Perceptions of Medical Providers on Morality and Decision-Making Capacity in Withholding and Withdrawing Life-Sustaining Treatment and Suicide.

BACKGROUND: This study attempts to understand if medical providers beliefs about the moral permissibility of honoring patient-directed refusals of life-sustaining treatment (LST) are tied to their beliefs about the patient's decision-making capacity. The study aims to answer: 1) does concern about a patient's treatment decision-making capacity relate to beliefs about whether it is morally acceptable to honor a refusal of LST, 2) are there differences between provider types in assessments of decision-making capacity and the moral permissibility to refuse LST, and 3) do provider demographics impact beliefs about decision-making capacity and the moral permissibility to refuse LST. Methods: A mixed-methods survey using Likert assessment and vignette-based questions was administered to medical providers within a single health system in the upper Midwest (N = 714) to assess their perspectives on the moral acceptance and decision-making capacity in cases of withholding and withdrawing treatment and suicide. Results: Behavioral health providers report accepting of the moral permissibility of suicide (91.2%) more than either medical providers (77.2%) or surgeons (74.4%) (n = 283). Decision-making capacity was questioned more in the vignettes of the patients refusing life-saving surgery (36%) and voluntarily starvation (40.8%) than in the vignette of the patient requesting to deactivate a pacemaker (13%) (n = 283). Behavioral health providers were more concerned about the capacity to refuse life-saving surgery (55.9%) than medical providers (33.8%) or surgeons (23.1%) (n = 283). Conclusions: Respondents endorse the moral permissibility of persons to withhold or withdraw from treatment regardless of motive. Clinical concerns about a patient's treatment decision-making capacity do not strongly correlate to views about the moral permissibility of honoring refusals of LST. Different provider types appear to have different thresholds for when to question treatment decision-making capacity. Behavioral health providers tend to question treatment decision-making capacity to refuse LST more than non-behavioral health providers.

Increased Incidence of Giant Cell Arteritis After Introduction of a Live Varicella Zoster Virus Vaccine.

BACKGROUND: Varicella zoster virus (VZV) has been associated with giant cell arteritis (GCA). The introduction of a live attenuated vaccine against this virus (ZVL) might have changed the incidence of GCA. METHODS: The incidence of GCA was retrospectively measured using 2 matched cohorts seen in a regional health system located in the Midwestern United States: ZVL recipients from the years 2007 through 2015 following the introduction of the vaccine and nonrecipients from the years 2000 through 2015. RESULTS: In the ZVL cohort, a significant increase of GCA was associated with clinical criteria alone for the diagnosis of GCA (hazard ratio [HR], 2.70; 95% CI, 1.48-4.45; P = .004). In addition, using only pathologically confirmed GCA, the same matched cohort comparison analysis also found that ZVL recipients were at significantly higher risk than those who did not receive ZVL (HR, 2.70; 95% CI, 1.48-4.95; P = .001). CONCLUSION: Using a matched cohort, retrospective comparison, ZVL was associated with an increased incidence of GCA.

The impact of adverse childhood experiences on healthcare utilization in children.

BACKGROUND: Adverse childhood experiences (ACEs) are related to long-term negative outcomes. The impact of these experiences on healthcare utilization in children has been understudied. OBJECTIVE: To examine the impact of ACEs on children's healthcare utilization, medical diagnoses, and pharmacological treatment. PARTICIPANTS AND SETTING: Children aged 6 months to 17 years who were screened for ACEs in the Behavioral Health Department or in primary care locations as part of an initial consultation visit and who had at least one subsequent healthcare visit during the study period were included in the study. METHODS: Adverse childhood experiences were measured using the ACE screening questionnaire designed by Felitti et al. (1998). Data from the year following administration of the ACE screening tool were retrospectively extracted from the electronic health record. RESULTS: Overall, 1,183 children met study inclusion criteria. Children with any reported ACEs were more likely to no show appointments (1-3 ACEs incidence rate ratio (IRR) [95 % confidence interval (CI)]: 1.40 [1.11-1.77]; 4+ ACEs IRR [95 % CI]: 1.41 [1.08-1.84]) and to use emergency services (1-3 ACEs IRR [95 % CI]: 1.24 [1.00-1.53]; 4+ ACEs: IRR [95 % CI]: 1.42 [1.11-1.81) than children with no ACEs. Those with 4+ ACEs used the telephone nurse advisor less frequently (1-3 ACEs IRR [95 % CI]: 0.67 [0.53-0.84]; 4+ ACEs IRR [95 % CI]: 0.69 [0.53-0.90]). Although ACE scores were associated with healthcare utilization, insurance status was more robustly associated with healthcare utilization than ACE score. CONCLUSIONS: Healthcare systems may employ results from this study to adopt trauma-informed care initiatives. Ensuring that all patients have insurance may be a first step toward improving healthcare utilization.

