"Devi Mangiare!" [You have to eat!]: Experiences of disordered eating among Italian-Australian women.

In this article, the researchers report findings on how food meanings, culture and gender intersect in the experiences of Italian-Australian women. In-depth narrative interviews were thematically analyzed using a feminist social constructionist framework informed by anthropological theories about "foodways" and culture. Three core themes were identified in the women's narratives: "il cibo e' tutto, il cibo e amore" - "food is everything, food is love"; "fare la bella figura" - "to make a good impression"; and "il mio piatto" - "it's my plate". The researchers demonstrate how gendered expectations of women in Italian-Australian culture intersect with food meanings, cultural ideals and practices to produce distinct experiences of disordered eating and restricted access to formal support. The relevance of the findings are likely to be applicable to other migrant communities across the world. Particularly where ethnic communities retain distinctive food related meanings and practices post migration, that may intersect with cultural ideals venerating female thinness and the psycho-medical models and practices that pathologize disordered eating.

Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology.

INTRODUCTION: Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice. METHODS: A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time. RESULTS: We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months. CONCLUSION: Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.

Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The PRIME Randomized Clinical Trial.

Importance: Timely analgesia is critical for children with injuries presenting to the emergency department, yet pain control efforts are often inadequate. Intranasal administration of pain medications provides rapid analgesia with minimal discomfort. Opioids are historically used for significant pain from traumatic injuries but have concerning adverse effects. Intranasal ketamine may provide an effective alternative. Objective: To determine whether intranasal ketamine is noninferior to intranasal fentanyl for pain reduction in children presenting with acute extremity injuries. Design, Setting, and Participants: The Pain Reduction With Intranasal Medications for Extremity Injuries (PRIME) trial was a double-blind, randomized, active-control, noninferiority trial in a pediatric, tertiary, level 1 trauma center. Participants were children aged 8 to 17 years presenting to the emergency department with moderate to severe pain due to traumatic limb injuries between March 2016 and February 2017. Analyses were intention to treat and began in May 2017. Interventions: Intranasal ketamine (1.5 mg/kg) or intranasal fentanyl (2 µg/kg). Main Outcomes and Measures: The primary outcome was reduction in visual analog scale pain score 30 minutes after intervention. The noninferiority margin for this outcome was 10. Results: Of 90 children enrolled, 45 (50%) were allocated to ketamine (mean [SD] age, 11.8 [2.6] years; 26 boys [59%]) and 45 (50%) to fentanyl (mean [SD] age, 12.2 [2.3] years; 31 boys [74%]). Thirty minutes after medication, the mean visual analog scale reduction was 30.6 mm (95% CI, 25.4-35.8) for ketamine and 31.9 mm (95% CI, 26.6-37.2) for fentanyl. Ketamine was noninferior to fentanyl for pain reduction based on a 1-sided test of group difference less than the noninferiority margin, as the CIs crossed 0 but did not cross the prespecified noninferiority margin (difference in mean pain reduction between groups, 1.3; 90% CI, -6.2 to 8.7). The risk of adverse events was higher in the ketamine group (relative risk, 2.5; 95% CI, 1.5-4.0), but all events were minor and transient. Rescue analgesia was similar between groups (relative risk, 0.89; 95% CI, 0.5-1.6). Conclusions and Relevance: Ketamine provides effective analgesia that is noninferior to fentanyl, although participants who received ketamine had an increase in adverse events that were minor and transient. Intranasal ketamine may be an appropriate alternative to intranasal fentanyl for pain associated with acute extremity injuries. Ketamine should be considered for pediatric pain management in the emergency setting, especially when opioids are associated with increased risk. Trial Registration: ClinicalTrials.gov Identifier: NCT02778880.

Lessons learned from administration of high-dose methylprednisolone sodium succinate for acute pediatric spinal cord injuries.

