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Recognition of out-of-hospital cardiac arrest (OHCA) during 9-1-1 calls is critically important, but little is known about how laypersons and emergency medical dispatchers (EMDs) communicate. We sought to describe 9-1-1 calls for OHCA.We performed a mixed-methods, retrospective analysis of 9-1-1 calls for OHCA victims in a large urban emergency medical services (EMS) system using a random sampling of cases containing the term "cardiopulmonary resuscitation" (CPR) in the EMS electronic report. A constant comparison qualitative approach with four independent reviewers continued until thematic saturation was achieved. Quantitative analysis employed computational linguistics. Callers' emotional states were rated using the emotional content and cooperation score (ECCS).Thematic saturation was achieved after 46 calls. Three "OHCA recognition" themes emerged [ 1) disparate OHCA terms used, 2) OHCA mimics create challenges, 3) EMD questions influence recognition]. Three "CPR facilitation" themes emerged [ 1) directive language may facilitate CPR, 2) specific instructions assist CPR, 3) caller's emotions affect CPR initiation]. Callers were generally "anxious but cooperative." Callers saying "pulse" was associated with OHCA recognition.Communication characteristics appear to influence OHCA recognition and CPR facilitation.Dispatch protocols that acknowledge characteristics of callers' communication may improve OHCA recognition and CPR facilitation.

Introduction As postoperative length of stay has decreased for many operations, the proportion of complications occurring post-discharge is increasing. Early identification and management of these complications requires overcoming barriers to effective post-discharge monitoring and communication. The aim of this study was to identify barriers to post-discharge monitoring and patient-clinician communication through a qualitative study of surgical patients and clinicians. Materials and methods Semi-structured interviews and focus groups were held with gastrointestinal surgery patients and clinicians. Participants were asked about barriers to post-discharge monitoring and communication. Each transcript was coded by 2 of 4 researchers, and recurring themes related to communication and care barriers were identified. Results A total of 15 patients and 17 clinicians participated in interviews and focus groups. Four themes which encompassed barriers to post-discharge monitoring and communication were identified from patient interviews, and 4 barriers were identified from clinician interviews and focus groups. Patient-identified barriers included education and expectation setting, technology access and literacy, availability of resources and support, and misalignment of communication preferences, while clinician-identified barriers included health education, access to clinical team, healthcare practitioner time constraints, and care team experience and consistency. Conclusions Multiple barriers exist to effective post-discharge monitoring and patient-clinician communication among surgical patients. These barriers must be addressed to develop an effective system for post-discharge care after surgery.

Background Enhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations. Methods To measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation. Results The assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%). The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers. Conclusions Higher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption. Level of evidence Level III. Type of study Mixed-methods survey.

Background The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation. Materials and methods We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research. Results We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers’ concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention. Conclusions We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

Summary Objective To investigate individual preferences for physical activity (PA) attributes in adults with chronic knee pain, to identify clusters of individuals with similar preferences, and to identify whether individuals in these clusters differ by their demographic and health characteristics. Design An adaptive conjoint analysis (ACA) was conducted using the Potentially All Pairwise RanKings of all possible Alternatives (PAPRIKA) method to determine preference weights representing the relative importance of six PA attributes. Cluster analysis was performed to identify clusters of participants with similar weights. Chi-square and ANOVA were used to assess differences in individual characteristics by cluster. Multinomial logistic regression was used to assess associations between individual characteristics and cluster assignment. Results The study sample included 146 participants; mean age 65, 72% female, 47% white, non-Hispanic. The six attributes (mean weights in parentheses) are: health benefit (0.26), enjoyment (0.24), convenience (0.16), financial cost (0.13), effort (0.11) and time cost (0.10). Three clusters were identified: Cluster 1 (n = 33): for whom enjoyment (0.35) is twice as important as health benefit; Cluster 2 (n = 63): for whom health benefit (0.38) is most important; and Cluster 3 (n = 50): for whom cost (0.18), effort (0.18), health benefit (0.17) and enjoyment (0.18) are equally important. Cluster 1 was healthiest, Cluster 2 most self-efficacious, and Cluster 3 was in poorest health. Conclusions Patients with chronic knee pain have preferences for PA that can be distinguished effectively using ACA methods. Adults with chronic knee pain, clustered by PA preferences, share distinguishing characteristics. Understanding preferences may help clinicians and researchers to better tailor PA interventions.

