Commentary on ethical dilemmas in the management of infants with necrotizing enterocolitis totalis.

This is a commentary on the manuscript titled "Ethical Dilemmas in the Management of Infants with Necrotizing Enterocolitis Totalis".

Postfundoplication retching: Strategies for management.

BACKGROUND: Retching is a common symptom in children following antireflux surgery, particularly in those with neurodisability. There is now a strong body of evidence that implicates retching as a major cause of wrap breakdown. Retching is not a symptom of gastroesophageal reflux disease; it is a component of the emetic reflex. In addition to causing wrap breakdown, it is indicative of the presence of nausea. It is a highly aversive experience and warrants treatment in its own right. METHODS: A framework was constructed for the management of postoperative retching, with strategies targeting different components of the emetic reflex. The impact of differing antireflux procedures upon retching was also considered. CONCLUSIONS: Once treatable underlying causes have been excluded, the approach includes modifications to feeds and feeding regimens, antiemetics and motility agents. Neuromodulation and other, novel, therapies may prove beneficial in future. Children at risk of postoperative retching may be identified before any antireflux surgery is performed. Fundoplication is inappropriate in these children because it does not treat their symptoms, which are not because of gastroesophageal reflux, and may make them worse. They are also at risk of wrap disruption. Alternative strategies for symptom management should be employed, and fundoplication should be avoided. LEVEL OF EVIDENCE: II-V.

Does retching matter? Reviewing the evidence-Physiology and forces.

Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure. Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking. Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown. Retching needs to be addressed if we are to reduce the incidence of wrap failure. Level of Evidence V.

Certified Child Life Specialists Lessen Emotional Distress of Children Undergoing Laceration Repair in the Emergency Department.

OBJECTIVE: The objective of this study is to evaluate the impact of certified child life specialists (CCLSs) on the emotional responses of children undergoing laceration repair in the emergency department (ED). METHODS: Patients 4 to 12 years of age who required laceration repair by suturing were prospectively enrolled at an urban tertiary pediatric ED. Certified child life specialists are not available at all times in our institution, allowing for a priori categorization of subjects into 2 comparison groups, those with and those without CCLS involvement. Subjects requiring anxiolysis, pharmacologic sedation, narcotics, or physical restraint were excluded. The Children's Emotional Manifestation Scale, a previously validated Likert-like tool, was used to quantify the patients' distress, with a higher score reflecting a more emotional child. Just before placement of the first suture, subjects were scored by trained independent observers. Baseline data included age, sex, race, type of local anesthetic, length and location of laceration, and analgesics administered. The primary endpoint of emotional score was compared with a 2-tailed Mann-Whitney U test, with a P < 0.05 considered statistically significant. RESULTS: Two hundred one patients constituted the final study cohort, with 103 (51%) having CCLS involvement. Study groups did not differ in regards to any baseline demographic or clinical characteristics. The median emotional score for patients with child life services was 7 (interquartile range, 6-9) versus 9 (interquartile range, 7.5-12) for those without (P < 0.0005). CONCLUSIONS: Certified child life specialist involvement is associated with less emotional distress for children undergoing laceration repair in the ED.

Association Between Hospital Financial Distress and Immediate Breast Reconstruction Surgery After Mastectomy Among Women With Ductal Carcinoma In Situ.

Importance: Hospital financial distress (HFD) is a state in which a hospital is at risk of closure because of its financial condition. Hospital financial distress may reduce the services a hospital can offer, particularly unprofitable ones. Few studies have assessed the association of HFD with quality of care. Objective: To examine the association between HFD and receipt of immediate breast reconstruction surgery after mastectomy among women diagnosed with ductal carcinoma in situ (DCIS). Design, Setting, and Participants: This retrospective cohort study assessed data from the Nationwide Inpatient Sample of 5760 women older than 18 years (mean [SD] age: 57.5 [13.2]) with DCIS who underwent mastectomy in 2008-2012 at hospitals categorized by financial distress. Women treated at 1156 hospitals located in 538 different counties across Arkansas, Arizona, California, Colorado, Connecticut, Florida, Iowa, Kentucky, Massachusetts, Maryland, Missouri, North Carolina, New Hampshire, New Jersey, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Utah, Virginia, Vermont, Washington, Wisconsin, West Virginia, and Wyoming were included. Of these, 2385 women (41.4%) underwent immediate breast reconstruction surgery. Women with invasive cancer were excluded. The database included unique hospital identification variables, and participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Data were analyzed from January 1, 2012, to February 28, 2014. Main Outcomes and Measures: The primary outcome was the adjusted association between HFD and receipt of immediate breast reconstruction surgery after mastectomy. Results: In this analysis of database information, 2385 of 5760 women (41.4%) received immediate breast reconstruction surgery. Of these, 693 (36.7%) were treated at a hospital under high HFD and received immediate breast reconstruction surgery compared with 863 (44.0%) treated at a hospital under low HFD (P < .001). Reconstruction surgery was associated with younger age, white race, private insurance, treatment at a teaching and cancer hospital, private hospital ownership, and the percentage of individuals in the county with insurance. After adjustment, women treated at hospitals under high HFD (OR, 0.79; 95% CI, 0.62-0.99) and medium HFD (OR, 0.76; 95% CI, 0.61-0.94) were significantly less likely to receive reconstruction than women treated at hospitals with low to no HFD. Conclusions and Relevance: The financial strength of the hospital where a patient receives treatment is associated with receipt of immediate breast reconstruction surgery. In addition to focusing on patient-related factors, efforts to improve quality should also focus on hospital-related factors.

