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Objectives: Experts recommend that providers discuss adolescent patients' sexual and reproductive health (SRH) at any health care encounter, including hospitalizations. The purpose of this qualitative study was to gain insight into hospitalized adolescents' experiences and perspectives on SRH discussions (SHDs) to better inform patient-centered care., Methods: Private semistructured interviews were conducted with hospitalized adolescents aged 13 to 17 years. Interviews were coded and analyzed using thematic analysis. Themes were developed through an iterative process with focus on the primary research aim., Results: Twenty participants were interviewed with a median age of 15.4 years. Adolescents expressed a range of preferences related to SHDs with providers. Themes included (1) experiences discussing SRH with providers, (2) SHDs during hospitalization, (3) communication preferences, and (4) perceptions of why providers initiate SHDs. Viewpoints about SHDs during hospitalizations varied, including that they addressed unmet needs, as well as that they seemed irrelevant to some participants. Aspects that facilitate SHDs include brevity with relevant depth, nonjudgmental provider demeanor, and reassurance of privacy. Some participants believed providers could judge the depth of discussion needed on the basis of the adolescent's age or personality., Conclusions: This study highlights variation in adolescents' preferences around SHDs with health care providers. Providers should initiate SHDs with statements of purpose and confidentiality. Given the variation in adolescents' perspectives, tools to privately collect self-reported behaviors before an SHD may help providers frame the conversation to the adolescent's specific SRH needs and communication style preferences., (Copyright © 2024 by the American Academy of Pediatrics.)

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language., Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection., Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source., Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English)., Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes., Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46)., Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Objective: The lack of evidence-based criteria to guide chest radiograph (CXR) use in young febrile infants results in variation in its use with resultant suboptimal quality of care. We sought to describe the features associated with radiographic pneumonias in young febrile infants., Study Design: Secondary analysis of a prospective cohort study in 18 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from 2016 to 2019. Febrile (≥38°C) infants aged ≤60 days who received CXRs were included. CXR reports were categorised as 'no', 'possible' or 'definite' pneumonia. We compared demographics, clinical signs and laboratory tests among infants with and without pneumonias., Results: Of 2612 infants, 568 (21.7%) had CXRs performed; 19 (3.3%) had definite and 34 (6%) had possible pneumonias. Patients with definite (4/19, 21.1%) or possible (11/34, 32.4%) pneumonias more frequently presented with respiratory distress compared with those without (77/515, 15.0%) pneumonias (adjusted OR 2.17; 95% CI 1.04 to 4.51). There were no differences in temperature or HR in infants with and without radiographic pneumonias. The median serum procalcitonin (PCT) level was higher in the definite (0.7 ng/mL (IQR 0.1, 1.5)) vs no pneumonia (0.1 ng/mL (IQR 0.1, 0.3)) groups, as was the median absolute neutrophil count (ANC) (definite, 5.8 K/mcL (IQR 3.9, 6.9) vs no pneumonia, 3.1 K/mcL (IQR 1.9, 5.3)). No infants with pneumonia had bacteraemia. Viral detection was frequent (no pneumonia (309/422, 73.2%), definite pneumonia (11/16, 68.8%), possible pneumonia (25/29, 86.2%)). Respiratory syncytial virus was the predominant pathogen in the pneumonia groups and rhinovirus in infants without pneumonias., Conclusions: Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonias, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias., Competing Interests: Competing interests: OR reports personal fees from Sanofi-Pasteur, Merck and Pfizer, and grants from Janssen and the Bill & Melinda Gates Foundation. These fees and grants are not related to this study. No other disclosures were reported., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking., Objective: To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations., Design, Setting, and Participants: In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks., Outcome: Consensus agenda of research priorities to identify and address health care disparities in PEC., Results: PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation., Conclusions and Relevance: These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

