall, this exploratory study identified important attributes of the physical environment that can support PCMH from rural residents' perspective.

Transitioning to academia: Exploring the experience of new family medicine faculty members at the beginning of their academic careers.

OBJECTIVE: To explore the experience of new family medicine faculty members at the beginning of their academic careers and determine what factors might facilitate their transition to an academic role in family medicine. DESIGN: Qualitative, phenomenologic study of new academic family physicians. SETTING: Eight Canadian departments of family medicine. PARTICIPANTS: English-speaking, full-time academic family physicians who had been in their first faculty position in a Canadian department of family medicine for 1 to 5 years. METHODS: Data were collected using semistructured, in-depth interviews that were audiotaped and transcribed verbatim. Data analysis employed an immersion and crystallization technique. The transcriptions were reviewed in an iterative and interpretive manner. Thirteen interviews were performed before saturation was reached. MAIN FINDINGS: The following 3 key themes were identified in relation to the experience of being a new academic family medicine faculty member: lack of or inadequate orientation; the challenges associated with transitioning to academia; and balancing the demands of the role. Orientation was often lacking or suboptimal, with participants left to navigate the transition process alone. The challenges associated with the transition to academia included the realities of clinical work and uncertainties about how to incorporate the various aspects of the new role into members' reality (eg, research). Trying to balance the demands of the academic role (eg, committee involvement, manual reviews), as well as finding work-life balance, was overwhelming. CONCLUSION: This study highlights the factors that might help recruit and retain academic faculty members in family medicine, as well as help them build successful academic careers. Orientation for these new members is an area that requires more attention. Clear parameters around division of time, support, and expectations for advancement should be explained at the beginning of new faculty members' academic appointments. Effective mentoring might help new faculty members have a more successful transition and reduce the risk of feeling overwhelmed and considering leaving academia.

Histologic Grade Is Predictive of Incidence of Epidermal Growth Factor Receptor Mutations in Metastatic Lung Adenocarcinoma.

Activating epidermal growth factor receptor (EGFR) mutations in metastatic non-small cell lung cancer (NSCLC) are associated with a high response rate to EGFR tyrosine kinase inhibitor (TKI). The current guidelines recommend routine EGFR mutational analysis prior to initiating first line systemic therapy. The clinical characteristics including smoking status, histologic type, sex and ethnicity are known to be associated with the incidence of EGFR mutations. We retrospectively analyzed 277 patients with metastatic NSCLC within Kaiser Permanente Northern California (KPNC); among these patients, 83 were positive for EGFR mutations. We performed both univariate and multivariable logistic regressions to identify predictors of EGFR mutations. We found that histologic grade was significantly associated with the incidence of EGFR mutation, regardless of ethnicity, sex and smoking status. In grade I (well differentiated) and II (moderately differentiated), histology was associated with significantly higher incidence of EGFR mutations compared to grade II-III (moderate-to-poorly differentiated) and III (poorly differentiated). Ever-smokers with grade III lung adenocarcinoma had 1.8% incidence of EGFR mutations. This study indicates that histologic grade is a predictive factor for the incidence of EGFR mutations and suggests that for patients with grade II-III or III lung adenocarcinoma, prompt initiation of first-line chemotherapy or immunotherapy is appropriate while awaiting results of EGFR mutational analysis, particularly for patients with history of smoking.

Therapeutic inhibition of BCL-2 and related family members.

INTRODUCTION: BCL-2 proteins are key players in the balance of cell life and death. Their roles in the development and biology of cancer have been well established and continue to be investigated. Understanding the mechanisms by which these proteins regulate apoptosis has led to the development of small molecule targeted therapies that act to overcome the cell's ability to evade programmed cell death. Areas covered: The biology of the intrinsic apoptotic pathway is reviewed with attention to the varied roles of the anti-apoptotic members of the BCL-2 family. BH3 profiling is reviewed. Historical therapeutic agents are addressed, and currently investigated BH3 mimetics are described with attention to clinical significance. The limitations of BCL-2 family targeted drugs with regard to on-target and off-target toxicities are explored. Agents under development for targeting MCL-1 and other BCL-2 family members are discussed. Expert opinion: ABT-199 (venetoclax) and other BH3 mimetics have entered the clinical arena and show promising results in both hematologic and solid malignancies. Use of agents targeting this system will likely expand, and likely a number of malignant diseases will be successfully targeted resulting in improved treatment responses and patient survival.

