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“Do you think she’ll be ready to go home tomorrow?” The team turns toward the father’s 6-year-old daughter. This is her tenth admission for status asthmaticus, and she is now on day 2 of continuous albuterol. “I know the roaches make her asthma worse, but our landlord is useless,” he explains. “I pick up her medications as often as I can, but the inhaler costs $200 since I lost my job and insurance.” The team explains the necessary steps before discharge. Outside the room, after a period of silence, the attending says, “Let’s space her albuterol and get her out of bed today.” Walking to the next room, the attending adds, “We should reach out to social work too.” As pediatric hospitalists, we encounter patients and families like this every day. Although we are confident in our ability to treat a patient’s acute illness and teach trainees evidence-based medical management, too often, we miss opportunities to both model and teach the role of the pediatrician-advocate in the hospital. Pediatrics was the first medical specialty to include “advocacy” in the Accreditation Council of Graduate Medical Education (ACGME) program requirements for residency training. However, the “advocacy” requirement is formally designated as an “ambulatory experience,” significantly limiting its scope and impact.1 Advocacy and advocacy training can, does, and should occur across all pediatric clinical settings and specialties. The inpatient setting, where pediatric residents spend the majority of their time, is particularly well-suited to advocacy training. Intentional advocacy training in the inpatient setting would improve the skills of future pediatrician-advocates while also elevating the quality of inpatient medical care. We propose, therefore, that the ACGME change the language of the advocacy training requirement to either explicitly include “inpatient advocacy” (advocacy on behalf of patients admitted to the hospital and/or in an effort to …

Objective To systematically review available evidence to develop guidelines for the prevention of transfusion reactions and monitoring of transfusion administration in dogs and cats.Design Evidence evaluation of the literature (identified through Medline searches through Pubmed and Google Scholar searches) was carried out for identified transfusion reaction types in dogs and cats. Evidence was evaluated using PICO (Population, Intervention, Comparison, Outcome) questions generated for each reaction type. Evidence was categorized by level of evidence (LOE) and quality (Good, Fair, or Poor). Guidelines for prevention and monitoring were generated based on the synthesis of the evidence. Consensus on the final recommendations and a proposed transfusion administration monitoring form was achieved through Delphi-style surveys. Draft recommendations and the monitoring form were made available through veterinary specialty listservs and comments were incorporated.Results Twenty-nine guidelines and a transfusion administration monitoring form were formulated from the evidence review with a high degree of consensusConclusions This systematic evidence evaluation process yielded recommended prevention and monitoring guidelines and a proposed transfusion administration form. However, significant knowledge gaps were identified, demonstrating the need for additional research in veterinary transfusion medicine.

Objective To systematically review available evidence to develop guidelines for diagnosis and treatment of transfusion-associated reactions in dogs and cats.Design Standardized and systemic evaluation of the literature (identified through Medline via PubMed and Google Scholar searches) was carried out for identified transfusion reaction types in dogs and cats. The available evidence was evaluated using PICO (Population, Intervention, Comparison, Outcome) questions generated for each reaction type. The evidence was categorized by level of evidence (LOE) and quality (Good, Fair, or Poor). Guidelines, diagnostic, and treatment algorithms were generated based on the evaluation of the evidence. Consensus on the final guidelines was achieved through Delphi-style surveys. Draft recommendations were disseminated through veterinary specialty listservs for review and comments, which were evaluated and integrated prior to final publication.Results Medline via PubMed and Google Scholar databases were searched. There were 14 Population Intervention Comparison Outcome questions identified and corresponding worksheets were developed focusing on the diagnosis and treatment of transfusion-associated reactions in dogs and cats. Fourteen guidelines and four algorithms were developed with a high degree of consensus.Conclusions This systematic evidence evaluation process yielded recommended diagnostic and treatment algorithms for use in practice. However, significant knowledge gaps were identified, demonstrating the need for additional research in veterinary transfusion medicine.

This cross-sectional study explores the use of physical restraint on youth at risk of harming themselves or others in the emergency department, stratified by race and ethnicity.

BACKGROUND AND OBJECTIVES: Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non–mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits. METHODS: We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005–2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression. RESULTS: From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non–mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69–4.44); there was no difference in LOS by payer type. CONCLUSIONS: The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.

BackgroundSequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital mortality. Many crisis standards of care use SOFA score to allocate medical resources during the COVID-19 pandemic.Research QuestionAre SOFA scores disproportionately elevated among Non-Hispanic Black and Hispanic patients hospitalized with COVID-19, compared to Non-Hispanic White patients?Study Design and MethodsRetrospective cohort study conducted in Yale New Haven Health System, including 5 hospitals with total of 2681 beds. Study population drawn from consecutive patients aged ≥18 admitted with COVID-19 from March 29thto August 1st, 2020. Patients excluded from the analysis if not their first admission with COVID-19, if they did not have SOFA score recorded within 24 hours of admission, if race and ethnicity data were not Non-Hispanic Black, Non-Hispanic White, or Hispanic, or if they had other missing data. The primary outcomes was SOFA score, with peak score within 24 hours of admission dichotomized as ResultsOf 2982 patients admitted with COVID-19, 2320 met inclusion criteria and were analyzed, of whom 1058 (45.6%) were Non-Hispanic White, 645 (27.8%) were Hispanic, and 617 (26.6%) were Non-Hispanic Black. Median age was 65.0 and 1226 (52.8%) were female. In univariate logistic screen and in full multivariate model, Non-Hispanic Black patients but not Hispanic patients had greater odds of an elevated SOFA score ≥6 when compared to Non-Hispanic White patients (OR 1.49, 95%CI 1.11-1.99).InterpretationCrisis standards of care utilizing the SOFA score to allocate medical resources would be more likely to deny these resources to Non-Hispanic Black patients.

BackgroundThe COVID-19 pandemic has had a devastating impact in the United States, particularly for Black populations, and has heavily burdened the healthcare system. Hospitals have created protocols to allocate limited resources, but there is concern that these protocols will exacerbate disparities. The sequential organ failure assessment (SOFA) score is a tool often used in triage protocols. In these protocols, patients with higher SOFA scores are denied resources based on the assumption that they have worse clinical outcomes. The purpose of this study was to assess whether using SOFA score as a triage tool among COVID-positive patients would exacerbate racial disparities in clinical outcomes.MethodsWe analyzed data from a retrospective cohort of hospitalized COVID-positive patients in the Yale-New Haven Health System. We examined associations between race/ethnicity and peak overall/24-hour SOFA score, in-hospital mortality, and ICU admission. Other predictors of interest were age, sex, primary language, and insurance status. We used one-way ANOVA and chi-square tests to assess differences in SOFA score across racial/ethnic groups and linear and logistic regression to assess differences in clinical outcomes by sociodemographic characteristics.ResultsOur final sample included 2,554 patients. Black patients had higher SOFA scores compared to patients of other races. However, Black patients did not have significantly greater in-hospital mortality or ICU admission compared to patients of other races.ConclusionWhile Black patients in this sample of hospitalized COVID-positive patients had higher SOFA scores compared to patients of other races, this did not translate to higher in-hospital mortality or ICU admission. Results demonstrate that if SOFA score had been used to allocate care, Black COVID patients would have been denied care despite having similar clinical outcomes to white patients. Therefore, using SOFA score to allocate resources has the potential to exacerbate racial inequities by disproportionately denying care to Black patients and should not be used to determine access to care. Healthcare systems must develop and use COVID-19 triage protocols that prioritize equity.

BackgroundSequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital mortality. Many crisis standards of care suggest the use of SOFA scores to allocate medical resources during the COVID-19 pandemic.Research questionAre SOFA scores elevated among Non-Hispanic Black and Hispanic patients hospitalized with COVID-19, compared to Non-Hispanic White patients?Study design and methodsRetrospective cohort study conducted in Yale New Haven Health System, including 5 hospitals with total of 2681 beds. Study population drawn from consecutive patients aged ≥18 admitted with COVID-19 from March 29thto August 1st, 2020. Patients excluded from the analysis if not their first admission with COVID-19, if they did not have SOFA score recorded within 24 hours of admission, if race and ethnicity data were not Non-Hispanic Black, Non-Hispanic White, or Hispanic, or if they had other missing data. The primary outcome was SOFA score, with peak score within 24 hours of admission dichotomized as ResultsOf 2982 patients admitted with COVID-19, 2320 met inclusion criteria and were analyzed, of whom 1058 (45.6%) were Non-Hispanic White, 645 (27.8%) were Hispanic, and 617 (26.6%) were Non-Hispanic Black. Median age was 65.0 and 1226 (52.8%) were female. In univariate logistic screen and in full multivariate model, Non-Hispanic Black patients but not Hispanic patients had greater odds of an elevated SOFA score ≥6 when compared to Non-Hispanic White patients (OR 1.49, 95%CI 1.11–1.99).InterpretationGiven current unequal patterns in social determinants of health, US crisis standards of care utilizing the SOFA score to allocate medical resources would be more likely to deny these resources to Non-Hispanic Black patients.