BACKGROUND. Gastrostomy placement after intracerebral hemorrhage (ICH) indicates the need for continued medical care and predicts patient dependence. Our objective was to determine the optimal machine learning technique to predict gastrostomy. METHODS. We included 531 patients in a derivation cohort and 189 patients from another institution for testing. We derived and tested predictions of the likelihood of gastrostomy placement with logistic regression using the GRAVo score (composed of Glasgow Coma Scale 50 years, black race, and hematoma volume >30 mL), compared to other machine learning techniques (kth nearest neighbor, support vector machines, random forests, extreme gradient boosting, gradient boosting machine, stacking). Receiver Operating Curves (Area Under the Curve, AUC) between logistic regression (the technique used in GRAVo score development) and other machine learning techniques were compared. Another institution provided an external test data set. RESULTS. In the external test data set, logistic regression using the GRAVo score components predicted gastrostomy (P

Objective To evaluate the effect of miPlan, a waiting-room contraceptive counseling mobile application (app), on interest in discussing long-acting reversible contraception (LARC) during the clinical encounter and LARC uptake. Study design This randomized controlled trial evaluated the miPlan contraceptive counseling app. African American and Latina young women ages 15–29 years attending four family planning clinics in a large Midwestern city were randomized to either: (1) use miPlan (intervention) prior to the contraceptive clinic visit or (2) contraceptive clinic visit alone (control). Groups were compared on knowledge of contraceptive effectiveness, interest in discussing LARC, behavioral intentions to use LARC, and LARC uptake. Results From February 2015 to January 2016, 207 young women were randomized to intervention (n=104) or control (n=103) group. Immediately following app use, the intervention group had an increase in knowledge and interest in learning about the implant. Immediate post visit, there was no significant difference in uptake of LARC between the two groups (p>.05). At three months post intervention, app users reported more knowledge of IUD effectiveness (52.3% vs 30.8%, p=.001) compared to controls. There was no significant difference in LARC use. Conclusion App use was not associated with an increase in using LARC methods. It was associated with increased knowledge of contraceptive effectiveness, an interest in learning about the implant, and behavioral intentions to use LARC methods. Implications The miPlan app is a feasible clinic adjunct for increasing contraceptive knowledge and intentions, however, it is not associated with increased LARC use. Mobile applications can offer an accessible complement to the contraceptive counseling visit.

Background Adverse postoperative outcomes related to smoking are well established, yet current smokers continue to be offered elective surgery in the US. It is unknown whether patients undergoing low-risk, elective procedures, who actively smoke experience increased risk of complications. We sought to determine the increased burden of complications following elective hernia repair procedures in patients identified as current smokers. Methods We identified patients undergoing elective incisional, inguinal, umbilical, or ventral hernia repair from 2011 to 2014 using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Multivariable logistic regression analysis was used to examine the association between current smoking and 30-day postoperative outcomes, adjusting for demographics and comorbidities. Results Of 220,629 patients who underwent elective hernia repair, 40,446 (18.3%) self-identified as current smokers within the past 12 months. Current smokers experienced an increased likelihood (Odds Ratio [95% Confidence interval]) of reoperation (OR 1.23 [95% CI 1.11–1.36]), readmission (OR 1.24 [95% CI 1.16–1.32]), and death (OR 1.53 [95% CI 1.06–2.22]). Furthermore, smokers experienced an increased risk of postoperative pulmonary, infectious, and wound complications, but there was no increased risk of requiring transfusion or of postoperative cardiac or thromboembolic events. Conclusions Current smokers were more likely to experience serious postoperative complications within 30 days. Given the volume of elective hernia surgery performed in the US, encouraging smoking cessation prior to offering elective repair could reduce postoperative complications, reoperation, readmission, and mortality.