Early Childhood Obesity Prevention: Challenges and Barriers of Implementing Child and Adult Care Food.

INTRODUCTION: The Child and Adult Care Food Program requirements promote healthy eating behaviors and increased physical activity in the daycare setting to help prevent childhood obesity. Some of these standards can be difficult to meet for early childhood education centers. This study examines the challenges and barriers daycare centers face when implementing these guidelines. METHODS: Focus groups consisting of participants from early childhood education centers within our community were conducted in April and May of 2018. RESULTS: Three focus groups were conducted, with a total of 7 childcare center directors. Eight themes that affect nutrition and physical activity curriculums at early childhood education centers arose: teacher philosophy and involvement, training/expertise of staff, parental involvement, financial constraints, children's interests, food availability, physical environment, and regulations/guidelines. Overall, participants expressed their sense that child care facilities are undervalued. They agreed that healthy, fresh food choices are expensive, difficult to obtain due to the volume needed, and require additional training to prepare. Emphasis on gross motor development has a varied level of support from families and teachers. Challenges and barriers to providing adequate gross motor activities include limited financial support, lack of physical space, lack of teacher willingness to engage in outdoor activity, and parental resistance. CONCLUSIONS: Financial constraints and the "undervaluing" of childcare contribute greatly to many of the challenges and barriers early childhood education centers face in meeting nutrition and physical activity standards. Findings from this study shed light on the significant role early childcare centers play in nurturing child development and the efforts these centers undertake in the interest of children.

Implementation of the adverse childhood experiences conversation in primary care.

BACKGROUND: Research has focused on screening for adverse childhood experiences, rather than provision of education as a part of routine anticipatory guidance. An adverse childhood experiences 'conversation' is one method that has not been studied empirically but represents a complimentary or alternative approach to screening which could overcome many existing barriers. OBJECTIVES: This study aims to examine parent/guardian and provider acceptability/feasibility of the adverse childhood experiences conversation during well-child visits in primary care. METHODS: Providers engaged in a conversation with parents/guardians of patients during well-child visits in a family medicine residency clinic. Parents/guardians and providers were surveyed following the visit to examine acceptability and feasibility. Quarterly assessments to further examine provider perspectives were completed. Data were collected for 1 year. RESULTS: In total, 238 parent/guardian and 231 provider surveys were completed. Most parents/guardians felt positively (76%) about and comfortable (81%) with the information discussed and 97% felt that the conversation should be had with their primary care provider specifically. Most providers (71%) indicated that parents/guardians were receptive to the conversation, that the conversations took 1-2 minutes (60%) and that there were few disclosures of adversity (9%), none of which required mandatory reporting. CONCLUSIONS: Results suggest that the adverse childhood experiences conversation is well received by parents/guardians and providers and is feasible to implement into primary care. The conversation could be used as a complimentary or alternative method to screening to further spread knowledge of toxic stress and health, provide resources for families and promote resilience.

Prevalence and Course of Treatment of Common Hip Diagnoses Presenting to a Sports Medicine Clinic.

BACKGROUND: Hip-related pain and pathology can have an overall negative impact on healthrelated quality of life. Prompt diagnosis and treatment of symptoms at the hip may expedite the recovery process and allow for an earlier return to normal activity. Knowing the prevalence of a condition can help facilitate the diagnostic process. However, the prevalence of hip diagnoses and associated courses of treatment have not been described. METHODS: A retrospective study was performed on patients presenting to a sports medicine clinic. Information on demographics, duration of pain, course of treatment, history of previous injury or surgery, and mechanism of injury was collected. Multivariate linear regression and multivariate logistic regression were utilized to describe differences in course of treatment between diagnostic groups. RESULTS: Six hundred eighteen patients were included in this study, with 641 hips analyzed. Femoroacetabular impingement syndrome (FAIS) was the most frequent diagnosis (212 hips), followed by "musculotendinous pain" and "hip pain, not otherwise specified." Of those diagnosed with FAIS, 30.1% had secondary diagnoses in other categories. Home exercise programs were the most commonly prescribed treatment, followed by injections and physical therapy. Having a diagnosis of FAIS or chondrolabral pathology increased the odds of surgery. CONCLUSION: Femoroacetabular impingement syndrome was the most common diagnosis in our cohort and had the highest frequency of concurrent diagnoses. A combination of a home exercise program, injection, and physical therapy made up the typical course of treatment, while surgery was utilized less frequently.