Managing In-Session "Surprises:" Provider Responses to Emergent Life Events during Evidence-Based Treatment Implementation.

This study aimed to: (1) pilot a psychotherapy coding system for provider responses to emergent life events (ELEs; unexpected events that have a significant negative impact on the client), (2) examine the impact of ELEs on evidence-based treatment (EBT) delivery in community settings. Raters coded 30 randomly-sampled EBT session recordings with and without reported ELEs. Inter-rater reliability and validity for the system were generally high. When an ELE occurred, providers were significantly less likely to deliver the EBT, and when they did, they rarely linked the EBT to the event. Findings highlight the potential for ELEs to disrupt EBT implementation.

Child STEPs in California: A cluster randomized effectiveness trial comparing modular treatment with community implemented treatment for youth with anxiety, depression, conduct problems, or traumatic stress.

OBJECTIVE: This study reports outcomes from a randomized effectiveness trial testing modular treatment versus multiple community-implemented evidence-based treatments for youth. METHOD: An ethnoracially diverse sample of 138 youth ages 5 to 15 (62 girls, 76 boys) whose primary clinical concerns involved diagnoses or clinical elevations related to anxiety, depression, disruptive behavior, and/or traumatic stress were treated by community therapists randomly assigned to 1 of 2 conditions: (a) modular treatment, which involved a single modular protocol (i.e., modular approach to therapy for children; MATCH) that allowed flexible selection and sequencing of procedures to fit the chosen treatment focus in the context of measurement feedback, and (b) community-implemented treatment (CIT), which was a county-supported implementation of multiple evidence-based practices for youth. RESULTS: Youth treated with MATCH showed significantly faster rates of improvement over time on clinical and functional outcomes relative to youth in the CIT condition and required significantly fewer sessions delivered over significantly fewer days. Caregiver-reported clinical improvement rates were significantly greater for MATCH (60%) versus CIT (36.7%). Further, youth in the CIT condition were significantly more likely to receive additional psychosocial treatment services and were significantly more likely to use a variety of psychotropic medications during the active treatment phase. CONCLUSIONS: These results extend prior findings, supporting the effectiveness and efficiency of a modular, multifocus approach that incorporates monitoring and feedback relative to community implementation of evidence-based treatments. (PsycINFO Database Record

Association of Recurrence of Infected Congenital Preauricular Cysts Following Incision and Drainage vs Fine-Needle Aspiration or Antibiotic Treatment: A Retrospective Review of Treatment Options.

Importance: Treatment modalities for preauricular sinus tract infections vary.  Effort should be taken to decrease methods that lead to increased recurrence after surgical excision. Objective: To determine whether incision and drainage (I & D) of infected congenital preauricular cysts is associated with increased rate of recurrence when compared with fine-needle aspiration or antibiotic treatment. Design, Setting, and Participants: This was a 9-year (2006-2014) retrospective cohort study undertaken at a tertiary care pediatric hospital. Children treated for preauricular sinus tract infections were identified using the procedure code for excision of preauricular pit, cyst, or sinus tract. Main Outcomes and Measures: Postexcision recurrence. Results: Sixty-nine children ranging in age from 4 months to 17 years (mean age, 5.9 years) underwent excision of a preauricular cyst. Thirty-seven of 69 patients (54%) were female. Fifty-seven of 69 (83%) had a preoperative history of infection; the remainder had chronic drainage. Of children with preoperative infection, 27 were initially treated with incision and drainage (I & D), 12 were treated with fine-needle aspiration only, and 18 received antibiotic therapy alone. Overall, the recurrence rate was 8 in 69 (11.6%). Among the 27 patients with a preoperative history of infection treated with I & D, 5 lesions (18.5%) recurred, and among those who only received preoperative antibiotic therapy or fine-needle aspiration 1 in 30 lesions (3.3%) recurred (absolute difference of 15.2%; 95% CI, -1.7% to 33.6%). Conclusions and Relevance: Among infants and children undergoing excision of preauricular cysts, a history of infection was not associated with a higher recurrence rate. There was, however, evidence to suggest that a higher rate of recurrence exists among children who had a preoperative history of infection treated with I & D. Our results suggest a more conservative treatment of infected preauricular pit and/or sinus.

Parent, Teacher, and School Stakeholder Perspectives on Adolescent Pregnancy Prevention Programming for Latino Youth.

