Recurrent and High‐frequency Use of the Emergency Department by Pediatric Patients

Objectives The authors sought to describe the epidemiology of and risk factors for recurrent and high‐frequency use of the emergency department (ED) by children. Methods This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12‐month follow‐up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high‐frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use. Results A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty‐four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma‐related diagnoses were more common among patients without recurrent visits than among those with high‐frequency recurrent visits (28% vs. 9%; p < 0.001). High‐frequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Conclusions Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits. Resumen Objetivos Describir la epidemiología y los factores de riesgo de revista e hiperfrecuentación del servicio de urgencias (SU) por parte de los pacientes pediátricos. Metodología Estudio de cohorte retrospectivo mediante una base de datos de niños entre 0 y 17 años inclusive, que acudieron a 22 SU de la Pediatric Emergency Care Applied Research Network durante 2007, con un seguimiento de 12 meses tras cada visita índice. Los diagnósticos del SU de cada visita se clasificaron como traumatológico, médico agudo o enfermedades médicas crónicas. Las revisitas se definieron como cualquier visita repetida; la hiperfrecuentación se definió como cuatro o más revisitas. Se utilizaron ecuaciones de estimación generalizada para medir la fuerza de las asociaciones entre las características al paciente y la visita y la revisita del SU. Resultados Un total de 695.188 niños tuvieron al menos una visita al SU en 2007, con 455.588 revisitas al SU en los 12 meses tras las visitas índice. Un 64% de los pacientes no tuvieron revisitas, un 20% tuvo una, un 8% tuvo dos, un 4% tuvo tres y un 4% tuvo cuatro o más revisitas. Los diagnósticos médicos agudos representan la mayoría de las visitas, con independencia del número de revisitas. A medida que el número de revisitas por paciente aumentaba, las enfermedades crónicas estaban más representadas, y el asma fue el diagnóstico más común en el SU. Los diagnósticos relacionados con lo traumatológico fueron más frecuentes entre los pacientes sin revisitas que entre aquéllos con hiperfrecuentación (28% vs. 9%; p < 0,001). La alta frecuencia de revisitas fue más frecuente en las clasificaciones de gravedad más altas. En el análisis multivariable, las revisitas se asociaron con una edad más joven, raza o etnia negra o hispana, y la tenencia de un seguro de salud público. Conclusiones Los factores de riesgo para la revisita al SU por los niños incluyen la edad, la raza o etnia, y el tipo de seguro médico. Aunque el asma juega un papel importante en la revisita al SU, las enfermedades agudas representan la mayoría de la revistas al SU.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106853/1/acem12347.pd

Using Geographic Information Systems to investigate variations in accessibility to ‘extended hours’ primary healthcare provision

There are ongoing policy concerns surrounding the difficulty in obtaining timely appointments to primary healthcare services and the potential impact on, for example, attendance at accident and emergency services and potential health outcomes. Using the case study of potential access to primary healthcare services in Wales, Geographic Information System (GIS)‐based tools that permit a consideration of population‐to‐provider ratios over space are used to examine variations in geographical accessibility to general practitioner (GP) surgeries offering appointment times outside of ‘core’ operating hours. Correlation analysis is used to explore the association of accessibility scores with potential demand for such services using UK Population Census data. Unlike the situation in England, there is a tendency for accessibility to those surgeries offering ‘extended’ hours of appointment times to be better for more deprived census areas in Wales. However, accessibility to surgeries offering appointments in the evening was associated with lower levels of working age population classed as ‘economically active’; that is, those who could be targeted beneficiaries of policies geared towards ‘extended’ appointment hours provision. Such models have the potential to identify spatial mismatches of different facets of primary healthcare, such as ‘extended’ hours provision available at GP surgeries, and are worthy of further investigation, especially in relation to policies targeted at particular demographic groups

Feasibility of Screening Patients With Nonpsychiatric Complaints for Suicide Risk in a Pediatric Emergency Department: A Good Time to Talk?