OBJECTIVE Methylprednisolone sodium succinate (MPSS) has been studied as a pharmacological adjunct that may be given to patients with acute spinal cord injury (ASCI) to improve neurological recovery. MPSS treatment became the standard of care in adults despite a lack of evidence supporting clinical benefit. More recently, new guidelines from neurological surgeon groups recommended no longer using MPSS for ASCI, due to questionable clinical benefit and known complications. However, little information exists in the pediatric population regarding MPSS use in the setting of ASCI. The aim of this paper was to describe steroid use and side effects in patients with ASCI at the authors' Level 1 pediatric trauma center in order to inform other hospitals that may still use this therapy. METHODS A retrospective chart review was conducted to determine adherence in ordering and delivery according to the guideline of the authors' institution and to determine types and frequency of complications. Inclusion criteria included age < 17 years, blunt trauma, physician concern for ASCI, and admission for ≥ 24 hours or treatment with high-dose intravenous MPSS. Exclusion criteria included penetrating trauma, no documentation of ASCI, and incomplete medical records. Charts were reviewed for a predetermined list of complications. RESULTS A total of 602 patient charts were reviewed; 354 patients were included in the study. MPSS was administered in 59 cases. In 34 (57.5%) the order was placed correctly. In 13 (38.2%) of these 34 cases, MPSS was administered according to the recommended timeline protocol. Overall, only 13 (22%) of 59 patients received the therapy according to protocol with regard to accurate ordering and administration. Among the patients with ASCI, 20 (55.6%) of the 36 who received steroids had complications, which was a significantly higher rate than in those who did not receive steroids (8 [24.2%] of 33, p = 0.008). Among the patients without ASCI, 10 (43.5%) of the 23 who received steroids also experienced significantly more complications than patients who did not receive steroids (50 [19.1%] of 262, p = 0.006). CONCLUSIONS High-dose MPSS for ASCI was not delivered to pediatric patients according to protocol with a high degree of reliability. Patients receiving steroids for pediatric ASCI were significantly more likely to experience complications than patients not receiving steroids. The findings presented, including complications of steroid use, support removal of high-dose MPSS as a treatment option for pediatric ASCI.

Effectiveness of interventions to improve medication use during rapid-sequence intubation in a pediatric emergency department.

PURPOSE: Results of a study to determine whether checklist-based interventions improved the selection and administration of rapid-sequence intubation (RSI) medications in a pediatric emergency department (ED) are reported. METHODS: A retrospective study of data collected during a quality-improvement project was conducted. Data sources included the electronic health record and video review. The central intervention was use of a 21-item RSI checklist, which included guidance for the physician team leader on medication selection and timing. A quick-reference card was developed to guide staff in preparing RSI medications. The main outcomes were (1) standard selection, defined as administration of indicated medications and avoidance of medications not indicated, and (2) efficient administration, defined as an interval of <30 seconds from sedative to neuromuscular blocker (NMB) infusion. RESULTS: A total of 253 consecutive patients underwent RSI during 3 consecutive periods: the historical (preimprovement) period (n = 136), the checklist only period (n = 68), and the checklist/card period (n = 49). The rate of standard selection of 3 RSI medications (atropine, lidocaine, and rocuronium) did not improve. The rate of efficient sedative and NMB administration improved from 56% in the historical period to 88% in the checklist period (p = 0.005). The median duration of RSI medication administration decreased from 28 seconds (interquartile range [IQR], 23-44 seconds) in the historical period to 19 seconds (IQR, 15-25 seconds) in the checklist/card period (p = 0.004). CONCLUSION: In a quality-improvement project in a pediatric ED, a checklist-based intervention improved RSI medication administration technique but not selection.

Sudden Collapse of a Preschool-Aged Child on the Playground.

PURPOSE: Primary cardiac events are rare in children. There is little information in the literature regarding the most appropriate emergency department (ED) management of this type of pediatric patient, especially with regard to medication use. SUMMARY: This case highlights the pediatric ED evaluation and treatment of sudden collapse in a child with an ultimate diagnosis of hypertrophic cardiomyopathy. Cardiac disorders represent 2% to 6% of cases of pediatric syncope presenting to EDs, particularly if there are previous prodromal symptoms and/or a history of exertion. Evaluation should include electrocardiogram, chest radiograph, and echocardiogram if available. Management should focus on decreasing the potential for a recurring arrhythmia while maintaining cardiac preload, which can be worsened with certain medication use. CONCLUSIONS: Although primary cardiac events in children are rare, a high index of suspicion should be maintained especially with a history of prodromal symptoms or collapse during exertion. If cardiac etiology is suspected, deliberate management should be used to exclude a treatment that could be detrimental. This case report provides an initial assessment and recommendations for management of these patients.

Pediatric emergency department discharge prescriptions requiring pharmacy clarification.

OBJECTIVES: The aims of the study were to analyze and classify reasons why retail pharmacies need to contact the pediatric emergency department (PED) for clarification on outpatient prescriptions generated using an electronic prescribing system and to categorize the severity of errors captured. METHODS: A retrospective chart review was conducted at a PED that cares for approximately 92,000 patients annually. All pharmacy callbacks documented in the electronic medical record between August 1, 2008 and July 31, 2009 were included. A datasheet was used to capture patient demographics (age, sex, race, insurance), prescriptions written, and reason for callback. Each call was then assigned a severity level, and time to respond to all calls was estimated. Frequencies were used to analyze the data. RESULTS: A total of 731 errors for 695 callbacks were analyzed from 49,583 prescriptions written at discharge. The most common errors included administrative/insurance issues 342/731 (47%) and prescription writing errors 298/731 (41%). The errors were classified as insignificant (340/729 [47%]), problematic (288/729 [40%]), significant (77/729 [11%]), serious (12/729 [1.64%]), and severe (12/729 [1.64%]). Almost 96% of errant prescriptions were not able to be filled as originally written and required a change by the prescriber. These calls required approximately 127 hours to complete. CONCLUSIONS: Prescription errors requiring a pharmacy callback are typically insignificant. However, 13.8% of callbacks about an error were considered significant, serious, or severe. Automated dose checking and verifying insurance coverage of prescribed medications should be considered essential components of prescription writing in a PED.