BACKGROUND: Surgeons play a pivotal role in the opioid epidemic but it is unknown how different members of a surgical team vary in the way they prescribe opioids after surgical episodes. STUDY DESIGN: We conducted a retrospective cohort study of all inpatient discharges for 5 common surgeries. Total number of tablets and total milligram equivalents (MME) prescribed were calculated and differences in prescription patterns were determined for attending surgeons, surgical residents and advanced practice providers. Using a generalized ordered logistic regression, we examined factors associated with ordering a higher number of tablets or MME. RESULTS: The median number of tablets (range) prescribed by rank were attending surgeon 30 (6–72), surgical resident 20 (6–189) and advanced care practitioner 40 (5–1000); p

Background: The prevalence of non-tuberculous mycobacteria (NTM) has been increasing worldwide in both developed and developing countries. NTM infection is clinically indistinguishable from tuberculosis and therefore poses significant challenges in patient management, especially in patients chronically treated for pulmonary TB. In this study, we evaluated a new highly sensitive Multiplex MTB/NTM assay that can differentiate M. tuberculosis complex (MTBC) from all NTM, including the treatable and most common NTM, M. avium complex (MAC). Methods: We developed and optimized a new open- Multiplex MTB/NTM assay with two gene-targets for MTBC (IS6110/senX3-regX3) and two targets for MAC (IS1311/DT1) with samples spiked with stored strains and testing 20 replicates. Patients with presumptive TB and NTM were enrolled at the Pneumology Department of The University Teaching Hospital of Point G, in Mali. Finding: In the development stage, the new assay showed a high analytic performance with 100% detections of MTBC and MAC at only 5 colony forming units (CFUs). Overall, without the treatment failure cases, the Multiplex assay and the Xpert showed a sensitivity and specificity of 83·3% [66·4-92·6] and 96·6% [88·6-99·0], and 96·7% [83·3-99·4] and 80% [55·5-82·3], respectively. The Multiplex assay successfully detected all (5/5) the MAC cases. Interpretation: Our new Multiplex assay demonstrates better specificity than Xpert for all group studies, in addition to detecting potential NTM cases. The assay could therefore complement the widely used Xpert assay and enhance discrimination of TB and NTM infections. Funding Statement: This work was supported by the National Institutes of Health (R03AI137674, U54EB027049, D43TW010350 and UM1AI069471). Declaration of Interests: There are no conflicts of interest. Ethics Approval Statement: The study was approved by the Ethics Committee of the Faculty of Medicine, Pharmacy and Odonto-stomatology of the University of Sciences, Technics and Technologies of Bamako (USTTB) and the Institutional Review Board of Northwestern University.

Background One major intent of the medical malpractice system in the United States is to deter negligent care and to create incentives for delivering high-quality health care. A study was conducted to assess whether state-level measures of malpractice risk were associated with hospital quality and patient safety. Methods In an observational study of short-term, acute-care general hospitals in the United States that publicly reported in the Centers for Medicaid & Medicare Services Hospital Compare in 2011, hierarchical regression models were used to estimate associations between state-specific malpractice environment measures (rates of paid claims, average Medicare Malpractice Geographic Practice Cost Index [MGPCI], absence of tort reform laws, and a composite measure) and measures of hospital quality (processes of care, imaging utilization, 30-day mortality and readmission, Agency for Healthcare Research and Quality Patient Safety Indicators, and patient experience from the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]). Results No consistent association between malpractice environment and hospital process-of-care measures was found. Hospitals in areas with a higher MGPCI were associated with lower adjusted odds of magnetic resonance imaging overutilization for lower back pain but greater adjusted odds of overutilization of cardiac stress testing and brain/sinus computed tomography (CT) scans. The MGPCI was negatively associated with 30-day mortality measures but positively associated with 30-day readmission measures. Measures of malpractice risk were also negatively associated with HCAHPS measures of patient experience. Conclusions Overall, little evidence was found that greater malpractice risk improves adherence to recommended clinical standards of care, but some evidence was found that malpractice risk may encourage defensive medicine.

Utilize Rasch analysis to develop an optimized self-reported measure of stress in pregnancy and examine the association with patient demographics and biologic measures of stress.Measured self-reported stress in pregnant women using 12 existing scales. Collected blood for biologic measures of stress (Epstein Barr Virus [EBV], C-Reactive Protein [CRP], Corticotropin Reactive Hormone [pCRH], and Adenocorticotropin Hormone [ACTH]). Used multidimensional scaling and Rasch analysis to produce an item reduced self-report measure.Enrolled 112 women. Survey items reduced to two factors: perceived stressors and buffers of stress. Women with a domestic partner had lower perceived stress (p = 0.003). Caucasian women reported higher buffers of stress (p = 0.045), as did women with private insurance (p 0.001), a planned pregnancy (p 0.01), and a domestic partner (p 0.001). Women with higher buffers of stress had lower levels of pCRH (adjusted p = 0.01).Item reduced, optimized measures of stress were associated with significant differences in patient demographics and biologic measures of stress.

