The Current State of the Pediatric Emergency Medicine Workforce and Innovations to Improve Pediatric Care

Many hospitals and emergency departments lack resources to optimally care for ill and injured children, perpetuating risks of receiving fragmented and “uneven” care. In this article, we describe the present state of our pediatric emergency medicine workforce as well as the impact that different innovations could have on the future of pediatric emergency care. Many innovative initiatives, including physician and advanced practice provider education and training, pediatric readiness recognition programs, telemedicine and in-situ simulation outreach, and community paramedicine are being utilized to help bridge access gaps and augment the reach of the pediatric emergency medicine workforce. Advocacy for reimbursement for novel care delivery models, such as community paramedicine and telemedicine, and funding for outreach education programming is essential. Also, better understanding of our current training models for and utilization of advanced practice practitioners in pediatric emergency medicine is crucial to understanding the diversity of workforce growth and opportunity

School-Based Telemedicine Interventions for Asthma: A Systematic Review.

BackgroundSchool health systems are increasingly investing in telemedicine platforms to address acute and chronic illnesses. Asthma, the most common chronic illness in childhood, is of particular interest given its high burden on school absenteeism.ObjectiveConduct a systematic review evaluating impact of school-based telemedicine programs on improving asthma-related outcomes.Data sourcesPubMed, Cochrane CENTRAL, CINAHL, ERIC, PsycINFO, Embase, and Google Scholar.Study eligibility criteriaOriginal research, including quasi-experimental studies, without restriction on the type of telemedicine.ParticipantsSchool-aged pediatric patients with asthma and their families.InterventionsSchool-based telemedicine.Study appraisal and synthesis methodsTwo authors independently screened each abstract, conducted full-text review, assessed study quality, and extracted information. A third author resolved disagreements.ResultsOf 371 articles identified, 7 were included for the review. Outcomes of interest were asthma symptom-free days, asthma symptom frequency, quality of life, health care utilization, school absences, and spirometry. Four of 7 studies reported significant increases in symptom-free days and/or decrease in symptom frequency. Five of 6 reported increases in at least one quality-of-life metric, 2 of 7 reported a decrease in at least 1 health care utilization metric, 1 of 3 showed reductions in school absences, and 1 of 2 reported improvements in spirometry measures.LimitationsVariability in intervention designs and outcome measures make comparisons and quantitative analyses across studies difficult. Only 2 of 7 studies were randomized controlled trials.Conclusions and implications of key findingsHigh-quality evidence supporting the use of school-based telemedicine programs to improve patient outcomes is limited. While available evidence suggests benefit, only 2 comparative trials were identified, and the contribution of telemedicine to these studies' results is unclear

Time and Out-of-Pocket Costs Associated with Respiratory Syncytial Virus Hospitalization of Infants

AbstractObjectiveThe objective of this study was to quantify time spent plus out-of-pocket costs associated with confirmed respiratory syncytial virus (RSV) hospitalization of infants not prophylaxed against RSV.MethodsA prospective survey was carried out at multiple tertiary care hospitals in the United States.PatientsThe patients consisted of a consecutive sample of infants <12 months, born between 33 and 35 weeks of gestation. One site also enrolled full-term infants hospitalized with confirmed RSV. Daily patient census identified eligible patients. Consenting caregivers of eligible subjects (n=84, 1 refusal) were interviewed on discharge day and by telephone ∼30 days following discharge regarding time and out-of-pocket costs due to RSV.ResultsTotal average out of pocket expenses were $643.69 (range$21–$16,867; SD$2,403) for premature and $214.42 (range$6–$827; SD$218) (P=.0158) for full-term subjects. Total average economic burden per admission was $4517.07 for premature and$2135.30 for full-term infants, including the value of lost productivity but excluding inpatient hospital and physician bills and lost income. Premature infants (n=48) had longer hospital stays (mean 6.9 days; SD 7.5 vs. 3.4 days; SD 2.6 days) (P=.001) with an associated mean total time spent by up to 5 adults of 281.7 hours (range 25–2819.7 hours; SD 465.8 hours) versus a mean of 139.7 hours (range 31.8–561.3 hours; SD 118.1 hours) for term infants (P=.109). Time and out-of-pocket costs continued after discharge.ConclusionsRSV hospitalization of infants is associated with substantial, previously unmeasured time and monetary losses. These losses continued following discharge. The economic burden on families and society appears heavier for infants born at 33 to 35 weeks of gestation than for full-term infants

Neuronal differentiation influences progenitor arrangement in the vertebrate neuroepithelium

Cell division, movement and differentiation contribute to pattern formation in developing tissues. This is the case in the vertebrate neural tube, in which neurons differentiate in a characteristic pattern from a highly dynamic proliferating pseudostratified epithelium. To investigate how progenitor proliferation and differentiation affect cell arrangement and growth of the neural tube, we used experimental measurements to develop a mechanical model of the apical surface of the neuroepithelium that incorporates the effect of interkinetic nuclear movement and spatially varying rates of neuronal differentiation. Simulations predict that tissue growth and the shape of lineage-related clones of cells differ with the rate of differentiation. Growth is isotropic in regions of high differentiation, but dorsoventrally biased in regions of low differentiation. This is consistent with experimental observations. The absence of directional signalling in the simulations indicates that global mechanical constraints are sufficient to explain the observed differences in anisotropy. This provides insight into how the tissue growth rate affects cell dynamics and growth anisotropy and opens up possibilities to study the coupling between mechanics, pattern formation and growth in the neural tube

Unmet medical needs and health care accessibility in seven countries of Eastern Europe

