Factors associated with intention to implement SBI and SUD treatment: a survey of primary care clinicians in Texas enrolled in an online course.

BACKGROUND: Substance use disorder (SUD) presents a range of public health challenges and consequences. Despite the prevention potential of screening and brief intervention (SBI) in the primary care setting, implementation is low. The purpose of this study was to assess associations of primary care clinicians' knowledge of SBI and SUD treatment, subjective norms, and perceived behavioral control with intention to incorporate SBI and SUD treatment into regular clinical practice. METHODS: This online survey was administered to primary care clinicians who practice in Texas between March 1, 2021, and February 5, 2023. Survey questions were mapped to factors in the Theory of Planned Behavior and included measures of knowledge, subjective norms, and perceived behavioral controls related to SBI and SUD treatment. Intention to engage in SBI and SUD treatment was assessed as the outcome. RESULTS: Of 645 participants included in this study, 59.5% were physicians. Knowledge was low, with less than half correctly reporting what was considered a standard drink (39.6%) and only 20% knew the correct number of alcoholic beverages considered risky drinking in 21-year-old non-pregnant women. Subjective norms, such as having colleagues within their practice support addressing SUDs, and perceived behavioral control such as having SUD screening routinized within clinic workflows, were positively associated with intention to implement SBI and SUD treatment in primary care settings. CONCLUSIONS: Modifying knowledge gaps, subjective norms, and perceived behavioral control requires a multipronged interventional approach that blends accessible clinician training with systemic workplace enhancements and a collective shift in professional norms.

Effect of age at initiation of the human papillomavirus vaccine on the association between race/ethnicity and completion of the vaccine series.

BACKGROUND: Up-to-date (UTD) of the human papillomavirus (HPV) vaccine series has been low despite 2016 recommendations for 2 doses among initiators <15 years of age and 3 doses for 15+ year olds. This study examined how age at initiation affected the association between race/ethnicity and UTD among adolescent HPV vaccine initiators. We also examined how administration of other adolescent vaccines affected UTD. METHODS: A secondary analysis of The National Immunization Survey - Teen data between 2016 and 2020 was conducted. Characteristics associated with initiation of the vaccine series was examined and used to evaluate UTD among initiators. All data were weighted. Associations between characteristics and HPV vaccine initiation were examined using Rao Scott chi-square tests and univariable logistic regression. Multivariable binary logistic regression models stratified by race/ethnicity calculated the strength of association between independent variables and odds of initiation and UTD among initiators. RESULTS: The final sample size was 99,719 with 67,855 (68.1 %) initiating HPV vaccination. Among HPV vaccine initiators, Hispanic and black adolescents had lower odds of UTD. However, 9-10-year-old initiators had increased odds (aOR: 5.71; 95 %CI: 3.78-8.63) of UTD compared to 12-year-old initiators. Increased odds of UTD among initiators younger than 12 years were found across racial/ethnic groups. Flu vaccination was associated with decreased odds of UTD among white (aOR: 0.76; 95 %CI:0.65-0.88) and black adolescents (aOR: 0.67; 95 %CI: 0.46-0.96). CONCLUSION: Strong recommendations to ensure patients are UTD on the HPV vaccine series are essential to improving UTD among all adolescents and follow-up should occur when administering other vaccines to reduce missed opportunities.

Standardization of Pediatric Noncardiac Operating Room to Intensive Care Unit Handoffs Improves Communication and Patient Care.

OBJECTIVES: Handoffs are critical points in transitioning care between multidisciplinary teams, yet data regarding intensive care unit (ICU) handoffs in pediatric noncardiac surgical patients are lacking. We hypothesized that standardized handoffs from the pediatric operating room (OR) to the ICU would improve physician presence, communication, and patient care parameters. METHODS: This quality improvement initiative was performed at a tertiary children's hospital. Stakeholders (anesthesiologists, nurses, intensivists, and surgeons) developed a standardized OR to pediatric and neonatal ICU handoff process based on common goals and outcomes of interest. Baseline data were collected before intervention. Implementation was carried out in 2 phases, phase 1 with a written handoff and Phase 2 with a scripted handoff process. Data collected by trained observers included handoff attendance, distractions, and transfer of essential patient information. As a surrogate for outcomes, patient care parameter data were collected for 6 hours after transfer. RESULTS: After phase 1, surgery and ICU physician attendance increased significantly, distractions decreased, and communication of essential patient data improved. In phase 2 (scripted handoff), attendance continued to rise, distractions remained decreased, and transfer of essential information was still improved compared with baseline. Mean handoff duration did not significantly change throughout the study. Certain patient care parameters (escalation of respiratory support, additional laboratory studies, vasopressor administration, antibiotic administration and timing) remained unchanged compared with baseline. However, the need for resuscitative fluid bolus or blood products significantly decreased after implementation phase 2. CONCLUSIONS: Standardized handoffs for pediatric noncardiac surgical patients from the OR to the ICU can improve provider attendance and communication.