Performance measures have been extensively studied for acute ischemic stroke, leading to guideline-established benchmarks. Factors influencing care efficiency for intracerebral hemorrhage (ICH) are not well delineated. We sought to identify factors associated with early recognition of ICH and to assess the association between early recognition and completion of emergency care tasks.Consecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted from 2009 to 2017 at an urban comprehensive stroke center, excluding patient transferred from other hospitals. We used stroke team activation as the indicator of early recognition and measured completion times for multiple ICH-relevant performance metrics including door to computed tomography (CT) acquisition and door to hemostatic medication initiation.We studied 204 cases. All stroke-related performance times were faster in patients managed with stroke team activation compared to no activation, including quicker door to CT acquisition (median 24 versus 48 minutes, P.001) and door to hemostatic medication initiation (63 versus 99 minutes, P = .005). These associations were confirmed in adjusted models. Stroke codes were activated in 43% of cases and were more likely in patients with shorter onset-to-arrival times, higher National Institutes of Health Stroke Scale scores, and higher Glasgow Coma Scale scores.Stroke team activation was associated with more rapid diagnostic and therapeutic interventions for patients with ICH, but activation did not occur in the majority of cases, implying absence of early recognition. A stroke team activation process improves care performance, but leveraging the advantages of existing systems will require improved triage tools to identify ICH in the acute setting.

Background The majority of patients with primary hyperparathyroidism (PHPT) are diagnosed without the classic signs of renal or osseous complications. Vague and subjective symptoms have been attributed to PHPT but have been difficult to measure during the medical encounter. The Patient-Reported Outcomes Measurement Information System (PROMIS) of the National Institutes of Health contains validated measures of physical and mental health that can be administered by the use of computer-adaptive testing (CAT). The objective of this study was to evaluate the feasibility of PROMIS assessment in the clinical setting to measure changes in patient-reported health before and after parathyroidectomy. We hypothesized that patients undergoing parathyroidectomy for PHPT would report greater improvement in mental and physical health compared with control patients. Methods Adult PHPT patients scheduled for parathyroidectomy and control patients requiring diagnostic thyroid operation were enrolled prospectively during a 6-month period. Patients were administered clinically relevant PROMIS health domains via CAT at a preoperative visit and 3 weeks after operation. A change in score of 5 or greater for each PROMIS instrument was defined as clinically important. Statistical significance of pre/post-surgery changes in scores was determined using paired t tests. Results A total of 35 patients with PHPT and 9 control patients completed the study. The mean number of PROMIS items answered during an assessment was 67 (range 51–121, SD 15.4). Median completion time was 8.2 minutes (range 3.4–38.4, SD 4.7). Clinically important improvement after parathyroidectomy in the PHPT group was greater than in the control group in 5 PROMIS domains. The score improvement experienced by PHPT patients was 8.8 in Fatigue, 6.7 in Sleep-Related Impairment, 5.0 in Anxiety, 7.0 in Applied Cognition, and 6.2 in Depression (all P Conclusion PROMIS is an efficient clinical assessment platform for measuring patient-reported outcomes in PHPT via CAT. Several domains of physical and mental health in patients with PHPT show statistically and clinically important improvement after parathyroidectomy.

Background The goal of this study was to assess systems and processes involved in the operating room (OR) to intensive care unit (ICU) handoff in an attempt to understand the criticality of specific steps of the handoff. Methods We performed a failure modes, effects, and criticality analysis (FMECA) of the OR to ICU handoff of deceased donor liver transplant recipients using in-person observations and descriptions of the handoff process from a multidisciplinary group of clinicians. For each step in the process, failures were identified along with frequency of occurrence, causes, potential effects and safeguards. A Risk Priority Number (RPN) was calculated for each failure (frequency × potential effect × safeguard; range 1-least risk to 1,000-most risk). Results Using FMECA, we identified 37 individual steps in the OR to ICU handoff process. In total, 81 process failures were identified, 22 of which were determined to be critical and 36 of which relied on weak safeguards such as informal human verification. Process failures with the greatest risk of harm were lack of preliminary OR to ICU communication (RPN 504), team member absence during handoff communication (RPN 480), and transport equipment malfunction (Risk Priority Number 448). Conclusion Based on the analysis, recommendations were made to reduce potential for patient harm during OR to ICU handoffs. These included automated transfer of OR data to ICU clinicians, enhanced ICU team member notification processes and revision of the postoperative order sets. The FMECA revealed steps in the OR to ICU handoff that are high risk for patient harm and are currently being targeted for process improvement.