Screening children for suicide risk when they present to the emergency department (ED) with nonpsychiatric complaints could lead to better identification and treatment of high-risk youth. Before suicide screening protocols can be implemented for nonpsychiatric patients in pediatric EDs, it is essential to determine whether such efforts are feasible

Towards mentoring as feminist praxis in early childhood education and care in England

Following our contribution to a study of mentoring in seven European countries, we explored epistemological and ontological inconsistencies within mainstream mentoring systems and their regulated practice in England. We considered how feminist mentoring praxis can unsettle conceptualisations of mentoring relationships and challenge inequity in the early education systems and the practice of teaching young children. Predominantly female, early childhood educators suffer from low status in England, and their working lives may be controlled and policed through inequitable systems. On entering the workforce, trainees encounter a reductionist policy milieu where mentoring structures and normative assessment arrangements contribute to inequity. Mentors play pivotal roles in inducting trainees into their worlds of work with young children. Mentoring relationships can determine whether trainees accept the status quo. Principles derived from feminist praxis enable mentors to practise an ‘engaged pedagogy’, co-constructing knowledge, subverting hierarchies and contesting taken-for-granted aspects of policy and practice

Inducible expression quantitative trait locus analysis of the MUC5AC gene in asthma in urban populations of children

BACKGROUND: Mucus plugging can worsen asthma control, lead to reduced lung function and fatal exacerbations. MUC5AC is the secretory mucin implicated in mucus plugging, and MUC5AC gene expression has been associated with development of airway obstruction and asthma exacerbations in urban children with asthma. However, the genetic determinants of MUC5AC expression are not established. OBJECTIVE: To assess single-nucleotide polymorphisms (SNPs) that influence MUC5AC expression and relate to pulmonary functions in childhood asthma. METHODS: We used RNA-sequencing data from upper airway samples and performed cis-expression quantitative trait loci (eQTL) and allele specific expression (ASE) analyses in two cohorts of predominantly Black and Hispanic urban children, a high asthma-risk birth cohort and an exacerbation-prone asthma cohort. We further investigated inducible MUC5AC eQTLs during incipient asthma exacerbations. We tested significant eQTLs SNPs for associations with lung function measurements and investigated their functional consequences in DNA regulatory databases. RESULTS: We identified two independent groups of SNPs in the MUC5AC gene that were significantly associated with MUC5AC expression. Moreover, these SNPs showed stronger eQTL associations with MUC5AC expression during asthma exacerbations, consistent with inducible expression. SNPs in one group also showed significant association with decreased pulmonary functions. These SNPs included multiple EGR1 transcription factor binding sites suggesting a mechanism of effect. CONCLUSIONS: These findings demonstrate the applicability of organ specific RNA-sequencing data to determine genetic factors contributing to a key disease pathway. Specifically, they suggest important genetic variations that may underlie propensity to mucus plugging in asthma and could be important in targeted asthma phenotyping and disease management strategies

Smoking, self-regulation and moral positioning: a focus group study with British smokers from a disadvantaged community

Smoking in many Western societies has become a both moral aand health issue in recent years, but little is known about how smokers position themselves and regulate their behaviour in this context. In this article, we report the findings from a study investigating how smokers from an economically disadvantaged community in the East Midlands (UK) respond to concerns about the health impact of smoking on others. We conducted ten focus group (FG) discussions with mixed groups (by smoking status and gender; N&thinsp;=&thinsp;58 participants) covering a range of topics, including smoking norms, self-regulation, and smoking in diverse contexts. We transcribed all FG discussions before analysing the data using techniques from discourse anlysis. Smokers in general positioned themselves as socially responsible smokers and morally upstanding citizens. This position was bolstered in two main ways: &lsquo;everyday accommodation', whereby everyday efforts to accommodate the needs of non-smokers were referenced, and &lsquo;taking a stand', whereby proactive interventions to prevent smoking in (young) others were cited. We suggest that smoking cessation campaigns could usefully be informed by this ethic of care for others