Background: In the United States, the third leading cause of a large bowel obstruction (LBO) is colonic volvulus with torsion occurring most commonly in the sigmoid and the cecum. Transverse colonic volvulus (TCV) is exceedingly rare and specific involvement of the splenic flexure (SFV) is even less common. The present analysis was undertaken to interrogate current trends in presentation, management, and outcomes of TCV., Methods: In the present report, the world literature was reviewed for the past 90 years (1932 to 2021). We conducted a systematic review to identify all cases of TCV following the PRISMA guidelines., Results: We identified 317 cases of TCV. This included SFV (n = 75), TCV in pediatric patients (n = 63), TCV in pregnant patients (n = 8), and TCV associated with other pathology such as Chilaiditi's syndrome (n = 11). Compared to sigmoid and cecal volvulus, TCV was rare (.94%). It affected slightly more women (54%) than men, commonly in their third decade of life (37.7 ± 23.8). The clinical presentation and diagnostic imaging were consistent with LBO. Compared to sigmoid volvulus, there was a limited role for conservative management and colonoscopic decompression was less effective. The most common operation was segmental resection (25%). Mortality was (20%) commonly because of cardiopulmonary complications and affected more women (63%). The average age of this cohort was 55.7±24.6 years old., Discussion: Our review showed that TCV is an uncommon surgical entity. The diagnosis is likely to be made at laparotomy. Prompt recognition is paramount in preventing ischemia necrosis and perforation. Compared to sigmoid and cecal volvulus, the mortality for TCV remains high.

Introduction: The management of young infants with skin and soft tissue infection is not well-defined., Methods: We performed a survey study of pediatric hospital medicine, emergency medicine, urgent care, and primary care physicians to assess the management of young infants with skin and soft tissue infection. The survey included 4 unique scenarios of a well-appearing infant with uncomplicated cellulitis of the calf with the combination of age ≤ 28 days vs 29-60 days and the presence vs absence of fever., Results: Of 229 surveys distributed, 91 were completed (40%). Hospital admission was chosen more often for younger infants (≤ 28 days) versus older infants regardless of fever status (45% vs 10% afebrile, 97% vs 38% febrile, both P  < 0.001). Younger infants were more likely to get blood, urine, and cerebrospinal fluid studies ( P  < 0.01). Clindamycin was chosen in 23% of admitted younger infants compared to 41% of older infants ( P  < 0.05)., Conclusions: Frontline pediatricians appear relatively comfortable with outpatient management of cellulitis in young infants and rarely pursued meningitis evaluation in any afebrile infants or older febrile infants., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis., Objective: To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results., Methods: Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results., Results: Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL., Conclusions: Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making., (Copyright © 2022 by the American Academy of Pediatrics.)

Objective: Racial disparities and differences exist in emergency care. Obtaining a sexual history is standard of care for adolescents with abdominal pain. Testing for sexually transmitted infections (STIs) and pregnancy should be based on historical findings. The objective of this study was to determine whether differential care was provided to adolescent female patients with abdominal pain based on patient race or healthcare provider characteristics by evaluating the documentation of sexual history, STI testing, and pregnancy testing., Methods: This was a retrospective chart review of female patients between the ages of 14 and 18 years with abdominal pain presenting to a pediatric emergency department. Patient and provider characteristics, sexual history documentation, STI, and pregnancy testing were abstracted. Data were analyzed using χ 2 test and logistic regression model., Results: Eight hundred eighty-six encounters were included in the analysis. Median patient age was 16 years (range, 14-18 years); 359 (40.5%) were non-White. Differential care was provided. Non-White patients compared with White patients were more likely to have a documented sexual history (59.9% vs 44.0%, P < 0.001), STI testing (24.8% vs 7.8%, P < 0.001), and pregnancy testing (76.6% vs 66.2%, P < 0.001). Among sexually active female patients, the racial disparity for STI testing persisted ( P = 0.010). Provider type and sex did not result in differences in sexual history documentation, STI, or pregnancy testing for non-White compared with White patients ( P > 0.05)., Conclusions: Differential care was provided to non-White adolescents with abdominal pain compared with White adolescents. They were more likely to have a documented sexual history, STI testing, and pregnancy testing. Healthcare provider characteristics did not impact patient care. This racial disparity resulted in better medical care for non-White adolescents, but this may be the consequence of underlying implicit bias., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

This chapter explores strategies for using virtual games in leadership education. Pedagogical practices, examples, and connections to leadership learning frameworks, learning goals, and competencies are also included. Implications for practice such as intentional design, pairing with other instructional strategies, and debriefing are also discussed with an emphasis on purposeful utilization., (© 2022 Wiley Periodicals, LLC.)