Objective Urgent clinician–clinician communications require routes of contact that are fast and dependable, and allow for the exchange of complex information. Despite the increasing focus on improving healthcare delivery systems over the past decade, few studies have examined the role of technology in clinician–clinician communication. The aim of this study was to review the literature examining the role of devices and technology in facilitating urgent clinician–clinician communication to identify critical areas for future research. Materials and methods A search of Pub Med was performed using the terms ((((“Critical Care”[Mesh] OR “urgent”)))) AND (((hospital communication systems[MeSH Terms]) OR health communication[MeSH Terms]) OR interdisciplinary communication[MeSH Terms]). Commentaries and editorials were excluded. Results The initial search returned 272 articles, which were reviewed to identify articles describing: (1) the role of technological support or devices in clinician–clinician communication, (2) technology-based interventions that improved clinician-to-clinician communication in hospitals or acute care facilities related to critically ill patients, or (3) critical information exchange. A total of 16 articles were included in the final review. These were grouped into three categories: alphanumeric pagers, cellular and smart telephones, and novel uses of technology. Discussion Breakdowns in clinician–clinician communication are complex and cannot be solved through the implementation of devices or technologically advanced systems alone. It is essential to understand the correlation between emerging technologies, a demanding workload, and clinician–clinician interaction. Enhanced communication of clinical ideas, opportunities for team discussion, and a sense of partnership and support require not just increased information, but enhanced delivery.

Background Childhood food allergy is a serious health problem. However, little is known about the frequency and manner in which it is currently diagnosed. Objective To describe parent report of physician practices in the diagnosis of pediatric food allergy. Methods Data from children with food allergy were identified for analysis from a representative survey administered in US households with children from June 2009 to February 2010. Analyses were performed at the level of the allergy. Demographic characteristics, symptom prevalence, and diagnostic methods were calculated as weighted proportions. Adjusted models were estimated to examine the association of reaction history and allergenic food with odds of physician diagnosis and testing. Results Food allergies (n = 3,218) to 9 common allergens were reported among 2,355 children in a sample of 38,480. We found that 70.4% of reported food allergy was diagnosed by a physician. Among physician-diagnosed food allergy, 32.6% was not evaluated with diagnostic testing, 47.3% was assessed with a skin prick test, 39.9% with a serum specific IgE test, and 20.2% with an oral food challenge. Odds of physician diagnosis and testing were significantly higher for severe versus mild/moderate food allergy. Urticaria and angioedema were not reported as symptoms in 40.7% and 34.6% of severe food allergies, respectively. Conclusion Thirty percent of parent-reported food allergies in this study were not diagnosed by a physician. One in 5 physician-diagnosed allergies was evaluated with oral food challenge. Understanding parent report of practices in food allergy provides insight into ways in which to streamline the diagnosis and management of care.

The present analysis relies upon data from three separate longitudinal studies to identify risk and protective factors associated with subsequent neglect during early childhood. All three studies (Fragile Families and Child Wellbeing [FFCW]; Healthy Families New York [HFNY]; Illinois Families Study-Child Wellbeing [IFS]) involve probabilistic samples or subsamples of low-income families with young children. Multivariate logistic regressions predicting official reports of investigated neglect allegations and a dichotomous indicator of neglect from the Parent–child Conflict Tactics Scale (CTS-PC) were conducted separately for each study, using common sets of predictors derived from baseline or initial survey waves. Across the three studies, consistencies emerged with respect to the predictors of both neglect outcomes. Specifically, consistencies emerged related to indicators of economic resources and hardships, parent well-being, and parenting. Understanding the predictors of child neglect is of critical importance to the development of child maltreatment prevention strategies since a clearer understanding of the risk and protective factors associated with neglect would enable more effectively targeted and tailored interventions.