Disparities between US Hispanic and non-Hispanic women in obesity-related perinatal outcomes: a prospective cohort study.

BACKGROUND: Mortality figures and national health surveillance data have demonstrated that Hispanics have a 24% lower risk of all-cause mortality compared to their non-Hispanic counterparts despite increased rates of obesity and related illnesses. OBJECTIVE: The aim of this study is to evaluate if this paradox exists for obesity-related perinatal outcomes in otherwise low-risk Hispanic women. MATERIALS AND METHODS: A prospective cohort study of low-risk women across all BMI classes with a singleton, non-anomalous term pregnancy admitted in active labor or undergoing induction of labor between May 2014 and April 2017. All demographic, obstetric, and neonatal outcomes were recorded, and the body mass index (BMI) closest to delivery was used for analysis. Data including composites of adverse maternal and neonatal outcomes were compared across BMI classes and between individuals of Hispanic and non-Hispanic ethnicity. Women with antenatal complications, prior cesarean delivery, and cesarean for non-reassuring fetal status were excluded. RESULTS: Of the 11,369 women who met inclusion criteria, 6303 (55%) were Hispanic. Eight percent of Hispanic women were normal weight (BMI: 18.5-24.9), 34% were overweight (BMI: 25-29.9), and 58% were obese (BMI > 30). Fourteen percent of non-Hispanic women were normal weight, 42% were overweight, and 44% were obese. The majority (65%) of women were multiparous. Rate of induction and birthweight increased across BMI for Hispanic and non-Hispanic groups, however the route of delivery was not significantly different (p = .22, 0.16, respectively). Although the association between BMI and composite perinatal complications did not differ by BMI class and ethnicity, the newborns of non-Hispanic women were more likely to be admitted to the neonatal intensive care unit with increasing maternal weight class (<0.001), even after adjusting for age, parity, marital status, prenatal visits, current tobacco use, type of labor, mode of delivery, and birthweight. CONCLUSION: There were no demonstrable differences in composite adverse maternal or neonatal outcomes between Hispanic and non-Hispanic obese women. However, newborns of non-Hispanic obese women were more likely to be transferred to the neonatal intensive care unit with increasing maternal BMI.

Intertwin differences in umbilical artery pulsatility index are associated with infant survival in twin-to-twin transfusion syndrome.

OBJECTIVES: To evaluate the association of intertwin differences in umbilical artery pulsatility index (DUAPI) and infant survival in twin-to-twin transfusion syndrome (TTTS). METHODS: Absolute DUAPI was calculated prior to laser surgery. Receiver-operating characteristics (ROC) curve analysis provided an intertwin DUAPI cutoff of 0.4 for the prediction of double twin survival to 30 days of life. Infant survival was compared between women with an intertwin DUAPI <0.4 and ≥0.4 in the whole cohort, in TTTS cases with Quintero stages I/II and in those with Quintero stages III/IV. Regression analyses were performed to evaluate the association of intertwin DUAPI <0.4 and infant survival adjusted for confounders. RESULTS: In total, 349 TTTS cases were included. Double twin survival to 30 days was observed in 67% (234/349) of cases. Significant differences in double twin survival was seen between intertwin DUAPI groups in the whole cohort (76.8 vs. 52.2%; p<0.001), in women with TTTS Quintero stage I or II (77.8 vs. 58.5%; p=0.015) as well as in women with TTTS Quintero stage III or IV (75 vs. 49.5%; p=0.001). Intertwin DUAPI <0.4 conferred a threefold increased chance for double twin survival. CONCLUSIONS: Small intertwin DUAPI is associated with increased double infant survival in early and advanced TTTS stages.

Painful Sleep: Insomnia in Patients with Chronic Pain Syndrome and its Consequences.