The study investigated the magnitude and structure of health care access barriers and utilisation inequalities in seven countries of Eastern Europe. Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, and Slovakia were examined over the period 2005-2009. The dataset containing 574,390 observations was derived from the European Union Statistics on Income and Living Conditions (EU-SILC). Logit and multinomial logit models were estimated for each country-year combination to inspect the relationship between respondents’ socio-economic characteristics, the probability of reporting unmet needs for examination or treatment, and the reason for the need not being met. We found that health care was most easily accessible in the Czech Republic and Slovakia. Affordability issues and prohibitive waiting times were prevalent in Poland and the Baltic States. Mobility and information represented minor access barriers. The poorest households, the unemployed, working age cohorts and women were more exposed to problems in accessing health care than the population at large. Access conditions improved over the analysed period. Substantial differences exist among countries that constitute an arguably homogenous group of post-communist, new EU member states. The nature of access barriers is indicative of coverage gaps and inadequacy of public sector resources relative to need, which call for systemic solutions

Unmet medical needs and health care accessibility in seven countries of Eastern Europe

The study investigated the magnitude and structure of health care access barriers and utilisation inequalities in seven countries of Eastern Europe. Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, and Slovakia were examined over the period 2005-2009. The dataset containing 574,390 observations was derived from the European Union Statistics on Income and Living Conditions (EU-SILC). Logit and multinomial logit models were estimated for each country-year combination to inspect the relationship between respondents’ socio-economic characteristics, the probability of reporting unmet needs for examination or treatment, and the reason for the need not being met. We found that health care was most easily accessible in the Czech Republic and Slovakia. Affordability issues and prohibitive waiting times were prevalent in Poland and the Baltic States. Mobility and information represented minor access barriers. The poorest households, the unemployed, working age cohorts and women were more exposed to problems in accessing health care than the population at large. Access conditions improved over the analysed period. Substantial differences exist among countries that constitute an arguably homogenous group of post-communist, new EU member states. The nature of access barriers is indicative of coverage gaps and inadequacy of public sector resources relative to need, which call for systemic solutions

Biomechanics of Pharyngeal Deglutitive Function Following Total Laryngectomy

Copyright © 2016 American Academy of Otolaryngology—Head and Neck Surgery Foundation. Reprinted by permission of SAGE PublicationsObjective: Post-laryngectomy surgery, pharyngeal weakness and pharyngoesophageal junction (PEJ) restriction are the underlying candidate mechanisms of dysphagia. We aimed to determine, in laryngectomees whether: 1) hypopharyngeal propulsion is reduced and/or PEJ resistance is increased; 2) endoscopic dilatation improves dysphagia; and 3) if so, whether symptomatic improvement correlate with reduction in resistance to flow across the PEJ. Methods: Swallow biomechanics were assessed in 30 total laryngectomees. Average peak contractile pressure (hPP) and hypopharyngeal intrabolus pressure (hIBP) were measured from combined high resolution manometry and video-fluoroscopic recordings of barium swallows (2, 5&10ml). Patients were stratified into severe dysphagia (Sydney Swallow Questionnaire (SSQ)>500) and mild/nil dysphagia (SSQ≤500). In 5 patients, all measurements were repeated after endoscopic dilatation. Results: Dysphagia was reported by 87%, and 57% had severe and 43% had minor/nil dysphagia. Laryngectomees had lower hPP than controls (110±14mmHg vs 170±15mmHg; p<0.05), while hIBP was higher (29±5mmHg vs 6±5mmHg; p<0.05). There were no differences in hPP between patient groups. However, hIBP was higher in severe than in mild/nil dysphagia (41±10mmHg vs 13±3mmHg; p<0.05). Pre-dilation hIBP (R2=0.97) and its decrement following dilatation (R2=0.98) were good predictors of symptomatic improvement. Conclusion: Increased PEJ resistance is the predominant determinant of dysphagia as it correlates better with dysphagia severity than peak pharyngal contractile pressure. While both baseline PEJ resistance and its decrement following dilatation are strong predictors of outcome following dilatation, the peak pharyngeal pressure is not. PEJ resistance is vital to detect as it is the only potentially reversible component of dysphagia in this context

Transcriptional analysis of temporal gene expression in germinating Clostridium difficile 630 endospores.

Clostridium difficile is the leading cause of hospital acquired diarrhoea in industrialised countries. Under conditions that are not favourable for growth, the pathogen produces metabolically dormant endospores via asymmetric cell division. These are extremely resistant to both chemical and physical stress and provide the mechanism by which C. difficile can evade the potentially fatal consequences of exposure to heat, oxygen, alcohol, and certain disinfectants. Spores are the primary infective agent and must germinate to allow for vegetative cell growth and toxin production. While spore germination in Bacillus is well understood, little is known about C. difficile germination and outgrowth. Here we use genome-wide transcriptional analysis to elucidate the temporal gene expression patterns in C. difficile 630 endospore germination. We have optimized methods for large scale production and purification of spores. The germination characteristics of purified spores have been characterized and RNA extraction protocols have been optimized. Gene expression was highly dynamic during germination and outgrowth, and was found to involve a large number of genes. Using this genome-wide, microarray approach we have identified 511 genes that are significantly up- or down-regulated during C. difficile germination (p≤0.01). A number of functional groups of genes appeared to be co-regulated. These included transport, protein synthesis and secretion, motility and chemotaxis as well as cell wall biogenesis. These data give insight into how C. difficile re-establishes its metabolism, re-builds the basic structures of the vegetative cell and resumes growth