Background: Viscoelastic tests including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are being used in patients with severe hemorrhage at trauma centers to guide resuscitation. Several recent studies demonstrated hypercoagulability in female trauma patients that was associated with a survival advantage. The objective of our study was to elucidate the effects of gender differences in TEG/ROTEM values on survival in trauma patients with severe hemorrhage., Methods: A retrospective review of consecutive adult patients receiving massive transfusion protocol (MTP) at 7 Level I trauma centers was performed from 2013 to 2018. Data were stratified by gender and then further examined by TEG or ROTEM parameters. Results were analyzed using univariate and multi-variate analyses., Results: A total of 1565 patients were included with 70.9% male gender (n = 1110/1565). Female trauma patients were older than male patients (43.5 ± .9 vs 41.1 ± .6 years, P = .01). On TEG, females had longer reaction times (6.1 ± .9 min vs 4.8 ± .2 min, P = .03), increased alpha angle (68.6 ± .8 vs 65.7 ± .4, P < .001), and higher maximum amplitude (59.8 ± .8 vs 56.3 ± .4, P < .001). On ROTEM, females had significantly longer clot time (99.2 ± 13.7 vs 75.1 ± 2.6 sec, P = .09) and clot formation time (153.6 ± 10.6 sec vs 106.9 ± 3.8 sec, P < .001). When comparing by gender, no difference for in-hospital mortality was found for patients in the TEG or ROTEM group ( P > .05). Multivariate analysis showed no survival difference for female patients (OR 1.11, 95% CI .83-1.50, P = .48)., Conclusions: Although a difference between male and females was found on TEG/ROTEM for certain clotting parameters, no difference in mortality was observed. Prospective multi-institutional studies are needed.

