Implementation of a firearm safety guidance training program for pediatric providers.

PURPOSE: Pediatric unintentional firearm injuries are potentially preventable with firearm safety guidance (FSG). In baseline assessment, we learned that providers feel uncomfortable delivering FSG due to lack of training, but are inclined to learn. Here we present the development and concept testing of an FSG training program. METHODS: Using Kern's 6 rules of curriculum development, a training template was developed: 1. Program development, 2. Review by multidisciplinary expert team, 3. Concept testing, and 4. Modifications. Foundations included: raising awareness, increasing provider knowledge of safe storage methods, introducing a visual aide (American Academy of Pediatrics [AAP] infographic), and providing examples of guidance delivery. In-person training was provided and modifications made until there was uniform provider satisfaction. Program effectiveness and satisfaction were evaluated through surveys and focus groups. Descriptive statistics and univariate analyses were utilized. RESULTS: Over one year, in-person training was provided to 44 pediatric providers (residents and practicing pediatricians) at 8 clinics. Modifications included: addition of a Spanish-version visual aide, instruction on safety device use, simulation scenarios, making the handout more child-friendly, and development of a home safety video to include firearm safety with other topics. Following training, routine FSG by pediatricians increased from 34% to 71% (p = 0.001). Focus groups revealed provider satisfaction with the AAP infographic and increased comfort of FSG delivery. CONCLUSION: Following development and quality improvement, our FSG training model received positive feedback and increased provider delivery by pediatric providers. This model could be used for development of FSG training programs in other settings.

Physician-driven or self-directed safe firearm storage guidance: Which one is best?

BACKGROUND/PURPOSE: Access to firearms is a preventable cause of unintentional injury and suicide in children. Pediatric physicians provide injury prevention guidance, but firearm safety may not routinely be included. The purpose of this pilot study was to evaluate the effectiveness of firearm safety guidance (FSG) provided by a physician. METHODS: Prospective, randomized-controlled, trial assessing physician-delivered FSG at two pediatric clinics in Houston, Texas. Firearm-owning parents were randomized to physician guidance (PG) versus control (CG) groups. The CG received a handout with firearm safety facts and a free cable lock. The PG additionally received FSG by a physician. Pre- and post-intervention surveys were conducted. Results were analyzed using descriptive statistics and Chi square analysis. RESULTS: Thirty-two families participated; most (70%) were satisfied with the guidance. Pre-intervention safe firearm storage was high in both groups, and the intervention did not lead to improved habits in either group [PG: Pre 93% vs. Post 89%, p = 0.7 and CG: Pre 82% vs. 78%, p = 0.7].There was no difference in use of the free cable lock among groups (44% vs. 22%, p = 0.9). The PG demonstrated improved knowledge of the state child access protection law (PG: Pre 60% vs. Post 100% vs. CG: Pre 29% vs. Post 67%; p = 0.02). CONCLUSIONS: For firearm-owning parents, physician-delivered safe storage guidance may not be more effective than self-directed guidance provided by a handout. A larger trial is underway to confirm the findings of this pilot study.

Pediatric Providers' Knowledge, Attitudes, Practice, and Barriers to Firearms Safety Counseling.

OBJECTIVES: Firearms-related injuries and deaths are a leading cause of death in children and young adults ages 5 to 24 years. This study evaluated the counseling practices and barriers to providing safe firearms storage education by pediatricians and advance practice providers. METHODS: An online survey was sent to 296 pediatric outpatient providers in Houston, Texas. Pediatric providers were asked about demographics, knowledge, attitudes, and current practices regarding firearms safety counseling. Descriptive and comparative analyses were performed. RESULTS: Survey respondents (N = 76) were 86% women and 87% physicians. Most (86%) agree that they should discuss firearms safety with parents, whereas only 32% report routine counseling. The most frequent barrier to providing education was insufficient time (63%), followed by unfamiliarity with guns (26%). CONCLUSIONS: Pediatric providers are interested in firearms safety counseling, but few incorporate it into their practice. Addressing barriers of time and comfort level around firearms are potential first steps to curbing a leading cause of injury death among children. Further research is needed to develop counseling methods that are time efficient and culturally competent for the pediatric office.

Improving Tracking of Postdischarge Results of Sexually Transmitted Infection Screening Tests in Hospitalized Adolescents and Young Adults: A Quality Improvement Initiative.

Hospitalizations offer chlamydia and gonorrhea screening opportunities for youth who may not seek preventive care. Tracking of screening test results still pending after hospital discharge is an important component of clinical care. This process can be improved by protocol use and enhanced by effective, automated electronic health record tools.

Acceptance of Routine HIV Testing by Hospitalized Adolescents and Young Adults.