Objective To use a systematic, evidence-based consensus process to develop definitions for transfusion reactions in dogs and cats.Design Evidence evaluation of the literature was carried out for identified transfusion reaction types in dogs and cats. Reaction definitions were generated based on synthesis of human and veterinary literature. Consensus on the definitions was achieved through Delphi-style surveys. Draft recommendations were made available through industry specialty listservs and comments were incorporated.Results Definitions with imputability criteria were developed for 14 types of transfusion reactions.Conclusions The evidence review and consensus process resulted in definitions that can be used to facilitate future veterinary transfusion reaction research.

OBJECTIVES In pediatric emergency departments (EDs), racial/ethnic minorities are less likely to receive needed and timely care; however, clinical protocols have the potential to mitigate disparities. Neonatal fever management is protocolized in many EDs, but the timeliness to antibiotic administration is likely variable. We investigated the timeliness of antibiotic administration for febrile neonates and whether timeliness was associated with patients' race/ethnicity. METHODS Retrospective cross-sectional study of febrile neonates evaluated in one pediatric ED that uses an evidence-based guideline for the management of neonatal fever between March 2010 and December 2015. Primary outcome was time from ED arrival to antibiotic administration. Analysis of variance tests compared mean time with antibiotic administration across race/ethnicity. Multivariable linear regression investigated racial/ethnic differences in time to antibiotic administration after adjusting for patient demographics, timing of visit, the number of physicians involved, and ED census. RESULTS We evaluated 317 febrile neonates. Of the 269 patients with racial/ethnic data (84.9%), 54% were white non-Hispanic, 13% were black non-Hispanic, and 23% were Hispanic. The mean time to antibiotic administration was 204 minutes (range = 51-601 minutes). There was no significant association between patient race/ethnicity and time to first antibiotic administration. Emergency department census was significantly associated with timeliness. CONCLUSIONS There was a 10-hour range in the time to antibiotic administration for febrile neonates; however, variability in timeliness did not differ by race or ethnicity. This study demonstrates the need to further examine the role of protocols in mitigating disparities as well as factors that influence timeliness in antibiotic administration to febrile neonates.

Background An inverse relationship between healthcare utilization and distance to care has been previously described. The purpose of this study was to evaluate this effect related to emergency and essential surgical care in central Haiti. Methods We conducted a retrospective review of operative logbooks from the Clinique Bon Sauveur in Cange, Haiti, from 2008 to 2010. We used Geographic Information Systems to map the home locations of all patients. Spearman's correlation was used to determine the relationship between surgical utilization and distance, and a multivariate linear regression model identified characteristics associated with differences in distances traveled to care. Results The highest annual surgical utilization rate was 184 operations/100 000 inhabitants. We found a significant inverse correlation between surgical utilization rate and distance from residence to hospital (r(s) = -0.68, p = 0.02). The median distance from residence to hospital was 55.9 km. Pediatric patients lived 10.1% closer to the hospital than adults (p

Although millions of women receive injuries from intimate partner violence (IPV) each year in the United States alone, there has been only limited research of acute injury patterns and the types, locations, and mechanisms of IPV injuries. The mechanism of being punched to the face with a fist resulting in blunt trauma—related injuries is most commonly reported. Strangulation, especially manual strangulation, is a frequently cited mechanism of injury; however, less is known about the types of injuries that result from strangulation. In general, clinicians should assess all patients who present for treatment of head, neck, and face injuries for IPV. There is little consistency between and much inaccuracy with medical terms used to describe types of injuries. To increase the accuracy and generalizability of findings from studies of acute IPV injuries, researchers need to use more standardized medical forensic terminology.

In the course of arguing "Against Interpretation," Susan Sontag claims that "[i]n place of a hermeneutics we need an erotics of art" (14). This challenge appears for the first time, without gloss or elaboration, as the last line of her essay. It is a com pelling but vague call for literary scholars?and good readers in general?to do something outside their ken: take a work on its own terms without constructing a paratext in which all the symbols are unpacked, all the meanings laid bare. Sontag identifies "interpretation" as "presupposing] a discrepancy between the clear mean ing of the text and the demands of (later) readers.... The modern style of interpreta tion excavates, and as it excavates, destroys; it digs 'behind' the text, to find a subtext which is the true one" (6). She also notes that "interpretation of this type indicates a dissatisfaction (conscious or unconscious) with the work, a wish to replace it by something else" (10). Many authors whom John Cowper Powys particularly admired, such as James Joyce and Henry James, wrote novels that invite and reward careful hermeneutic ex plication. Sontag names Joyce and James in her short list of authors "around whom thick encrustations of interpretation have taken hold" (8). Their novels operate on several levels of significance simultaneously, developing intricate, intellectual rela tions between implied author and authorial audience, prompting the latter's interpre tation largely through their progressive exploitation and resolution of various tensions and instabilities.1 But in response to the influence of his contemporaries, Powys composed several digressive, improbable, ecstatic fictions that employ a con spicuously unfamiliar system of narrative progression, baffling his authorial audi ence's efforts at interpretation. The neglect shown to Powys's work by most scholars and teachers alike may be seen as a symptom of this bafflement.