Background The fear of committing clinical errors in perioperative care has a negative impact on the psychological well-being of surgical team members and ultimately on patient care. We assessed the perceptions and attitudes of surgical teams relative to committing errors, the impact of errors, and the culture of safety. Methods Pediatric cardiac surgery team members at three academic hospitals were surveyed. The survey included scaled, open-ended questions and a clinical vignette. Respondents were asked about the safety climate, team climate, stress recognition, and the impact of error as they relate to making and the anticipation of making clinical errors. Results The response rate was 69%. Safety attitudes were influenced by the work environment climate. Many respondents felt unable to express disagreement and had difficulty raising safety concerns. Staffing levels, equipment availability, production pressures, and hectic schedules were concerns. Respondents admitted that errors occurred repeatedly, and that guidelines and policies were often disregarded. Conclusions A psychometrically sound teamwork culture tool was used and demonstrated that surgical teams are influenced by the recognition of medical errors and that these errors carry significant personal burden. The findings suggest that the safety attitudes among team members may impact their performance and need to be carefully taken into consideration. Providers' reluctance to share safety events with others, as well as the perceived powerlessness to prevent events, must be addressed as part of an overall strategy to improve patient care outcomes. The study points to the need to address teamwork culture in efforts to improve patient care.

This analysis examines whether young children's (N= 494) general physical health is associated with parental employment, welfare receipt, and health care access within a low-income population transitioning from welfare to work. A latent physical health measure derived from survey and medical chart data is used to capture children's poor health, and parental ratings of child health are used to identify excellent health. Controlling for a host of factors associated with children's health outcomes, results show that children of caregivers who are unemployed and off welfare have better health than children of caregivers who are working and off welfare. Children whose caregivers are unemployed and on welfare, or combining work and welfare, have health outcomes similar to children of caregivers who are working and off welfare. Health care access characteristics, such as gaps in health insurance coverage, source of primary care setting, and type of health insurance are associated with children's general physical health. Implications of these results for state TANF programs are discussed.

Purpose This study estimates the annual incidence and describes the nature, types, and contributing factors involved in patient safety problems in adolescent medical care. Methods This study uses data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents and "critical incidence analysis" data reported by pediatric clinicians to elucidate the nature, types, and contributing factors in adolescent patient safety problems. Results The incidence of adverse events in adolescents in the Colorado and Utah Medical Practice Study was 2.74 (CI 95% = 2.62–2.86), significantly higher than all other age groups of children. The incidence of preventable adverse events in adolescents was 0.95 (CI 95% = 0.65–1.25), significantly higher than that of children 1–12 years old, but not significantly different than infants. Diagnostic events were most common, followed by medication events. Services associated with the highest frequency of events were pharmacy and Family Practice. In the critical incident analysis, adolescent-specific factors contributed to 54.8% of the described patient safety problems. Discomfort with adolescents, a factor not described for other age groups of children, contributed to 17% of the adolescent patient safety problems. Conclusions Adolescents experience relatively high rates of patient safety problems compared with other age groups of children. Adolescents represent a defined population with a patient safety risk profile that differs from adults and younger children. The substantial contribution of adolescent-specific factors suggests that patient safety improvements, to be effective, should address adolescent-specific risks.

BACKGROUND & AIMS: The value of adjuvant bile acid dissolution therapy after extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is under debate. A double-blind, randomized, multicenter trial was conducted to determine the safety and efficacy of repeated ESWL with and without adjuvant bile acid therapy. METHODS: At five centers, 153 patients with gallstones and good gallbladder emptying were randomized to undergo up to six high-energy lithotripsy sessions combined with ursodeoxycholic acid (UDCA, 750 mg/day; n=77) or placebo (n = 76). RESULTS: Six months after the initial treatment, 77% of patients with small single stones ( 20 mm in diameter), and 41% with multiple stones were free of stones. Administration of UDCA had no effect on stone disappearance in the whole study group but tended to improve stone disappearance rates in patients with large single stones and tended to decrease biliary adverse effects in patients with multiple stones. CONCLUSIONS: Repeated high-energy ESWL without adjuvant bile acid therapy represents a safe and effective treatment in patients with small single stones and good gallbladder emptying. In patients with large single stones and multiple stones, adjuvant bile acid therapy may be beneficial. (Gastroenterology 1997 May;112(5):1603-9)