An Ounce of Prevention: Deaths Averted From Primary Prevention Interventions.

INTRODUCTION: The U.S. lags in the nationwide implementation of primary prevention interventions that have been shown to be efficacious. However, the potential population health benefit of widespread implementation of these primary prevention interventions remains unclear. METHODS: The meta-analytic literature from October 2013 to March 2014 of primary prevention interventions published between January 2000 and March 2014 was reviewed. The authors then estimated the number of deaths that could have been averted in the U.S. in 2010 if all rigorously studied, efficacious primary prevention interventions for which population attributable risk proportions could be estimated were implemented nationwide. RESULTS: A total of 372,054 (15.1%) of all U.S. deaths in 2010 would have been averted if all rigorously studied, efficacious primary prevention interventions were implemented. Two in three averted deaths would have been from cardiovascular disease or malignancy. CONCLUSIONS: A substantial proportion of deaths in the U.S. in 2010 could have been averted if efficacious primary prevention interventions were implemented nationwide. Further investment in the implementation of efficacious interventions is warranted to maximize population health in the U.S.

Functional outcomes in Hirschsprung disease: A single institution's 12-year experience.

AIMS: Hirschsprung disease (HD) is a chronic condition associated with long-term morbidity. We assessed the short and long-term functional outcomes of operated patients in a single institution over a 12-year period. MATERIALS AND METHODS: We conducted a retrospective review of all children operated for HD between 2002 and 2014. Postoperative functional outcomes were assessed using the Rintala Bowel Function Score (BFS, 0-20, 20=best score). We assessed hospital admissions, complications including Hirschsprung associated enterocolitis (HAEC) and the need for further surgical procedures. RESULTS: 72 (52 male) patients were studied, of whom, 6 (8%) had a positive family history, 5 (7%) had Trisomy 21 and 5 (7%) had total colonic HD. The median age at diagnosis was 6.5days (2 days-6.7 years) and median follow-up was 6years (1-12years). All patients except two underwent a Duhamel pull-through procedure. The median age at surgery was 4months (6days-90months). 37 (51%) procedures were performed single-stage and 7 (10%) were laparoscopically assisted. Our early complication rate was 15%; 11 (15%) patients were treated for HAEC and 43 (60%) did not require any further surgery. 12 (17%) underwent injection of botulinum toxin, 7 (10%) needed residual spur division and 4 (5%) required an unplanned, post pull-through enterostomy for obstructive defecation symptoms and HAEC. Two (3%) patients underwent an Antegrade Colonic Enema (ACE) stoma. The median BFS was 17 (5-20). There were two deaths both out of hospital. CONCLUSIONS: Long-term functional outcomes following Duhamel Pull-Through surgery are satisfactory although 40% of patients needed some form of further surgical intervention. The management of anal sphincter achalasia has improved with the use of botulinum toxin and we advocate aggressive and early management of this condition for symptoms of obstructive defecation and HAEC. LEVEL OF EVIDENCE: III.

Childhood trauma and neighborhood-level crime interact in predicting adult posttraumatic stress and major depression symptoms.