BACKGROUND AND OBJECTIVES: Youth carry a disproportionate burden of new HIV infections. With our study, we aimed to characterize HIV testing experiences among adolescents and young adults admitted to a children's hospital that is located in a high HIV-prevalent community and implemented routine HIV testing for all patients ≥13 years of age. METHODS: A total of 120 patients aged 13 to 24 years old who were admitted to our hospital and had a documented offer of routine HIV testing on admission were invited to complete a self-administered survey that asked about sex, race and/or ethnicity, HIV risk behaviors, and attitudes toward routine HIV testing in the hospital. Date of birth, admission diagnosis, and verification of HIV testing and results were collected by chart review. RESULTS: Study participants (N = 99) were 17.4 ± 2.3 years old, 52% female, 47% Hispanic, and 29% African American. Additional characteristics include the following: 65% had previous sexual activity, 11% had a history of sexually transmitted infections, and 12% were worried about their risk for HIV. Forty-seven percent of participants accepted HIV testing, with older patients (P < .01) and those reporting previous sexual activity (P < .01) and a previous HIV test (P < .01) being more likely to accept testing. A total of 96% of participants agreed that the hospital is a good place to offer HIV testing. CONCLUSIONS: Our findings support offering routine HIV testing to youth admitted to children's hospital. Given the high incidence of new and undiagnosed HIV infections among youth, additional venues for HIV testing are essential.

Utility of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in a child with chronic granulomatous disease.

We report the fluorodeoxyglucose positron emission tomography/computed tomography (FDG - PET/CT) findings in an 11-month-old boy with suspected milk protein allergy, presented to the hospital with 2-month history of fever of unknown origin and failure to thrive. It showed FDG avid lymphadenopathy above and below the diaphragm and splenic focus, which could represent diffuse inflammatory process or lymphoma. Subsequent jejunal biopsy showed non-necrotizing granulomas.

Low rates of mother-to-child HIV transmission in a routine programmatic setting in Lilongwe, Malawi.

BACKGROUND: The Tingathe program utilizes community health workers to improve prevention of mother-to-child transmission (PMTCT) service delivery. We evaluated the impact of antiretroviral (ARV) regimen and maternal CD4+ count on HIV transmission within the Tingathe program in Lilongwe, Malawi. METHODS: We reviewed clinical records of 1088 mother-infant pairs enrolled from March 2009 to March 2011 who completed follow-up to first DNA PCR. Eligibility for antiretroviral treatment (ART) was determined by CD4+ cell count (CD4+) for women not yet on ART. ART-eligible women initiated stavudine-lamivudine-nevirapine. Early ART was defined as ART for ≥14 weeks prior to delivery. For women ineligible for ART, optimal ARV prophylaxis was maternal AZT ≥6 weeks+sdNVP, and infant sdNVP+AZT for 1 week. HIV transmission rates were determined for ARV regimens, and factors associated with vertical transmission were identified using bivariate logistic regression. RESULTS: Transmission rate at first PCR was 4.1%. Pairs receiving suboptimal ARV prophylaxis were more likely to transmit HIV (10.3%, 95% CI, 5.5-18.1%). ART was associated with reduced transmission (1.4%, 95% CI, 0.6-3.0%), with early ART associated with decreased transmission (no transmission), compared to all other treatment groups (p = 0.001). No association was detected between transmission and CD4+ categories (p = 0.337), trimester of pregnancy at enrollment (p = 0.100), or maternal age (p = 0.164). CONCLUSION: Low rates of MTCT of HIV are possible in resource-constrained settings under routine programmatic conditions. No transmissions were observed among women on ART for more than 14 weeks prior to delivery.

The Tingathe programme: a pilot intervention using community health workers to create a continuum of care in the prevention of mother to child transmission of HIV (PMTCT) cascade of services in Malawi.

INTRODUCTION: Loss to follow-up is a major challenge in the prevention of mother to child transmission of HIV (PMTCT) programme in Malawi with reported loss to follow-up of greater than 70%. Tingathe-PMTCT is a pilot intervention that utilizes dedicated community health workers (CHWs) to create a complete continuum of care within the PMTCT cascade, improving service utilization and retention of mothers and infants. We describe the impact of the intervention on longitudinal care starting with diagnosis of the mother at antenatal care (ANC) through final diagnosis of the infant. METHODS: PMTCT service utilization, programme retention and outcomes were evaluated for pregnant women living with HIV and their exposed infants enrolled in the Tingathe-PMTCT programme between March 2009 and March 2011. Multivariate logistic regression was done to evaluate maternal factors associated with failure to complete the cascade. RESULTS: Over 24 months, 1688 pregnant women living with HIV were enrolled. Median maternal age was 27 years (IQR, 23.8 to 30.8); 333 (19.7%) were already on ART. Among the remaining women, 1328/1355 (98%) received a CD4 test, with 1243/1328 (93.6%) receiving results. Of the 499 eligible for ART, 363 (72.8%) were successfully initiated. Prior to, delivery there were 93 (5.7%) maternal/foetal deaths, 137 (8.1%) women transferred/moved, 51 (3.0%) were lost and 58 (3.4%) refused ongoing PMTCT services. Of the 1318 live births to date, 1264 (95.9%) of the mothers and 1285 (97.5%) of the infants received ARV prophylaxis; 1064 (80.7%) infants were tested for HIV by PCR and started on cotrimoxazole. Median age at PCR was 1.7 months (IQR, 1.5 to 2.5). Overall transmission at first PCR was 43/1047 (4.1%). Of the 43 infants with positive PCR results, 36 (83.7%) were enrolled in ART clinic and 33 (76.7%) were initiated on ART. CONCLUSIONS: Case management and support by dedicated CHWs can create a continuum of longitudinal care in the PMTCT cascade and result in improved outcomes.