Quantitative measurements of inequality in geographic accessibility to pediatric care in Oita Prefecture, Japan: Standardization with complete spatial randomness

<p>Abstract</p> <p>Background</p> <p>A quantitative measurement of inequality in geographic accessibility to pediatric care as well as that of mean distance or travel time is very important for priority setting to ensure fair access to pediatric facilities. However, conventional techniques for measuring inequality is inappropriate in geographic settings. Since inequality measures of access distance or travel time is strongly influenced by the background geographic distribution patterns, they cannot be directly used for regional comparisons of geographic accessibility. The objective of this study is to resolve this issue by using a standardization approach.</p> <p>Methods</p> <p>Travel times to the nearest pediatric care were calculated for all children in Oita Prefecture, Japan. Relative mean differences were considered as the inequality measure for secondary medical service areas, and were standardized with an expected value estimated from a Monte Carlo simulation based on complete spatial randomness.</p> <p>Results</p> <p>The observed mean travel times in the area considered averaged 4.50 minutes, ranging from 1.83 to 7.02 minutes. The mean of the observed inequality measure was 1.1, ranging from 0.9 to 1.3. The expected values of the inequality measure varied according to the background geographic distribution pattern of children, which ranged from 0.3 to 0.7. After standardizing the observed inequality measure with the expected one, we found that the ranks of the inequality measure were reversed for the observed areas.</p> <p>Conclusions</p> <p>Using the indicator proposed in this paper, it is possible to compare the inequality in geographic accessibility among regions. Such a comparison may facilitate priority setting in health policy and planning.</p

A Critical Examination of Feedback in Early Reading Games

Learning games now play a role in both formal and informal learning, including foundational skills such as literacy. While feedback is recognised as a key pedagogical dimension of these games, particularly in early learning, there has been no research on how commercial games available to schools and parents reify learning theory into feedback. Using a systematic content analysis, we examine how evidence-based feedback principles manifest in five widely-used learning games designed to foster young children's reading skills. Our findings highlight strengths in how games deliver feedback when players succeed. Many of the games, however, were inconsistent and not proactive when providing error feedback, often promoting trial and error strategies. Furthermore, there was a lack of support for learning the game mechanics and a preference for task-oriented rewards less deeply embedded in the gameplay. Our research provides a design and research agenda for the inclusion of feedback in early learning games

Sickness behaviour pushed too far – the basis of the syndrome seen in severe protozoal, bacterial and viral diseases and post-trauma

Certain distinctive components of the severe systemic inflammatory syndrome are now well-recognized to be common to malaria, sepsis, viral infections, and post-trauma illness. While their connection with cytokines has been appreciated for some time, the constellation of changes that comprise the syndrome has simply been accepted as an empirical observation, with no theory to explain why they should coexist. New data on the effects of the main pro-inflammatory cytokines on the genetic control of sickness behaviour can be extended to provide a rationale for why this syndrome contains many of its accustomed components, such as reversible encephalopathy, gene silencing, dyserythropoiesis, seizures, coagulopathy, hypoalbuminaemia and hypertriglyceridaemia. It is thus proposed that the pattern of pathology that comprises much of the systemic inflammatory syndrome occurs when one of the usually advantageous roles of pro-inflammatory cytokines – generating sickness behaviour by moderately repressing genes (Dbp, Tef, Hlf, Per1, Per2 and Per3, and the nuclear receptor Rev-erbα) that control circadian rhythm – becomes excessive. Although reversible encephalopathy and gene silencing are severe events with potentially fatal consequences, they can be viewed as having survival advantages through lowering energy demand. In contrast, dyserythropoiesis, seizures, coagulopathy, hypoalbuminaemia and hypertriglyceridaemia may best be viewed as unfortunate consequences of extreme repression of these same genetic controls when the pro-inflammatory cytokines that cause sickness behaviour are produced excessively. As well as casting a new light on the previously unrationalized coexistence of these aspects of systemic inflammatory diseases, this concept is consistent with the case for a primary role for inflammatory cytokines in their pathogenesis across this range of diseases