Quality and cost of student lunches brought from home.

IMPORTANCE: The nutritional quality and cost of lunches brought from home are overlooked and understudied aspects of the school food environment. OBJECTIVES: To examine the quality and cost of lunches brought from home by elementary and intermediate school students. DESIGN, SETTING, AND PARTICIPANTS: An observational study was conducted in 12 schools (8 elementary and 4 intermediate) in one Houston, Texas, area school district from October 6, 2011, to December 5, 2011. Participants included 242 elementary and 95 intermediate school students who brought lunches from home. EXPOSURES: Lunches brought from home. MAIN OUTCOMES AND MEASURES: Foods brought and amounts eaten were recorded along with student grade level and sex. Nutrient and food group content were calculated and compared with current National School Lunch Program (NSLP) guidelines. Per-serving prices for each item were collected from 3 grocery stores in the study area and averaged. RESULTS: Compared with the NSLP guidelines, lunches brought from home contained more sodium (1110 vs ≤640 mg for elementary and 1003 vs ≤710 mg for intermediate students) and fewer servings of fruits (0.33 cup for elementary and 0.29 cup for intermediate students vs 0.50 cup per the NSLP guidelines), vegetables (0.07 cup for elementary and 0.11 cup for intermediate students vs 0.75 cup per the NSLP guidelines), whole grains (0.22-oz equivalent for elementary and 0.31-oz equivalent for intermediate students vs 0.50-oz minimum per the NLSP guidelines), and fluid milk (0.08 cup for elementary and 0.02 cup for intermediate students vs 1 cup per the NSLP guidelines). About 90% of lunches from home contained desserts, snack chips, and sweetened beverages, which are not permitted in reimbursable school meals. The cost of lunches from home averaged $1.93 for elementary and $1.76 for intermediate students. Students from lower-income intermediate schools brought significantly higher-priced ($1.94) lunches than did students from middle-income schools ($1.63). CONCLUSIONS AND RELEVANCE: Lunches brought from home compared unfavorably with current NSLP guidelines. Strategies are needed to improve the nutritional quality of lunches brought from home.

Campus-based snack food vending consumption.

OBJECTIVE: To evaluate the purchases of university vending machine clientele and to understand what consumers purchase, purchase motivations, and purchase frequency after implementation of a vending policy designed to promote access to healthier snack options. METHODS: Cross-sectional data collection from consumers at 8 campus vending machines purposefully selected from a list of highest-grossing machines. Vending machines were stocked with 28.5% green (choose most often), 43% yellow (occasionally), and 28.5% red (least often) food items. RESULTS: Consumers were predominately students (86%) and persons aged 18-24 years (71%). Red vending choices were overwhelmingly selected over healthier vending options (59%). Vended snack food selections were most influenced by hunger (42%) and convenience (41%). Most consumers (51%) frequented vending machines at least 1 time per week. CONCLUSIONS AND IMPLICATIONS: Despite decreased access to less healthful red snack food choices, consumers chose these snacks more frequently than healthier options in campus vending machines.

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

BACKGROUND: Narcotics are responsible for many adverse drug events in children and there has been an increase in opioid oversedation events in hospitalised patients. OBJECTIVES: To use improvement methods to prevent perioperative opioid oversedation adverse events while continuing to provide appropriate pain control. METHODS: Interventions included revising the post-anaesthesia order form so that prescribers could choose only one narcotic and one dose for moderate pain and one narcotic and one dose for severe pain, modifying a nursing tool to provide more objective criteria for assessing patient sedation level, and restructuring the pain service. Clinicians on the Acute Pain Service saw all postoperative patients receiving intravenous patient-controlled analgesia or neuraxial narcotics in the mornings and afternoons and a nurse saw them on weekday evenings. RESULTS: The rate of opioid-related oversedation events decreased from 0.15 per 1000 patient days at baseline to 0.111 during the intervention period to 0.074 in the post-intervention period. The days between events increased from 21.0 to 27.5 to 48.8 during the same periods. The number of opioid-related oversedation events decreased from 22 to 17 to 5 during these periods, respectively. CONCLUSIONS: Opioid-related oversedation events decreased over the course of the study. Because the perioperative period is an especially likely time for opioid oversedation events, strict opioid prescribing practices, while maintaining adequate pain control and improved sedation assessment during the perioperative period, were emphasised. The restructured pain service and increased visits by pain team experts were also associated with the reduction in oversedation events.