Insomnia is a chronic condition that occurs a minimum of three times per week over a period of three or more subsequent months. There are multiple causes of insomnia, and even though it is considered a symptom, it can be associated with chronic illnesses. Chronic pain syndrome, which is defined as pain that persists for a period longer than 3 months, is one of several etiologies of insomnia. The prevalence of insomnia among chronic pain patients is greater in comparison with the general population (percentage or ratio). Chronic pain is common in patients with rheumatoid arthritis, spinal pain (such as chronic back pain) and fibromyalgia. The prevalence of in-somnia is also higher in cancer patients when compared to the general population. When the clinical history indicates a straightforward diagnosis of chronic pain syndrome, patients will complain of insomnia as part of their symptomatology. It is imperative to manage their underlying illness to alleviate their sleep disorder. Various medications may be used to relieve and even improve pain symptoms. Other than pharmacological interventions, non-pharmacological alternatives such as yoga, meditation, acupuncture, and psychotherapy can help improve the quality of life of these patients. The purpose of this article is to review the diagnosis and management of insomnia in chronic pain syndrome and its impact on the quality of life.

Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation.

BACKGROUND: Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS: We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant. RESULTS: Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%. CONCLUSION: Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis.

INTRODUCTION: The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). METHODS: We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. RESULTS: Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = -0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. CONCLUSION: As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Surgical site infection reporting: more than meets the agar.

BACKGROUND/PURPOSE: Surgical site infection (SSI) rate in pediatric appendicitis is a commonly used hospital quality metric. We hypothesized that surveillance of organ-space SSI (OSI) using cultures alone would fail to capture many clinically-important events. METHODS: A prospective, multidisciplinary surveillance program recorded 30-day SSI and hospital length of stay (LOS) for patients <18years undergoing appendectomy for perforated appendicitis from 2012 to 2015. Standardized treatment pathways were utilized, and OSI was identified by imaging and/or bacterial cultures. RESULTS: Four hundred ten appendectomies for perforated appendicitis were performed, and a total of 84 OSIs (20.5%) were diagnosed with imaging. Positive cultures were obtained for 39 (46%) OSIs, whereas 45 (54%) had imaging only. Compared to the mean LOS for patients without OSI (5.2±2.9days), LOS for patients with OSI and positive cultures (13.7±5.4days) or with OSI without cultures (10.4±3.7days) was significantly longer (both p<0.001). The OSI rate identified by positive cultures alone was 9.5%, whereas the clinically-relevant OSI rate was 20.5%. CONCLUSIONS: Using positive cultures alone to capture OSI would have identified less than half of clinically-important infections. Utilizing clinically-relevant SSI is an appropriate metric for comparing hospital quality but requires agreed upon standards for diagnosis and reporting. LEVEL OF EVIDENCE: II. TYPE OF STUDY: Diagnostic study.

How Should Surgical Residents Be Educated About Patient Safety: A Pilot Randomized Controlled Trial.

INTRODUCTION: The Accreditation Council for Graduate Medical Education mandates patient safety education without specific curricular guidelines. We hypothesized that a dedicated, adjunctive resident safety workshop (SW) led by surgical faculty compared with an online curriculum (OC) for hospital personnel alone would improve residents' patient safety perceptions and behaviors. MATERIALS AND METHODS: A pilot randomized controlled trial was performed from 2014 to 2015 within a university-based general surgery residency. Control and intervention groups, stratified by postgraduate year, participated in a hospital-based OC; the intervention group participated in an additional SW. Primary outcomes were perceptions of safety culture, teamwork, and speaking up as per the validated safety attitudes questionnaire (SAQ) at 6 and 12 months postintervention. Secondary outcomes included behavioral scores from blinded surgical faculty using the Oxford NonTechnical Skills scale. RESULTS: A total of 51 residents were enrolled (control = 25, intervention = 26). SAQ response rates were 100%, 100%, and 76% at baseline, 6 months, and 12 months, respectively. SAQ scores were similar at baseline between groups and did not change significantly at 6 or 12 months, independent of postgraduate year (PGY) level. Overall NonTechnical Skills scores were similar between groups, but senior residents (≥PGY 4) in the OC + SW group scored significantly higher in teamwork, decision-making, and situation awareness (all p < 0.05). CONCLUSION: An adjunctive, dedicated resident SW compared with a hospital-based OC alone did not significantly improve overall perceptions of patient safety. However, senior residents participating in the SW demonstrated improved patient safety perceptions and had significantly better intraoperative safety behaviors than senior residents in the OC group. Future curricular enhancements should include PGY-level specific education, iterative reviews, and increased faculty involvement. A larger randomized trial may be warranted.