Narrative Medicine: The Power of Shared Stories to Enhance Inclusive Clinical Care, Clinician Well-Being, and Medical Education.

The COVID-19 pandemic exacerbated the problem of secondary trauma and moral injury for health care workers. This reality, together with the epidemic of social isolation and loneliness, has brought the mental health of health care practitioners and patients to the forefront of the national conversation. Narrative medicine is an accessible, diversity-honoring, low-cost, underutilized pedagogical framework with potentially revolutionary benefits for enhancing patient care, supporting the underserved, mitigating clinician burnout, and improving team dynamics. Herein, the authors review the literature on these benefits and then discuss methods for integrating narrative medicine into clinical care and medical education at the undergraduate and graduate levels as well as continuing medical education.

Proposed solutions by the American College of Allergy, Asthma, and Immunology and advocacy experts to address racial disparities in atopic dermatitis and food allergy.

Atopic dermatitis (AD) and food allergies are more prevalent and more severe in people with skin of color than White individuals. The American College of Allergy, Asthma, and Immunology (ACAAI) sought to understand the effects of racial disparities among patients with skin of color with AD and food allergies. The ACAAI surveyed its members (N = 200 completed), conducted interviews with health care providers and advocacy leaders, and hosted a roundtable to explore the challenges of diagnosis and management of AD and food allergies in people with skin of color and to discuss potential solutions. Most of the survey respondents (68%) agreed that racial disparities make it difficult for people with skin of color to receive adequate treatment for AD and food allergies. The interviews and roundtable identified access to care, burden of costs, policies and infrastructure that limit access to safe foods and patient education, and inadequate research involving people with skin of color as obstacles to care. Proposed solutions included identifying ways to recruit more people with skin of color into clinical trials and medical school, educating health care providers about diagnosis and treating AD and food allergy in people with skin of color, improving access to safe foods, creating and disseminating culturally appropriate materials for patients, and working toward longer appointment times for patients who need them. Challenges in AD and food allergy in persons with skin of color were identified by the ACAAI members. Solutions to these challenges were proposed to inspire actions to mitigate racial disparities in AD and food allergy.

Exclusion of SARS-COV-2 From Two Maine Overnight Camps July-August 2020.

OBJECTIVES: Summer camp can positively affect self-esteem and social skills. Most United States summer camps did not open during 2020 because of concerns about severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). Our objective is to describe exclusion strategies successfully used by 2 summer camps in Maine. METHODS: Before camp arrival, all attendees were asked to quarantine at home for 14 d and perform a daily symptom checklist. Salivary specimens were submitted by mail for SARS-COV-2 PCR testing 4 d before arrival, and again 4 d after arrival. At camp, multiple layers of nonpharmaceutical interventions (NPIs) were used. RESULTS: A total of 717 (96.7%) prospective attendees underwent remotely supervised saliva collection; 4 were positive and did not come to camp. Among the 20 who did not submit a sample, 3 did not come to camp; the other 17 underwent screening and a rapid antigen test for SARS-COV-2 immediately upon arrival and before reporting to communal living spaces; all were negative. All campers and staff were re-tested by salivary polymerase chain reaction 4 d after arrival, and all were negative. CONCLUSIONS: We demonstrate that it is possible to safely operate overnight camps during a pandemic, thus supporting the continued physical and socioemotional growth of children, using multiple layers of NPIs.

Recognition and Management of Pediatric Sepsis in a Resource-Limited Emergency Department in Mwanza, Tanzania: A Qualitative Study.

OBJECTIVE: The World Health Organization aims to reduce worldwide under-five mortality rates (U5MR), with a focus on resource-limited settings (RLS). Tanzania reports a mean U5MR of 54 per 1000 live births, largely due to treatable infectious diseases that may lead to sepsis, accounting for 40% of the under-five deaths. Bugando Medical Centre in Mwanza, Tanzania represents a resource-limited setting in Sub-Saharan Africa and estimates a 14% pediatric mortality rate. We sought to better understand provider experience in recognizing and managing pediatric sepsis in the emergency department (ED) at Bugando Medical Centre in Mwanza, Tanzania. METHODS: We conducted a qualitative study with a purposive sampling of 14 Bugando Medical Centre ED providers from January to February 2019, via minimally structured interviews, to identify factors influencing the recognition and management of children presenting to the ED with concern for sepsis. Interviews were conducted in English, audio recorded, and transcribed. Data saturation determined the sample size. Three primary coders independently coded all transcripts and developed an initial coding list. Consensus among all authors generated a final coding scheme. A grounded theory approach guided data analysis. RESULTS: We achieved thematic saturation after 13 interviews. Responses identified patient-, provider-, and health care system-related factors influencing sepsis recognition and management in children presenting to the ED. Patient-related factors include the use of traditional healers, limited parent health literacy, and geographic factors impacting access to medical care. Provider-related factors include limited knowledge of pediatric sepsis, lack of a standard communication process among providers, and insufficient experience with procedural skills on children. Health care system-related factors include limited personnel and resources, delayed transfers from referral hospitals, and lack of standard antibiotic-use guidelines. CONCLUSIONS: This qualitative study identified patient, provider, and health care system-related factors that influence the emergency care of children with suspected sepsis in a quaternary hospital in Mwanza, Tanzania. These factors may serve as a framework for educational opportunities to improve the early recognition and management of pediatric sepsis in a resource-limited setting.