Teen pregnancy remains a public health concern particularly among Latinos, whose pregnancy rate of 83.5 per 1000 girls constitutes one of the highest rates of teen pregnancy among all ethnic and racial groups in the United States. To enhance the effectiveness of interventions for diverse Latino populations in the US, it is crucial to assess the community's understanding of the etiology of the problem of adolescent pregnancy and to implement programs that reflect the local community's beliefs and preferences. We present findings from six focus groups held with parents (n = 18), teachers (n = 23) and school stakeholders (n = 8) regarding teen pregnancy prevention among Latino youth at a high school located in a large, Midwestern city. Two investigators analyzed data iteratively using a template organizing approach. A consensus emerged across the groups regarding content that emphasized respect for oneself and one's family, a focus on personal and shared responsibility in reproductive health behavior, information about the "realities" or consequences associated with engaging in sexual activity, and information about contraceptives. The strong request from participants to include a parental education component reflects the community's belief that parents play a crucial, protective role in the socialization and development of adolescent sexual behavior, a view that is supported by empirical research. Findings highlight the importance of involving local school communities in identifying adolescent pregnancy prevention strategies that are responsive to the community's cultural values, beliefs, and preferences, as well as the school's capacity and teacher preferences.

Preventing Complications of Pediatric Tracheostomy Through Standardized Wound Care and Parent Education.

Importance: Pediatric tracheostomy is commonly performed for upper airway obstruction and prolonged mechanical ventilation. Children undergoing tracheostomy typically have multiple chronic medical problems that place them at high risk for readmission and additional complications. Objective: To determine whether the institution of a postoperative protocol for parent education and wound care with a nurse trained in tracheostomy care decreases the rate of readmission and other complications. Design, Setting, and Participants: A case series and medical record review was conducted of children 18 years and younger who underwent tracheostomy at a tertiary pediatric medical center between January 1, 2009, and December 31, 2014. Intervention: A postoperative tracheostomy care and education protocol. Main Outcomes and Measures: Overall 30-day readmission rate, 30-day tracheostomy-related readmission rate, tracheostomy wound complications, and additional factors that may have affected readmission rates and wound complications (age at the time of tracheostomy, discharge location, indication for tracheostomy). Results: A total of 191 children (118 boys and 73 girls) were included; of these, 112 participated in the education protocol and 79 children did not. Following institution of the education protocol, there was no decrease in the overall readmission rate (26.8% before the protocol vs 26.6% after the protocol; difference, 0.2%; 95% CI, -12.5% to 13.0%) or in the tracheostomy-related readmission rate (10.1% before the protocol vs 7.1% after the protocol; difference, 3.0%; 95% CI, -5.0% to 11.0%). Overall, 68.6% of readmissions were associated with medical comorbidities (95% CI, 55.9% to 81.3%). There was a significant decrease in tracheostomy-related wound complications after institution of the protocol (31.6% to 17.9%; difference, 13.7%; 95% CI, 1.6% to 26.0%). Multiple logistic regression analysis showed that children who were discharged home were significantly more likely to be readmitted for a tracheostomy-related complication than were patients discharged to an advanced care facility (odds ratio, 14.47; 95% CI, 3.08 to 67.92). Conclusions and Relevance: Tracheostomy care requires expertise for all caregivers and is challenging for people without specialized training. Specialized nursing and education protocols are associated with decreased complications of tracheostomy wounds. Children who are discharged directly to home are at higher risk for readmission compared with children discharged to advanced care facilities. Further development of caregiver education protocols is necessary to continue to reduce readmissions and tracheostomy-related complications.

A Model for Creating a Supportive Trauma-Informed Culture for Children in Preschool Settings.

The all too common exposure of young children to traumatic situations and the life-long consequences that can result underscore the need for effective, developmentally appropriate interventions that address complex trauma. This paper describes Head Start Trauma Smart (HSTS), an early education/mental health cross-systems partnership designed to work within the child's natural setting-in this case, Head Start classrooms. The goal of HSTS is to decrease the stress of chronic trauma, foster age-appropriate social and cognitive development, and create an integrated, trauma-informed culture for young children, parents, and staff. Created from a community perspective, the HSTS program emphasizes tools and skills that can be applied in everyday settings, thereby providing resources to address current and future trauma. Program evaluation findings indicate preliminary support for both the need for identification and intervention and the potential to positively impact key outcomes.