Previous research has identified several individual-level factors that modify the risk of childhood trauma on adult psychiatric symptoms, including symptoms of major depression (MD) and posttraumatic stress (PTS). Neighborhood-level factors also influence the impact of individual-level exposures on adult psychopathology. However, no prior studies to our knowledge have explored cross-level interactions between childhood trauma and neighborhood-level factors on MD and PTS symptoms. The purpose of this study was therefore to explore cross-level interactions between a neighborhood-level factor - neighborhood-level crime - and childhood trauma on MD and PTS symptoms. Participants in this study (N=3192) were recruited from a large public hospital, and completed self-report inventories of childhood trauma and MD and PTS symptoms. Participant addresses were mapped onto 2010 census tracts, and data on crime within each tract were collected. Multilevel models found a significant cross-level interaction between childhood trauma and neighborhood crime on MD symptoms, such that the influence of high levels of childhood trauma on MD symptoms was enhanced for participants living in high-crime neighborhoods. Supplementary analyses found variation in the strength of cross-level interaction terms by types of childhood trauma and crime, with the strongest associations including emotional neglect paired with personal and property crime. The results provide preliminary support for interventions that help childhood trauma survivors find housing in less vulnerable neighborhoods and build skills to cope with neighborhood crime.

Quality and Outcomes of Treatment of Hypercalcemia of Malignancy.

Using a nationwide database, 4,874 patients with hypercalcemia of malignancy were identified. The in-hospital mortality rate was 6.8%. Overall, 1,971 (40.4%) patients received pamidronate and 1,399 (28.7%) received zoledronic acid during hospitalization. Calcitonin was utilized in 1,337 (27.4%) patients while glucocorticoids were administered to 1,311 (26.9%). Use of contraindicated medications was noted in 136 (2.8%) patients who received thiazide diuretics and 12 (0.2%) who received lithium. Tumor site, presence of bone metastases, and severity of illness were predictors of treatment. There was no association between treatment with bisphosphonates, calcitonin, or glucocorticoids and morbidity or mortality.

Relationship between surgical oncologic outcomes and publically reported hospital quality and satisfaction measures.

BACKGROUND: Hospital-level measures of patient satisfaction and quality are now reported publically by the Centers for Medicare and Medicaid Services. There are limited metrics specific to cancer patients. We examined whether publically reported hospital satisfaction and quality data were associated with surgical oncologic outcomes. METHODS: The Nationwide Inpatient Sample was utilized to identify patients with solid tumors who underwent surgical resection in 2009 and 2010. The hospitals were linked to Hospital Compare, which collects data on patient satisfaction, perioperative quality, and 30-day mortality for medical conditions (pneumonia, myocardial infarction [MI], and congestive heart failure [CHF]). The risk-adjusted hospital-level rates of morbidity and mortality were calculated for each hospital and the means compared between the highest and lowest performing hospital quartiles and reported as absolute reduction in risk (ARR), the difference in risk of the outcome between the two groups. All statistical tests were two-sided. RESULTS: A total of 63197 patients treated at 448 hospitals were identified. For patients at high vs low performing hospitals based on Hospital Consumer Assessment of Healthcare Providers and Systems scores, the ARR in perioperative morbidity was 3.1% (95% confidence interval [CI] = 0.4% to 5.7%, P = .02). Similarly, the ARR for mortality based on the same measure was -0.4% (95% CI = -1.5% to 0.6%, P = .40). High performance on perioperative quality measures resulted in an ARR of 0% to 2.2% for perioperative morbidity (P > .05 for all). Similarly, there was no statistically significant association between hospital-level mortality rates for MI (ARR = 0.7%, 95% CI = -1.0% to 2.5%), heart failure (ARR = 1.0%, 95% CI = -0.6% to 2.7%), or pneumonia (ARR = 1.6%, 95% CI = -0.3% to 3.5%) and complications for oncologic surgery patients. CONCLUSION: Currently available measures of patient satisfaction and quality are poor predictors of outcomes for cancer patients undergoing surgery. Specific metrics for long-term oncologic outcomes and quality are needed.

There goes the neighborhood effect: bias owing to nondifferential measurement error in the construction of neighborhood contextual measures.