Objectives: Hospitals are an important nontraditional setting in which to address adolescent reproductive health. However, opportunities for intervention are frequently missed, especially for boys and patients hospitalized for noningestion complaints. Our global aim was to increase delivery of reproductive health care to adolescents hospitalized through our children's hospital Pediatric Hospital Medicine service., Methods: We performed 2 quality improvement intervention cycles: (1) provider education and monthly reminder e-mails and (2) an automated electronic health record (EHR) adolescent history and physical note template with social history prompts while discontinuing reminder e-mails. The primary outcome measure was sexual history documentation (SHD). Secondary measures were sexually transmitted infection (STI) testing and contraception provision. Statistical process control charts were used to analyze effectiveness of interventions., Results: From July 2018 through June 2019, 528 Primary Hospital Medicine encounters were included in this study and compared with published baseline data on 150 encounters. Control charts revealed a special cause increase in SHD from 60% to 82% overall, along with 37% to 73% for boys and 57% to 80% for noningestion hospitalizations. Increased SHD correlated with cycle 1 and was maintained through cycle 2. Percent STI testing significantly increased but did not shift or trend toward special cause variation. Contraception provision, length of stay, and patient relations consultations were not affected., Conclusions: The interventions were successful in increasing SHD, including among boys and noningestion hospitalizations. The EHR enhancement maintained these increases after reminder emails were discontinued. Future interventions should specifically address STI testing and provision of contraception., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Purpose: Clean catch urine samples may be an alternative specimen to test for chlamydia and gonorrhea infections. The aim of this study was to determine the sensitivity and specificity of clean urine for chlamydia and gonorrhea in women., Methods: This was a noninferiority prospective cohort study of women aged 14-22 years requiring chlamydia and gonorrhea testing. Patients provided a vaginal swab (gold standard), clean urine (test sample), and dirty urine (usual care). All samples were analyzed using Hologic's Aptima Combo2 Assay, a second-generation nucleic acid amplification test. The sensitivity and specificity of the clean and dirty urine were calculated and compared., Results: Three hundred and twenty-three females were included, mean age 17.0 ± 1.6 years. For chlamydia, 59 participants were positive by vaginal swab. The sensitivity of clean urine to diagnose chlamydia was 86.2% (95% CI: 74.8%-93.1%) and specificity was 98.8% (95% CI: 96.5%-99.8%). The sensitivity of dirty urine to diagnose chlamydia was 89.8% (95% CI: 79.2%-95.6%), and the specificity was 99.6% (95% CI 97.6%-100%). For gonorrhea, 18 participants were positive by vaginal swab. The sensitivity of clean urine to diagnose gonorrhea was 94.4% (95% CI: 72.4%-100%) and specificity was 99.7% (95% CI: 98.0%-100.0%). The sensitivity of dirty urine to diagnose gonorrhea was 100% (95% CI: 79.3%-100%) and specificity was 99.7% (95% CI: 98.0%-100%). Specificity of clean urine was noninferior compared with dirty urine for diagnosing chlamydia (p = .0004) and gonorrhea (p < .0001)., Conclusions: Clean urine samples may be an alternative option to diagnose chlamydia and gonorrhea in women., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess justice system involvement among adolescents in the pediatric emergency department and identify associations with risk and protective factors., Study Design: We conducted a cross-sectional, computerized survey of adolescents to assess for personal, justice system involvement, and nonhousehold justice system involvement (ie, important people outside of household). We assessed sexual behaviors, violent behaviors, substance use, school suspension/expulsion, parental supportiveness, and participant mood (score <70 indicates psychological distress). We compared differences between groups using the χ 2 tests, Fisher exact tests, t tests, and performed multivariable logistic regression analyses., Results: We enrolled 191 adolescents (mean age 16.1 years, 61% female). Most (68%) reported justice system involvement: personal (13%), household (42%), and nonhousehold (40%). Nearly one-half (47%) were sexually active and 50% reported school suspension/expulsion. The mean score for mood was 70.1 (SD 18); adolescents with justice system involvement had had lower mood scores (68 vs 74, P = .03) compared with those without justice system involvement. In a multivariable model, school expulsion/suspension was significantly associated with reporting any justice system involvement (OR 10.4; 95% CI 4.8-22.4)., Conclusions: We identified the pediatric emergency department as a novel location to reach adolescents at risk for poor health outcomes associated with justice system involvement. Future work should assess which health promotion interventions and supports are desired among these adolescents and families., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: This study aimed to assess adolescent and parent perspectives on parent notification after disclosure of adolescent relationship abuse (ARA) to a health care provider., Methods: A computerized survey was administered to a convenience sample of adolescents aged 14-18 years and their parents presenting to three Midwestern pediatric emergency departments. The survey assessed the acceptability of parent notification after hypothetical adolescent disclosure of different forms of ARA (i.e., physical, cyber, psychological and sexual ARA, reproductive coercion, controlling behavior, and feeling unsafe) to a health care provider. Chi-square and Fisher's exact tests were used to examine possible relationships between acceptability of parent notification and prior ARA victimization, adolescent dating relationship status, and demographic factors., Results: One-hundred fifty adolescent-parent dyads and 53 individual adolescents participated in this study. Most adolescents and parents found it acceptable to inform parents after disclosure of any type of ARA, although acceptability was higher among parents for all types of abuse assessed. Adolescent-parent dyads were more likely to both agree that parent notification was acceptable after disclosure of physical ARA, compared with other forms of ARA. Acceptability of parent notification after some types of ARA disclosure was less common among adolescents reporting previous sexual activity, prior ARA victimization, and adolescents currently in a dating relationship., Conclusions: Most adolescents and parents found parent notification after ARA disclosure acceptable. However, adolescents most at risk, including those who reported previous sexual activity, prior ARA victimization, and those in a dating relationship, were less likely to find parent notification acceptable. Further study to assess barriers or concerns with parent involvement is crucial to optimizing provider response after ARA disclosure., (Copyright © 2020. Published by Elsevier Inc.)