"First do no harm": Clinical practice guidelines, mesolevel structural racism, and medicine's epistemological reckoning.

This paper presents a critique of clinical practice guidelines (CPGs) that standardize the use of race as a proxy for biological difference in medical settings. Drawing on the illustrative example of a pediatric UTI testing guideline, we contend that when CPGs necessitate that Black patients meet a higher threshold of illness severity or duration than their non-Black counterparts to receive comparable medical testing or other medical care, they function as mesolevel sites of race-racism reification processes (see Sewell, 2016) that contribute to the reproduction of racial health disparities. We describe broader implications and make recommendations for the conceptualization and implementation of future research in the sociological study of race, health, and medicine.

Bacterial meningitis post-PCV7: declining incidence and treatment.

The epidemiology of bacterial meningitis in the United States has changed tremendously in the past 20 years. Since the introduction of the Haemophilus influenzae type b vaccine in 1988, the incidence of H. influenzae type b meningitis has declined by at least 97%, and Streptococcus pneumoniae has emerged as the most common etiologic agent. The PCV7 (7-valent pneumococcal conjugate vaccine [Prevnar]; Wyeth Pharmaceuticals) vaccine, which targets 7 pneumococcal serotypes, was introduced in 2000 and has had an enormous impact on both the incidence and epidemiology of bacterial meningitis. This article reviews the impact of the PCV7 vaccine and the most up-to-date evidence on diagnosis and empiric therapy of suspected bacterial meningitis in the current day.

Update on urinary tract infections in the emergency department.

PURPOSE OF REVIEW: To review recent changes in the diagnostic and therapeutic approach to pediatric urinary tract infection in the emergency department. RECENT FINDINGS: Updated guidelines from the American Academy of Pediatrics have significantly changed the approach to UTI, risk-stratifying patients according to their likelihood of UTI, and re-defining criteria for diagnosis of UTI. New studies have delineated important risk factors for concomitant bacteremia and adverse events. Procalcitonin has emerged as the inflammatory marker most predictive of upper versus lower urinary tract infection and renal scarring. Delays in empiric antibiotic therapy are associated with increased rates of renal scarring. Corticosteroids are a potential adjunctive therapy to antibiotics. SUMMARY: Timely diagnosis and therapy of UTI are essential. New guidelines may alter the traditional approach to evaluation and management. Future studies will likely focus on the impact of the new guidelines, further delineate the role of procalcitonin in predicting UTI, and explore the role of corticosteroids as an adjunct to antibiotic therapy.

Factors determining access to surgery for children with congenital cardiac disease in Guatemala, Central America.

BACKGROUND: Surgical intervention for children with congenital cardiac disease in the developing world often occurs late. Our objective was to identify factors that placed Guatemalan children at risk for delayed care. METHODS: We investigated the medical and socioeconomic background of 178 children under the age of 18 years who received their first corrective surgery for congenital cardiac disease at the Unidad de Cirugía Cardiovascular de Guatemala in 2002. A retrospective review of medical records was performed. Each case was stratified into one of three surgical classes based upon customary practice in the United States of America. The outcome we measured was age at surgery, adjusting for the surgical class. Logistic regression was performed and odds ratios calculated. RESULTS: In univariate analyses, patients presented later for surgery if they were from rural areas (p equals 0.001), did not have social security membership (p equals 0.004), or paid any amount towards the cost of their surgery (p less than 0.001). Age at surgery was also positively correlated with the distance of the home of the patient from the surgical centre (p equals 0.002). For the subset of patients who applied for financial assistance, we found that children presented later for surgery if they required institutional support (p equals 0.001), or came from households of larger size (p less than 0.001). CONCLUSIONS: Guatemalan children with congenital cardiac disease may be at risk for delayed surgical care if they come from rural areas, areas distant from the surgical centre, or from families without membership of social security.