BACKGROUND: Multilevel studies of neighborhood effects on health frequently aggregate individual-level data to create contextual measures. For example, percent of residents living in poverty and median household income are both aggregations of Census data on individual-level household income. Because household income is sensitive and complex, it is likely to be reported with error. METHODS: To assess the impact of such error on effect estimates for neighborhood contextual factors, we conducted simulation studies to relate neighborhood measures derived from Census data to individual body mass index, varying the extent of nondifferential misclassification/measurement error in the underlying Census data. We then explored the impact on the magnitude of bias owing to the form of variables chosen for neighborhood measure and outcome, modeling technique used, size and number of neighborhoods, and categorization of neighborhoods. RESULTS: For neighborhood contextual variables expressed as percentages (eg, percent of residents living in poverty), nondifferential misclassification in the underlying individual-level Census data always biases the parameter estimate for the neighborhood variable away from the null. However, estimates of differences between quantiles of neighborhoods using such contextual variables are unbiased. Aggregation of the same underlying individual-level Census income data into a continuous variable, such as median household income, also introduces bias into the regression parameter. Such bias is non-negligible if the sampled groups are small. CONCLUSIONS: Decisions regarding the construction and analysis of neighborhood contextual measures substantially alter the impact on study validity of measurement error in the data used to construct the contextual measure.

More neighborhood retail associated with lower obesity among New York City public high school students.

Policies target fast food outlets to curb adolescent obesity. We argue that researchers should examine the entire retail ecology of neighborhoods, not just fast food outlets. We examine the association between the neighborhood retail environment and obesity using Fitnessgram data collected from 94,348 New York City public high school students. In generalized hierarchical linear models, the number of fast food restaurants predicted lower odds of obesity for adolescents (OR:0.972 per establishment; CI:0.957-0.988). In a "placebo test" we found that banks--a measure of neighborhood retail ecology--also predicted lower obesity (OR:0.979 per bank; CI:0.962-0.994). Retail disinvestment might be associated with greater obesity; accordingly, public health research should study the influence of general retail disinvestment not just food-specific investment.

Variation in ovarian conservation in women undergoing hysterectomy for benign indications.

OBJECTIVE: Emerging data suggest that oophorectomy at the time of hysterectomy for benign indications may increase long-term morbidity and mortality. We performed a population-based analysis to estimate the rates of oophorectomy in women undergoing hysterectomy for benign indications. METHODS: The Perspective database was used to estimate the rate of ovarian preservation in women aged 40-64 years who underwent hysterectomy for benign indications. Hierarchical mixed-effects regression models were developed to estimate the influence of patient, procedural, physician, and hospital characteristics on ovarian conservation. Between-hospital variation in ovarian preservation also was estimated. RESULTS: Among 752,045 women, 348,972 (46.4%) underwent bilateral oophorectomy, whereas 403,073 (53.6%) had ovarian conservation. Stratified by age, the rate of ovarian conservation was 74.3% for those younger than 40 years of age; 62.7% for those 40-44 years of age; 40.8% for those 45-49 years of age; 25.2% for those 50-54 years of age; 25.5% for those 55-59 years of age; and 31.0% for those 60-64 years of age. Younger age and more recent year of surgery had the strongest association with ovarian conservation. The observed patient, procedural, physician, and hospital characteristics accounted for only 46% of the total variation in the rate of ovarian conservation; 54% of the variability remained unexplained, suggesting a large amount of intrinsic between-hospital variation in the decision to perform oophorectomy. CONCLUSION: The rate of ovarian conservation is increasing, particularly among women younger than 50 years old. Although demographic and clinical factors influence the decision to perform oophorectomy, there appears to be substantial between-hospital variation in performance of oophorectomy that remains unexplained by measurable patient, physician, or hospital characteristics. LEVEL OF EVIDENCE: II.

Increased screening colonoscopy rates and reduced racial disparities in the New York Citywide campaign: an urban model.

OBJECTIVES: In 2003, in response to low colonoscopy screening rates and significant sociodemographic disparities in colonoscopy screening in New York City (NYC), the NYC Department of Health and Mental Hygiene, together with the Citywide Colon Cancer Control Coalition, launched a multifaceted campaign to increase screening. We evaluated colonoscopy trends among adult New Yorkers aged 50 years and older between 2003 and 2007, the first five years of this campaign. METHODS: Data were analyzed from the NYC Community Health Survey, an annual, population-based surveillance of New Yorkers. Annual prevalence estimates of adults who reported a timely colonoscopy, one within the past 10 years, were calculated. Multivariate models were used to analyze changes over time in associations between colonoscopy screening and sociodemographic characteristics. RESULTS: Overall, from 2003 to 2007 the proportion of New Yorkers aged 50 years and older who reported timely colonoscopy screening increased from 41.7% to 61.7%. Racial/ethnic and sex disparities observed in 2003 were eliminated by 2007: prevalence of timely colonoscopy was similar among non-Hispanic whites, non-Hispanic blacks, Hispanics, men, and women. However, Asians, the uninsured, and those with lower education and income continued to lag in receipt of timely colonoscopies. CONCLUSIONS: The increased screening colonoscopy rate and reduction of racial/ethnic disparities observed in NYC suggest that multifaceted, coordinated urban campaigns can improve low utilization of clinical preventive health services and reduce public-health disparities.