Using cyclosporin A, long-term survival after heart-lung transplantation became possible. The drug blocks the immune system more selectively and leaves the tracheal wound healing unimpaired. Since 1981, 501 clinical cases have been collected by the registry of the International Society for Heart Transplantation. Candidates for heart-lung transplantation reveal signs of irreversible heart and lung diseases that may have been caused by cardiac lesions (valvular diseases, Eisenmenger reaction due to congenital malformations) or by pulmonic disorders (primary pulmonary hypertension, emphysema, fibrosis). The standard surgical procedure, which combines donor and recipient tracheas, right atria, and aortas, makes three anastomoses necessary. Immunosuppressive regimen includes cyclosporin A (blood trough levels of 300 to 500 ng/mL), azathioprine (1 to 2 mg/kg), and rabbit antithymocyte globulin (1 to 4 mg immunoglobulin G/kg). After the first two postoperative weeks, rabbit antithymocyte globulin is replaced by methylprednisolone (0.3 to 0.1 mg/kg; 500 mg are given intravenously after opening the aortic cross-clamp; 3 x 125 mg on postoperative day 1). After heart-lung transplantation an extreme variety of problems may evolve. Early postoperative complications (within the first postoperative month) comprise acute isolated lung rejection, multiorgan failure, and bacterial pneumonia. Diagnosis of acute lung rejection proves difficult; it includes clinical signs, chest radiographic appearances, and cytoimmunological monitoring. Transbronchial lung biopsies are of similar value for precise diagnosis as are endomyocardial specimens after heart transplantation. Late postoperative complications (after 1 postoperative month) comprise viral pneumonia, fungal infection, tuberculosis, and chronic obliterative bronchiolitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective Long-acting reversible contraceptive (LARC) methods, such as the intrauterine device and implant, are highly effective but used by less than 10% of US women. The objective of our study was to improve LARC interest by enhancing clinic counseling. Study Design A quality improvement methodology was used to evaluate intrauterine device service delivery in 3 Chicago Title X clinics. To address identified barriers, we developed a theory-based iOS application (app) for patients to use in the clinic waiting room using human-centered design. The final prototype was tested in a randomized controlled trial in a Title X clinic with sexually active females (79% African American) under age 30 years. Our sample of 60 was chosen to detect an increase from 10% (baseline) to 45% (app intervention) in the proportion of patients expressing interest in discussing a LARC method during their clinic visit with 80% power and two-sided α = 0.05. After completing demographic and baseline knowledge questionnaires, participants were randomized 1:1 to intervention (app) or standard care arms. App users also completed a posttest. Our primary outcome was expressed interest in discussing a LARC method during the clinic visit. Secondary outcomes were contraceptive knowledge and LARC selection. Results App testers (n = 17) preferred interactive, visually appealing design and video testimonials. In the pilot randomized controlled trial (n = 52), app users had a significantly higher knowledge of contraceptive effectiveness ( P = .0001) and increased interest in the implant (7.1-32.1%, P = .02) after the intervention. Users were highly satisfied with the app. Staff reported no problems using the app in the clinic. Conclusion Use of a theory-based counseling app offers a novel method to optimize wait time while minimizing clinic flow disruption. Preliminary data demonstrate that app use was associated with improvements in patients' contraceptive knowledge and interest in the implant.

The objective of the study was to determine the trends and racial differences in late preterm induction (LPI) of labor in the United States.Data from the National Vital Statistics System were used to identify women eligible for induction between 34 and 42 weeks' gestation from 1991 to 2006. Annual LPI rates were calculated, and maternal race/ethnicity was classified into 4 groups. Changes in the frequency and odds of LPI, stratified by race/ethnicity, were assessed using logistic regression.Among the 42.0 million eligible women, LPI rates increased from 0.46% to 1.37% (P.01) over 16 years. LPI rates were highest for black women (P.01) each year, and after adjusting for confounding factors, the odds of LPI were highest (P.01) and rose most rapidly (P.01) for black women (non-Hispanic white: odds ratio [OR], 1 [referent]; Hispanic white: OR, 0.76; black: OR, 1.31; other: OR, 0.81; P.01).LPI rates were persistently highest and rose most rapidly for black women.