Background: Necrotizing soft tissue infections (NSTIs) are life-threatening surgical emergencies associated with high morbidity and mortality. Fungal NSTIs are considered rare and have been largely understudied. The purpose of this study was to study the impact of fungal NSTIs and antifungal therapy on mortality after NSTIs., Methods: A retrospective chart review was performed on patients with NSTIs from 2012 to 2018. Patient baseline characteristics, microbiologic data, antimicrobial therapy, and clinical outcomes were collected. Patients were excluded if they had comfort care before excision. The primary outcome measured was in-hospital mortality., Results: A total of 215 patients met study criteria with a fungal species identified in 29 patients (13.5%). The most prevalent fungal organism was Candida tropicalis (n = 11). Fungal NSTIs were more prevalent in patients taking immunosuppressive medications (17.2% versus 3.2%, P = 0.01). A fungal NSTI was significantly associated with in-hospital mortality (odds ratio, 3.13; 95% confidence interval, 1.16-8.40; P = 0.02). Furthermore, fungal NSTI patients had longer lengths of stay (32 d [interquartile range, 16-53] versus 19 d [interquartile range, 11-31], P < 0.01), more likely to require initiation of renal replacement therapy (24.1% versus 8.6%, P = 0.02), and more likely to require mechanical ventilation (64.5% versus 42.0%, P = 0.02). Initiation of antifungals was associated with a significantly lower rate of in-hospital mortality (6.7% versus 57.1%, P = 0.01)., Conclusions: Fungal NSTIs are more common in patients taking immunosuppressive medications and are significantly associated with in-hospital mortality. Antifungal therapy is associated with decreased in-hospital mortality in those with fungal NSTIs. Consideration should be given to adding antifungals in empiric treatment regimens, especially in those taking immunosuppressive medications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Adolescents are disproportionately affected by sexually transmitted infections (STIs). Failure to diagnose and treat STIs in a timely manner may result in serious sequelae. Adolescents frequently access the emergency department (ED) for care. Although ED-based STI screening is acceptable to both patients and clinicians, understanding how best to implement STI screening processes into the ED clinical workflow without compromising patient safety or efficiency is critical. The objective of this study was to conduct direct observations documenting current workflow processes and tasks during patient visits at six Pediatric Emergency Care Applied Research Network (PECARN) EDs for site-specific integration of STI electronically-enhanced screening processes. Workflow observations were captured via TaskTracker, a time and motion electronic data collection application that allows researchers to categorize general work processes and record multitasking by providing a timestamp of when tasks began and ended. Workflow was captured during 118 patient visits across six PECARN EDs. The average time to initial assessment by the most senior provider was 76 min (range 59-106 min, SD = 43 min). Care teams were consistent across sites, and included attending physicians, advanced practice providers, nurses, registration clerks, technicians, and students. A timeline belt comparison was performed. Across most sites, the most promising implementation of a STI screening tool was in the patient examination room following the initial patient assessment by the nurse.

Given incarcerated women's frequent transitions between jail and community, it is important to seize opportunities to provide comprehensive health care. A potential time to provide care might be when getting tested for sexually transmitted infections (STIs). Our objective was to determine the proportion of women receiving STI testing and correlates, following jail release. This secondary analysis was of one-year follow-up data from women who participated in a jail-based cervical health literacy intervention in three Kansas City jails from 2014 to 2016. Most (82%) completed the survey in the community. The analysis included 133 women. Mean age 35 years (19-58 years). Sixty-two percent obtained STI testing within one-year post-intervention. Using logistic regression this was associated with younger age (odds ratio [OR] = 0.87; 95% confidence interval [CI] 0.80, 0.95), receiving high school education (OR = 4.33; 95% CI 1.00, 18.74), having insurance (OR = 4.32; 95% CI 1.25, 14.89), no illicit drug use (OR = 0.09; 95% CI 0.01, 0.81), and no drinking problem (OR = 0.04; 95% CI 0.00, 0.45). In this study, many women sought STI testing following jail release. Clinicians/public health practitioners may find it useful to engage these high-risk women in broader women's health services seeking STI testing.