Business travel and self-rated health, obesity, and cardiovascular disease risk factors.

OBJECTIVE: To assess associations between extent of travel for business and health. METHODS: Associations between business travel and cardiovascular disease risk factors were assessed using medical record data from 13,057 patients provided by EHE International, Inc. RESULTS: Compared with light travelers (1 to 6 nights per month), nontravelers were more likely to report poor/fair health (odds ratio = 1.58; 95% confidence interval [CI]: 1.33 to 1.87) and the odds ratios increased with increasing travel, reaching 2.61 (95% CI: 1.57 to 4.33) among extensive travelers (>20 nights per month). Compared with light travelers, the odds ratios for obesity were highest among nontravelers (odds ratio = 1.33; 95% CI: 1.18 to 1.50) and extensive travelers (odds ratio = 1.92; 95% CI: 1.25 to 2.94). Although the differences were small, nontravelers and extensive travelers had the highest diastolic blood pressure and lowest high-density lipoprotein cholesterol levels. CONCLUSION: Poor self-rated health and obesity are associated with extensive business travel.

Using Google Street View to audit neighborhood environments.

BACKGROUND: Research indicates that neighborhood environment characteristics such as physical disorder influence health and health behavior. In-person audit of neighborhood environments is costly and time-consuming. Google Street View may allow auditing of neighborhood environments more easily and at lower cost, but little is known about the feasibility of such data collection. PURPOSE: To assess the feasibility of using Google Street View to audit neighborhood environments. METHODS: This study compared neighborhood measurements coded in 2008 using Street View with neighborhood audit data collected in 2007. The sample included 37 block faces in high-walkability neighborhoods in New York City. Field audit and Street View data were collected for 143 items associated with seven neighborhood environment constructions: aesthetics, physical disorder, pedestrian safety, motorized traffic and parking, infrastructure for active travel, sidewalk amenities, and social and commercial activity. To measure concordance between field audit and Street View data, percentage agreement was used for categoric measures and Spearman rank-order correlations were used for continuous measures. RESULTS: The analyses, conducted in 2009, found high levels of concordance (≥80% agreement or ≥0.60 Spearman rank-order correlation) for 54.3% of the items. Measures of pedestrian safety, motorized traffic and parking, and infrastructure for active travel had relatively high levels of concordance, whereas measures of physical disorder had low levels. Features that are small or that typically exhibit temporal variability had lower levels of concordance. CONCLUSIONS: This exploratory study indicates that Google Street View can be used to audit neighborhood environments.

Disparities in the food environments of New York City public schools.

BACKGROUND: Studies of the food environment near schools have focused on fast food. Research is needed that describes patterns of exposure to a broader range of food outlet types and that examines the influence of neighborhood built environments. PURPOSE: Using data for New York City, this paper describes the prevalence of five different food outlet types near schools, examines disparities by economic status and race/ethnicity in access to these food outlets, and evaluates the extent to which these disparities are explained by the built environment surrounding the school. METHODS: National chain and local fast-food restaurants, pizzerias, small grocery stores ("bodegas"), and convenience stores within 400 m of public schools in New York City were identified by matching 2005 Dun & Bradstreet data to 2006-2007 school locations. Associations of student poverty and race/ethnicity with food outlet density, adjusted for school level, population density, commercial zoning, and public transit access, were evaluated in 2009 using negative binomial regression. RESULTS: New York City's public school students have high levels of access to unhealthy food near their schools: 92.9% of students had a bodega within 400 m, and pizzerias (70.6%); convenience stores (48.9%); national chain restaurants (43.2%); and local fast-food restaurants (33.9%) were also prevalent within 400 m. Racial/ethnic minority and low-income students were more likely to attend schools with unhealthy food outlets nearby. Bodegas were the most common source of unhealthy food, with an average of nearly ten bodegas within 400 m, and were more prevalent near schools attended by low-income and racial/ethnic minority students; this was the only association that remained significant after adjustment for school and built-environment characteristics. CONCLUSIONS: Nearly all New York City public school students have access to inexpensive, energy-dense foods within a 5-minute walk of school. Low-income and Hispanic students had the highest level of exposure to the food outlets studied here.