Long-term micronutrient surveillance after gastric bypass surgery in an integrated healthcare system.

BACKGROUND: The number of patients undergoing bariatric surgery in the United States is growing. While gastric bypass surgery is an important tool in the management of obesity, it requires lifelong metabolic monitoring and medical management. Data describing compliance with recommended laboratory follow-up are limited, particularly in long-term and primary care settings. OBJECTIVES: To evaluate postoperative follow-up laboratory testing for patients after laparoscopic Roux-en-Y gastric bypass (LRYGB). SETTING: Academic-affiliated community hospital. METHODS: A review of patients who underwent LRYGB from 2001 to 2016 was performed. The location of patients' follow-up care and compliance with recommended laboratory testing were determined from patient records. Compliance was analyzed at 1-year intervals. RESULTS: One thousand four hundred ninety patients underwent LRYGB. Five years after their surgical date, patients were more likely to follow-up with primary care than bariatric surgery clinic (369 versus 159 patients). At 5 years postoperative, 82%, 85%, and 68% of patients that followed-up with primary care did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively. Patients that followed-up in bariatric clinic were slightly more likely to have recommended labs completed. At 5 years postprocedure, 81%, 55%, and 48% did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively. CONCLUSION: Most patients do not have the recommended laboratory testing completed, regardless of where their follow-up care occurred. This study identified a gap in long-term postoperative care for patients who have undergone gastric bypass surgery. Further studies will be necessary to develop interventions aimed at improving adherence to recommended monitoring after LRYGB.

The relationship between adverse childhood experiences, healthcare utilization, cost of care and medical comorbidities.

BACKGROUND: Prior research suggests that those experiencing adverse childhood experiences (ACEs) may be higher utilizers of the healthcare system. The frequency and financial impact of kept, cancelled and no-showed visits is largely unknown. OBJECTIVE: To examine the impact of adverse childhood experiences (ACEs) on healthcare utilization in a sample of US adults. PARTICIPANTS AND SETTING: Two thousand thirty-eight adult patients who completed an ACE screening within the behavioral health department of a medium sized, Midwestern healthcare system during 2015-2017 were included. METHODS: Data was extracted retrospectively from 1-year post ACE screen. RESULTS: Individuals with high ACEs (4+) made more but kept fewer appointments than those with no or moderate (1-3) ACEs (p < 0.0001). Individuals with high ACES had more late-cancelled and no-showed appointments compared to those with no ACEs (p's < .0001). Relationships were significant even after controlling for age, gender, and insurance type. Those with high ACEs had the greatest impact on potential lost revenue given that they late-cancelled and no-showed more appointments. Those with high ACEs also had more medical comorbidities, medications, and needed care coordinator than those with moderate or no ACEs (p's < .05) CONCLUSIONS: Results from this study should be used to inform providers and health care systems on the effects of adversity on patterns of utilization of health care and encourage innovative strategies to better address the needs of these patients.

Effect of air temperature on the rectal temperature gradient at rest and during exercise.

The purpose of the current study was to determine the effect of air temperature on the rectal temperature gradient at rest and during exercise. It was hypothesized that the rectal temperature gradient would be exacerbated in cold environments and attenuated in warm environments both at rest and during exercise. Each subject completed three exercise bouts on a motor driven treadmill at approximately 55% of their previously determined maximal oxygen uptake. Three different air temperatures (10, 22, 39°C) were used for the exercise bouts. Rectal temperature was measured at rest and every 5 min during each exercise bout using 4 temperature sensors affixed at 4, 7, 10 and 13 cm past the anal sphincter. Readings obtained from the 4-cm depth were significantly (p<0.05) lower than those obtained at deeper insertion depths both at rest and during exercise for all three air temperatures. Furthermore, the results showed that the rectal temperature gradient was exacerbated in cold environments and attenuated in warm environments both at rest and during exercise.