Background: Adolescents and young adults account for half of the 20 million new cases of sexually transmitted infections each year. Expedited partner therapy (EPT) has been shown to decrease reinfection rates and is recommended by the Centers for Disease Control and Prevention. We aimed to (1) assess adolescents' awareness of EPT, (2) assess their likelihood of giving EPT received in the pediatric emergency department (PED) to their partner(s), and (3) identify factors associated with increased likelihood of giving EPT to their partner(s)., Methods: Adolescents and young adults aged 14 to 22 years seeking care in 2 PEDs participated in a survey. Main outcomes were EPT awareness and likelihood of giving EPT to his/her partner(s). Patients were dichotomized into likely and not likely to provide partner(s) with EPT based on answers to a 5-point Likert scale question. χ and t tests were used to analyze the data., Results: Three hundred ninety-three participants were included. Only 11% (n = 42) were aware of EPT; however, 80% (n = 316) reported to be likely to give EPT received in the PED to his/her partner(s). Study site, being sexually active, and engaging in high-risk sexual behaviors were associated with an increased likelihood of giving EPT to their partner(s) (P < 0.05)., Conclusions: Many adolescents are not aware of EPT; however, most were theoretically likely to give EPT received in the PED to his/her partner(s). With increasing rates of sexually transmitted infections and high utilization of the PED for adolescent reproductive health services, efforts to incorporate the use of EPT in PED workflows would be beneficial.

Background: Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL., Methods: A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed., Results: A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001)., Conclusions: Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.

Objective: This study aimed to determine the emotional intelligence (EI) of surgical faculty and evaluate its relationship with resident evaluations of faculty behaviors., Design: This study retrospectively collected faculty EI scores as well as general surgery resident evaluations of faculty. Parametric and nonparametric tests were used for statistical analysis., Setting: The study was conducted at the University of Texas Southwestern in the Department of Surgery in Dallas, Texas. This is an academic, tertiary care center., Participants: Surgical faculty members at a single institution in 2018 completed the Emotional Intelligence Appraisal, a 28-item, electronic assessment with possible scores ranging from zero to 100. Aggregate, anonymous resident evaluations of faculty members were collected from the program director's office. Faculty with fewer than 8 resident evaluations were excluded., Results: In total, 59 faculty members participated (89%). The sample was mostly white (69.2%), male (63.5%), with an average of 47 ± 10 years of age, 12.2 ± 10 years in practice, and 44 ± 24 evaluations per faculty member. The group's mean EI score was 76 ± 7.7. Faculty EI scores were found to have a moderate, positive correlation with resident rotational evaluations of faculty (r(51) = 0.52, p < 0.001). Faculty EI scores did not significantly correlate with resident evaluations of faculty intraoperative behaviors., Conclusions: The results of this study suggest that a majority of our faculty are competent with regard to EI. Furthermore, faculty EI is an important factor in the clinical learning environment and correlates with resident rotational evaluations of teaching behaviors., (Copyright © 2020. Published by Elsevier Inc.)

Background: Necrotizing soft tissue infections (NSTI) are a surgical emergency with significant morbidity and mortality rates. It has been thought that NSTIs are best treated in large tertiary centers. However, the effect of transfer has been under-studied. We examined whether transfer status is associated with a higher mortality rate in NSTIs. Methods: We conducted a retrospective review of patients with an International Classification of Disease (ICD) code associated with NSTI seen from 2012-2015 at two tertiary care institutions. Patients transferred to a tertiary center (T-NSTI) were compared with those who were treated initially at a tertiary center (P-NSTI). The primary endpoint was in-hospital death. Results: A total of 138 patients with NSTI met our study criteria, 39 transfer patients (28.0%) and 99 (72.0%) who were treated primarily at our institutions. The mortality rate was significantly higher for T-NSTI patients than P-NSTI patients (35.9% versus 14.1%; p < 0.01) with an adjusted odds ratio of 5.33 (95% confidence interval 1.02-28.30; p = 0.04). The need for hemodialysis was an independent predictor of in-hospital death. Treatment at a Level 1 trauma center and current smoking status were independent protectors???? of in-hospital death. For the transfer patients, the timing of transfer and debridement status were not different in survivors and non-survivors. However, there was a trend toward a lower in-hospital mortality rate if patients were transferred early without prior debridement than in all other transfers (21.4% versus 40.0%; p = 0.21). The in-hospital mortality rate was significantly lower at the Level 1 trauma center than at the non-trauma tertiary center (15.5% versus 34.3%; p = 0.02). Conclusion: Transfer status is an independent predictor of in-hospital death in patients with NSTI. Larger, multi-institutional studies are needed to elucidate further what factors contribute to the higher mortality rate in these patients.