Little is known about pediatric surgical disease in resource-poor countries. This study documents the surgical care of children in central Haiti and demonstrates the influence of the 2010 earthquake on pediatric surgical delivery. METHODS: We conducted a retrospective review of operations performed at Partners in Health/Zanmi Lasante hospitals in central Haiti. RESULTS: Of 2,057 operations performed prior to the earthquake, 423 were pediatric (20.6%). Congenital anomalies were the most common operative indication (159/423 operations; 33.5%). Pediatric surgical volume increased significantly after the earthquake, with 670 operations performed (23.0% post-earthquake v. 20.6% pre-earthquake, p=.03). Trauma and burns became the most common surgical diagnoses after the disaster, and operations for non-traumatic conditions decreased significantly (p

Acceptance of basic surgical care as an essential element of any properly functioning health system is growing. To justify investment in surgical interventions, donors require estimates of the economic benefit of treating surgical disease. The present study aimed to establish a methodology for valuing the potential economic benefit of surgical intervention using cleft lip and palate (CLP) in sub-Saharan Africa (SSA) as a model.Economic modeling of cleft lip and cleft palate (CLP) in SSA was performed with retrospective demographic and economic data from 2008. The total number of Disability-Adjusted Life-Years (DALYs) secondary to CLP in 2008 was calculated from accepted clefting incidence rates and disability weights taken from the Global Burden of Disease Project. DALYs were then converted to monetary terms ($US), using both a human capital approach and Value of a Statistical Life (VSL) approach.With the human capital approach, the potential economic benefit if all incident cases of CLP in SSA in 2008 were repaired at birth ranged from $252 million to $441 million. With VSL, the potential economic benefit of the same CLP repair would range from $5.4 billion to $9.7 billion.Cleft lip and cleft palate can have a substantial impact on the economic health of countries in the developing world. Further studies should be directed at quantifying the economic benefit of surgical interventions and quantifying their costs with an economically sound approach.

Forensic nursing experts and other health professionals often testify regarding the injuries women and men receive from violence. Bruise discoloration can provide an opportunity for health professionals to grossly estimate the age of impact and determine if it is consistent with a given reported history. However, there is much confusion in the literature and clinical practice as to the accuracy of dating bruises. This article will demonstrate that using the color of the bruise as the primary criteria to determine its age is not the best practice. The limited available research and related literature on the topic are flawed and inconsistent. Finally, recommendations will be made for future research and clinical practice.

Background Background rates of latent tuberculosis infection in low prevalence regions of Britain are unknown. These would be valuable data for interpreting positive IGRA results, and guiding cost-benefit analyses. The management of a large outbreak of tuberculosis occurring in a rural district hospital provided an opportunity to determine the background rates and epidemiology of IGRA-positivity amongst unselected hospital patients in a low-prevalence region of U.K. Methods As part of a public health surveillance project we identified 445 individuals exposed to the index cases for clinical assessment and testing by a TB-specific interferon-γ release assay (IGRA): T-Spot.TB. Uniquely, an additional comparator group of 191 age-matched individuals without specific recent exposure, but with a similar age distribution and demographic, were recruited from the same wards where exposure had previously occurred, to undergo assessment by questionnaire and IGRA. Results Rates of IGRA positivity were 8.7% (95%CI, 4.2-13, n=149) amongst unexposed patients, 9.5%(3.0-22, n=21) amongst unexposed staff, 22%(14–29, n=130) amongst exposed patients, 11%(6.1-16, n=142) amongst exposed staff. Amongst the individuals without history of recent exposure to the outbreak, IGRA-positivity was associated with prior TB treatment (OR11, P.04) and corticosteroid use (OR5.9, P.02). Background age-specific prevalences of IGRA-positivity amongst unexposed individuals were: age Conclusions Background rates of IGRA-positivity remain high amongst unselected white-Caucasian hospital inpatients in U.K. These data will aid interpretation of future outbreak studies. As rates peak in the 5th and 6th decade, given an ageing population and increasing iatrogenic immunosuppression, reactivation of LTBI may be a persistent hazard in this population for several decades to come.