Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine impacts on social-emotional development at school entry of a pediatric primary care intervention (Video Interaction Project [VIP]) promoting positive parenting through reading aloud and play, delivered in 2 phases: infant through toddler (VIP birth to 3 years [VIP 0-3]) and preschool-age (VIP 3 to 5 years [VIP 3-5]). METHODS:Factorial randomized controlled trial with postpartum enrollment and random assignment to VIP 0-3, control 0 to 3 years, and a third group without school entry follow-up (Building Blocks) and 3-year second random assignment of VIP 0-3 and control 0 to 3 years to VIP 3-5 or control 3 to 5 years. In the VIP, a bilingual facilitator video recorded the parent and child reading and/or playing using provided learning materials and reviewed videos to reinforce positive interactions. Social-emotional development at 4.5 years was assessed by parent-report Behavior Assessment System for Children, Second Edition (Social Skills, Attention Problems, Hyperactivity, Aggression, Externalizing Problems). RESULTS:= .006). Multilevel models revealed significant VIP 0-3 linear effects and age × VIP 3-5 interactions. CONCLUSIONS:Phase VIP 0-3 resulted in sustained impacts on behavior problems 1.5 years after program completion. VIP 3-5 had additional, independent impacts. With our findings, we support the use of pediatric primary care to promote reading aloud and play from birth to 5 years, and the potential for such programs to enhance social-emotional development.

BACKGROUND: Emerging experimental evidence suggests that air pollution may contribute to development of obesity and diabetes, but studies of children are limited. OBJECTIVES: We hypothesized that pollution effects would be magnified after bariatric surgery for treatment of obesity, reducing benefits of surgery. METHODS: In 75 obese adolescents, excess weight loss (EWL), high-density lipoprotein (HDL) cholesterol, triglycerides, alkaline phosphatase (ALP) and hemoglobin A1c (HbA1c ) were measured prospectively at baseline and following laparoscopic adjustable gastric banding (LAGB). Residential distances to major roads and the average two-year follow-up exposure to particulate matter <2.5 mum (PM2.5 ), nitrogen dioxide (NO2 ) and ozone were estimated. Associations of exposure with change in outcome and with attained outcome two years post-surgery were examined. RESULTS: Major-roadway proximity was associated with reduced EWL and less improvement in lipid profile and ALP after surgery. NO2 was associated with less improvement in HbA1c and lower attained HDL levels and change in triglycerides over two years post-surgery. PM2.5 was associated with reduced EWL and reduced beneficial change or attained levels for all outcomes except HbA1c . CONCLUSIONS: Near-roadway, PM2.5 and NO2 exposures at levels common in developed countries were associated with reduced EWL and metabolic benefits of LAGB. This novel approach provides a model for investigating metabolic effects of other exposures.

In the management of epithelial ovarian cancers, imaging is used for cancer detection and staging, both before and after initial treatment. The decision of whether to pursue initial cytoreductive surgery for ovarian cancer depends in part on accurate staging. Contrast-enhanced CT of the abdomen and pelvis (and chest where indicated) is the current imaging modality of choice for the initial staging evaluation of ovarian cancer. Fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT and MRI may be appropriate for problem-solving purposes, particularly when lesions are present on CT but considered indeterminate. In patients who achieve remission, clinical suspicion for relapse after treatment prompts imaging evaluation for recurrence. Contrast-enhanced CT is the modality of choice to assess the extent of recurrent disease, and fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT is also usually appropriate, as small metastatic foci may be identified. If imaging or clinical examination confirms a recurrence, the extent of disease and timing of disease recurrence then determines the choice of treatments, including surgery, chemotherapy, and radiation therapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

INTRODUCTION/BACKGROUND:To prevent errors, healthcare professional and safety organizations recommend using milliliters (mL) alone for oral liquid medication dosing instructions and devices. In 2018, for federal incentives under the Quality Payment Program, one requirement is for Electronic Health Records (EHRs) to automatically use mL alone whenever oral liquid medications are prescribed. Current perceptions and practices of primary care providers (PCPs) regarding dosing units for oral liquid medications were assessed. METHODS:Pediatricians, family practitioners, nurse practitioners, and internists participating in the 2015 DocStyles web-based survey were asked about their perceptions and practices regarding dosing units for oral liquid medications. RESULTS:Three-fifths of PCPs (59.0%) reported that using mL alone is safest for dosing oral liquid medications; however, nearly three-quarters (72.0%) thought that patients/caregivers prefer instructions that include spoon-based units. Within each specialty, fewer PCPs reported they would prescribe using mL alone than reported that using mL alone is safest (P<.0001 for all). Among PCPs who think mL-only dosing is safest, those who perceived patients/caregivers prefer spoon-based units were less likely to prescribe using mL alone (odds ratio: 0.45, 95% CI: 0.34-0.59). Pediatricians were more likely than other PCPs to report that it is safest to use mL alone (80.8% vs 54.7%) and that they would use mL alone when prescribing (56.8% vs 30.9%) (P<.0001 for both). CONCLUSIONS:Because fewer than two-thirds of pediatricians and one-third of other PCPs would use mL alone in dosing instructions, additional education to encourage prescribing and communicating with patients/caregivers using mL alone may be needed.