Background: While the prevalence of HIV infection in the population is 0.5%, it is higher among trauma patients as are rates of unknown seropositivity. Routine HIV screening for all trauma evaluations was implemented at our urban level I center in 2009. We aimed to evaluate use and results of the program in our trauma population., Methods: This was a retrospective analysis of all trauma evaluations between July 2015 and February 2018. After passage of legislation rescinding the requirement for consent to perform HIV testing, our trauma service instituted an order set which automatically tested for HIV unless the ordering physician opted out. Patients found to be infected with HIV were to be counseled and referred to specialty care., Results: Of 6175 consecutive trauma evaluations during the study period, 449 (7.3%) patients had been screened within the prior year and were excluded. Of the remaining cohort, 2024 (35.3%) patients were screened with 27 (1.3%) testing positive. Among those testing positive for infection, 100% were male, 77% white, 63% non-Hispanic, and 70% lacked insurance. Twenty-five (92.6%) patients received counseling and 19 were referred to specialty care. Age, gender, race, ethnicity, Injury Severity Score, trauma activation level, and payor type were not significant predictors for positive HIV screen on logistic regression analysis., Conclusions: Despite a significantly higher rate of HIV in the trauma population, only a third of patients are screened. Such high infection rates justify the existence of this screening program but steps must be taken to increase screening rate., Level of Evidence: Level 3., (Published by Elsevier Inc.)

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33-3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: The purpose of this paper is to gain insight into justice-involved women's preferences for an internet-based Sexual Health Empowerment (SHE) curriculum., Design/methodology/approach: The authors analyzed data from four focus groups conducted with 52 women in a minimum-security county jail in a Midwestern US city., Findings: Women reported daily access to the internet while in the community and use of the internet for searching about health concerns. Four themes emerged in the discussion about preferences for an internet-based SHE curriculum, that it cover healthy sexual expression, how to access resources, video as an educational modality and a non-judgmental approach., Practical Implications: Justice-involved women are potentially reachable through internet-based health education. Their preferences for content and modality can be used to inform internet-based sexual health programming designed specifically for this population. Using this modality could offer easily disseminated, low-cost and consistent messaging about sexual health for a vulnerable group of women., Originality/value: Though internet-based health education programming has been widely utilized in the general population, less attention has been paid to if and how these programs could be utilized with a vulnerable group of women who move between the justice system and communities. This exploratory study begins to fill that gap., (© Emerald Publishing Limited.)

Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background Expedited partner therapy (EPT) is an effective method to treat sexually transmissible infections (STIs) and prevent re-infections. Pharmacy staff play a vital role in the success of EPT. This study aims to assess pharmacy staff knowledge of EPT and identify potential barriers to filling EPT prescriptions., Methods: The study was a cross-sectional, Internet-based survey distributed to members of the Pharmacy Society of Wisconsin. Non-retired pharmacists and pharmacy technicians were eligible. EPT knowledge was dichotomised into 'yes' versus 'no/unknown'. Statistical analyses included the χ2 test and Student's two-sided t-test; using an α of 0.05., Results: Ninety-four questionnaires were analysed: 74 pharmacists, 20 pharmacy technicians. Overall, 73 (78%) knew EPT is legal in Wisconsin, 86% of pharmacists versus 45% of pharmacy technicians, P < 0.01. The mean time from graduation/training was less for participants who knew EPT is legal versus those who did not (12.8 years vs 20.2 years, P < 0.01). Sixty-four (68%) participants worked in an outpatient setting, of which 12 (19%) knew of a formal workplace EPT policy. Thirty-two (40%) of the 81 participants who had heard of EPT thought nameless EPT prescriptions should not be legal, commonly citing patient safety concerns., Conclusions: This study demonstrated inconsistent knowledge of EPT between pharmacists and pharmacy technicians. Knowledge of workplace EPT policies and patient safety concerns were barriers to EPT. Addressing these knowledge and policy barriers will be vital to improve the utilisation of EPT.

