Sickle cell disease (SCD) is an important topic for emergency medicine audiences because complications of the disease account for a large proportion of hematologic emergencies that are seen in the ...emergency department each year. Early recognition and aggressive management of emergency complications of SCD can help to reduce the morbidity and mortality associated with this disease. Although the treatment recommendations for some complications of SCD are based on expert opinion, there has been advancement in the understanding of the pathogenesis of the disease and evidence regarding the treatment options available for managing acute complications. This continuing medical education article will provide a summary of the clinical manifestation and management of the most common acute complications of SCD: infection, vaso-occlusive episode, acute chest syndrome, splenic sequestration, stroke, and priapism.
Eliminating Race-Based Medicine Wright, Joseph L; Davis, Wendy S; Joseph, Madeline M ...
Pediatrics (Evanston),
07/2022, Volume:
150, Issue:
1
Journal Article
Peer reviewed
Race-based medicine has been pervasively interwoven into the fabric of health care delivery in the United States for more than 400 years. Race is a historically derived social construct that has no ...place as a biologic proxy. In addition to valid measures of social determinants of health, the effects of racism require consideration in clinical decision-making tools in ways that are evidence informed and not inappropriately conflated with the limiting phenotype of race categorization. This policy statement addresses the elimination of race-based medicine as part of a broader commitment to dismantle the structural and systemic inequities that lead to racial health disparities.
Recent publications should have resulted in increased hydroxyurea usage in children with sickle cell disease (SCD). We hypothesized that hydroxyurea use in children with SCD increased over time and ...was associated with decreased acute care visits.
This was a secondary analysis of the Truven Health Analytics-IBM Watson Health MarketScan Medicaid database from 2009 to 2015. The multistate, population-based cohort included children 1 to 19 years old with an
or
diagnosis of SCD between 2009 and 2015. Changes in hydroxyurea were measured across study years. The primary outcome was the receipt of hydroxyurea, identified through filled prescription claims. Acute care visits (emergency department visits and hospitalizations) were extracted from billing data.
A mean of 5138 children each year were included. Hydroxyurea use increased from 14.3% in 2009 to 28.2% in 2015 (
< .001). During the study period, the acute-care-visit rate decreased from 1.20 acute care visits per person-year in 2009 to 1.04 acute care visits per person-year in 2015 (
< .001); however, the drop in acute care visits was exclusively in the youngest and oldest age groups and was not seen when only children enrolled continuously from 2009 to 2015 were analyzed.
There was a significant increase in hydroxyurea use in children with SCD between 2009 and 2015. However, in 2015, only ∼1 in 4 children with SCD received hydroxyurea at least once. Increases in hydroxyurea were not associated with consistently decreased acute care visits in this population-based study of children insured by Medicaid.
There is a need to increase the number of physician-scientists from underrepresented in medicine (URiM) groups. To engage URiM medical students, a committee of pediatric departmental leaders at the ...Children's Hospital of Philadelphia created the Summer Underrepresented in Medicine Medical Student Research program. This 8-week, onsite research and clinical experience takes place during the summer between students' first and second years of medical school.
Applications were solicited between 2019-2023 through nationwide outreach to medical school deans and members of URiM student organizations. Accepted students were assigned a mentor to lead their research and clinical exposure. A curriculum highlighting aspects of academic medicine was developed. Students received a $3,000-$5,500 stipend for in-person participation. In 2020 and 2021, adjustments were made (e.g., virtual programming) to avoid interruptions during the COVID-19 pandemic.
In the 2019-2023 application cycles, 298 students applied. Of 128 students who participated, 78 (61%) completed a postprogram survey. Students' survey feedback was positive. They indicated the program met expectations (mean rating = 1.3; scale: 1 = strongly agree to 5 = strongly disagree). Students reported they learned valuable information/skills (mean = 1.3) and that participation was worth time spent away from other responsibilities (mean = 1.3). The 2019 cohort (n = 12) achieved a 100% residency match rate. In addition, 4 (33%) of these students reported they are obtaining additional degrees or are performing research. After the program, many mentors continued to include students in their research projects.
Next steps include incorporating a standardized, scored rubric for selecting applicants; adding 3 lead mentors, an executive committee, and a faculty advisory board; establishing earlier pathway programming (e.g., at elementary and middle school levels); continuing to track/support alumni throughout their careers; and pursuing federal funding to expand the program.
The primary objective of this study is to describe the experiences of pediatric patients with sickle cell disease (SCD) and their caregivers who have presented to the emergency department (ED) for ...management of vaso-occlusive pain events.
We conducted a qualitative systematic review. The search protocol was developed to identify both published and unpublished literature that met inclusion/exclusion criteria. Included articles were primary hospital-based research with study populations that included (but were not limited to) pediatric patients aged 21 years or younger and qualitative or mixed-method analysis.
Four themes were identified: (1) patients and caregivers perceive the ED as the last resort; (2) health care professionals in the ED lacked knowledge about SCD but rejected patients' and caregiver's attempts to share experience or advocate for their needs; (3) patients' accounts of pain are doubted because they do not always have "typical" signs of pain; and (4) caregivers identify racism as a reason for suboptimal care in the ED.
There are multiple opportunities to improve management for vaso-occlusive pain events in the ED, including education of health care providers about SCD and complications, partnership between patients/caregivers and providers, and efforts to reduce the impact of systemic racism on health care delivery.
Pediatric departments and children's hospitals (hereafter pediatric academic settings) increasingly promote the tenets of diversity, equity, and inclusion (DEI) as guiding principles to shape the ...mission areas of clinical care, education, research, and advocacy. Integrating DEI across these domains has the potential to advance health equity and workforce diversity. Historically, initiatives toward DEI have been fragmented with efforts predominantly led by individual faculty or subgroups of faculty with little institutional investment or strategic guidance. In many instances, there is a lack of understanding or consensus regarding what constitutes DEI activities, who engages in DEI activities, how faculty feel about their engagement, and what is an appropriate level of support. Concerns also exist that DEI work falls disproportionately to racial and ethnic groups underrepresented in medicine, exacerbating what is termed the minority tax. Despite these concerns, current literature lacks quantitative data characterizing such efforts and their potential impact on the minority tax. As pediatric academic settings invest in DEI programs and leadership roles, there is imperative to develop and use tools that can survey faculty perspectives, assess efforts, and align DEI efforts between academic faculty and health systems. Our exploratory assessment among academic pediatric faculty demonstrates that much of the DEI work in pediatric academic settings is done by a small number of individuals, predominantly Black faculty, with limited institutional support or recognition. Future efforts should focus on expanding participation among all groups and increasing institutional engagement.
Study objective We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. ...Methods We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval CI 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.
Implicit Bias in Pediatric Academic Medicine Johnson, Tiffani J; Ellison, Angela M; Dalembert, George ...
Journal of the National Medical Association,
01/2017, Volume:
109, Issue:
3
Journal Article
Peer reviewed
Open access
Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty ...responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders.
Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention.
Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates.
Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.
Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0-28 days). We examined variation in adherence to these ...recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates.
Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI.
Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5-68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P < .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9-86.9) received recommended management.
There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.
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