Background: Previous studies have shown that ED patients have significantly higher rates of food insecurity than the general population. However, little research has examined the impact of food insecurity on health or the health service use of ED patients. In this study, we examine the relationship between food insecurity and frequent ED use. We hypothesized that food insecurity would be independently associated with frequent ED use. Methods: We surveyed a random sample of ED patients at an urban, public hospital from Nov 2016-Sept 2017. To minimize sampling bias, research assistants (RAs) followed strict protocols for randomly approaching patients. Surveying occurred across all days and hours. Eligible patients were: >=18 years old, clinically stable, not arrested or incarcerated, spoke English or Spanish, and had not already participated. RAs administered a survey covering a wide range of health-related topics. Frequent ED use was defined as self-report of >=4 visits to any ED in the past year including the current visit. Food insecurity was defined as responding positively to any of 4 food insecurity questions from the USDA Food Security Module. We performed chi-squared and Kruskal-Wallis tests for bivariate relationships and multivariable logistic regression to examine the independent association of food insecurity with frequent ED use while controlling for potential confounders. Results: 52% of approached were ineligible, mainly because they were medically unfit, intoxicated, or in prison/police custody. 2,396 of 2,924 eligible patients participated (81.9%). 31.0% reported frequent ED use and 50.9% reported food insecurity. Food insecurity rates were higher among frequent vs. non-frequent ED users (62.9% vs. 45.5%, p<001). Food insecurity remained a significant predictor of frequent ED use in multivariable analyses (OR 1.47, 95%CI 1.19-1.82). This relationship was partially mediated by self-reported overall health, cost-related medication nonadherence, anxiety, and depression. Conclusion: Food insecurity was common and was independently associated with frequent ED use in this study. We plan future longitudinal analyses to confirm and further explore this relationship. In the meantime, interventions and studies of frequent ED users should consider the potential role of food insecurity

OBJECTIVE:The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation. RESEARCH DESIGN AND METHODS:Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences. RESULTS:< 0.001). CONCLUSIONS:A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.

Background: Increasing numbers of patients with cancer present to emergency departments (EDs), but there is little information on their ED care. Our objective was to describe the epidemiology of patients with active cancer presenting to US EDs. Methods: Prospective observational study using a convenience sample of ED patients >=18 years of age with active cancer presenting to 18 sites of the Comprehensive ONcologic Emergencies Research Network (CONCERN). ED patient surveys and 30-day chart reviews were completed. Descriptive statistics are reported. Results: We enrolled 1,075 patients (n per ED range 18-71). Mean age was 62 years with 52% female, 12% African American, 3.1% Asian, and 7.2% Hispanic. Common cancer types were gastrointestinal (20%); leukemia, myeloma and lymphoma (18%); lung (13%); and breast (11%). Seventy-two percent (n=773) had received cancer therapy within the prior 30 days including 495 (46%) chemotherapy,108 (10%) radiation, and 85 (7.9%) surgery. Emergency severity index scores included 0.9% Level 1, 40% Level 2, and 51% Level 3. Symptoms at presentation included nausea (32%), shortness of breath (35%), chest pain (16%), and abdominal pain (32%). ED nausea medicine was administered to 260 (25%), including half of those complaining of (160/326, 49%). Fifteen percent (n=152) had fever a%o38.0AdegreeC in the ED or within the prior 24 hours and 27% received ED antibiotics (n=285). Pain was present in 56% (n=604) and was moderate in 17% (n=186) and severe in 31% (n=338). Forty-eight percent (n=519) had pain medications in the ED including 35% with opioids (n=381). Only 35% (n=66) of those with moderate and 69% (n=232) of those with severe pain received opioids in the ED. Twenty five percent of all patients (n=274) had a final ED pain score in the moderate or severe range. Fifty-seven percent (n=615) were admitted (including 10% to stepdown or intensive care units), 6.6% (n=70) were placed in an ED observation unit, 1.9% (n=20) died in the ED, and 32% (n=342) were discharged. Thirty-day mortality was 5.8% (n=62) and 30- day ED revisit rate was 27% (n=286). Conclusion: ED patients with active cancer present with a substantial symptom burden and are frequently undertreated in the ED. This is a high acuity population with high rates of admission, revisit, and mortality. Further study to improve processes of care for this population is warranted