Objectives: There is limited literature about physicians' adherence to 2010 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines specific to specimen collection testing methods in adolescent females in the emergency setting is limited. The objectives are to (1) determine physician adherence to CDC guidelines for specimen collection/testing for chlamydia and gonorrhea, (2) determine physician characteristics associated with guideline adherence, and (3) describe physicians' knowledge of expedited partner therapy (EPT) laws., Methods: This is a cross-sectional, anonymous, Internet-based survey of physician members of the American Academy of Pediatrics Section of Emergency Medicine. Questions addressed practice patterns and knowledge through clinical scenarios of adolescent girls. Descriptive statistics are used to report frequency. Fisher exact and χ analyses are used to compare physician subgroups: gender, years in practice, practice setting, and geographical region., Results: Overall, 257 physicians responded and 231 were analyzed; 62.4% females; 46.0% in practice for ≤ 7 years; 86.2% in academic medicine. Specimen collection/testing in an asymptomatic patient were consistent with guidelines for 85.6% of respondents, but decreased to 37.4% for a symptomatic patient. Guideline adherence was not different between physician subgroups. Only 30.4% of physicians reported state EPT law knowledge., Conclusions: Adherence with the CDC guidelines for chlamydia/gonorrhea specimen collection/testing for adolescents in the emergency setting is inadequate, and EPT knowledge is poor. With increased emergency department use by adolescents, it is critical that physicians know and implement the current recommendations to improve adolescent health outcomes.

Over 200,000 women are diagnosed with breast cancer each year, and incarcerated women face unique risks associated with poor access to healthcare. Regular mammography can diagnose breast cancer early, giving the patient the best chance of survival. The objective of this study was to determine the proportion of jail incarcerated women who have received a mammogram and were up-to-date based on the most recent United States Preventive Services Task Force recommendations. This was a secondary analysis of data collected among jailed women who participated in a cervical cancer literacy program. Rates of mammography were calculated for the group overall and for those women 50 years or older. Subgroups were compared using chi-squared tests. Two hundred sixty-one women were included in the analysis, of which 42.1% ( N  = 110) had ever had a mammogram. Of women 50 years old or older ( N  = 28), 75.0% had ever received a mammogram, yet only 39.3% were up-to-date (within the past 2 years). Factors associated with up-to-date mammography included being up-to-date on cervical cancer screening (76.9%) compared with women who were not up-to-date on cervical cancer screening (12.5%), p  < 0.01, and women experiencing intimate partner violence (IPV) in the past year (71.4%) compared with women with no IPV in the past year (14.2%), p  = 0.02. The low rates of up-to-date mammography highlight the need for more breast cancer prevention programming among women with criminal justice histories., Competing Interests: No competing financial interests exist.

Background: Expedited partner therapy (EPT) is an effective strategy for partner management of sexually transmitted infections. Some states, including Wisconsin, allow EPT prescriptions to be filled without a patient name. This study determined the refusal rates of nameless EPT prescriptions in Milwaukee pharmacies., Methods: In this cross-sectional study, 3 trained research assistants of different age, sex, and race posed as "patients" and visited 50 pharmacy locations from one pharmacy chain in Milwaukee County, WI, to fill nameless EPT prescriptions. A χ test was used to compare demographics of patients, pharmacists, and pharmacies. Multiple logistic regression was used to identify factors associated with prescription refusal., Results: Twenty-nine (58%) of 50 nameless EPT prescriptions were refused. Univariate analysis showed that prescriptions were more likely to be refused if the pharmacy was in the suburbs (77%) compared with Milwaukee city (43%; P = 0.01), if the pharmacist was older than the patient (82%) compared with being younger (46%) or within the same age group (33%; P = 0.01 for both), and if the patient was white (78%) compared with nonwhite (47%; P = 0.03). Multivariable regression revealed significantly higher refusals for pharmacies located in the suburbs compared with the city (odds ratio, 5.3; 95% confidence interval, 1.4-20.3; P = 0.03) and in patients who were white compared with nonwhite (odds ratio: 4.8; 95% confidence interval, 1.2-19.8; P = 0.01)., Conclusions: More than half of nameless EPT prescriptions were refused in Milwaukee county pharmacies, more frequently at suburban pharmacies and for white patients. Increased pharmacist education regarding EPT is essential to help combat the sexually transmitted infection crisis.