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Background: The clinical features of Multisystem Inflammatory Syndrome in Children (MIS-C) have been well documented, but there is limited data regarding the short term and longitudinal outcomes of children living in rural areas. We report the demographic and clinical features, as well as the multi-specialty follow-up of patients with MIS-C served by a large tertiary care rural health system. Methods: Patients that met the Centers for Disease Control (CDC) case definition of MIS-C admitted between March 1, 2020, and March 31, 2021, were included in this case series. Manual chart review was used to report demographic characteristics, clinical, laboratory and radiologic features during acute hospitalization and multispecialty follow-up, and adherence to follow-up 6–10 weeks after hospital discharge. Results: Twenty-one patients with MIS-C were admitted at our center during the review period. Ninety percent of the cohort required intensive care during hospitalization. Of 19 patients with measured ejection fractions, 52 % had some degree of left ventricular dysfunction on admission; nine patients had electrocardiogram changes on admission. The majority of patients had elevated inflammatory markers during hospitalization. Most patients had resolution of symptoms, improvement in inflammatory markers, and normal cardiac function at the time of discharge. Follow-up with pediatric cardiology, hematology-oncology and infectious disease was indicated for most patients at discharge. Of these, 100 % of patients kept initial follow-up appointments with pediatric cardiology and infectious disease, while 94 % kept initial follow-up appointments with pediatric hematology-oncology. Conclusion: Though most patients were critically ill during hospitalization, the majority had resolution of cardiac abnormalities and inflammatory markers at discharge and timely follow-up with multiple subspecialists after admission with MIS-C.

Introduction: The objective of this study is to evaluate severe maternal morbidity (SMM) of rural parturients delivering at rural compared to urban hospitals in the US. Methods: We identified patients aged 18-40 years in a multi-institutional claims database who lived in a rural ZIP code and delivered at a rural or urban hospital between October-December of 2015 and October-December of 2022. The primary outcome was SMM, and the secondary outcome was SMM exclusive of blood transfusions. We combined exact ZIP code matching and propensity score matching to compare SMM risk among patients living in the same rural community and delivering in urban as compared to rural hospitals. Results: A total of 214 296 patients from 571 ZIP codes were identified, including 47% delivering at rural facilities and 53% delivering at urban facilities. The SMM rate was 1.1% (0.3% excluding blood transfusions). After matching, urban versus rural delivery was associated with increased odds of SMM other than blood transfusion (odds ratio 2.44; 95% confidence interval 1.81-3.28), but was not associated with differences in risk of any SMM. Conclusion: There was no evidence of reduced SMM for rural patients delivering at an urban rather than a rural hospital. SMM exclusive of blood transfusions was increased for rural patients delivering at urban hospitals after matching on ZIP code and predictors of urban hospital delivery. Our findings undermine the assumption that delivery at a rural facility has inherently greater risks relative to delivery at an urban facility. As some health systems face challenges to maintain rural labor and delivery units, patient safety must be considered if confronted with the possibility of unit or hospital closures.

Objectives The study aims to assess the impacts of a sports medicine (SM) track on musculoskeletal (MSK) knowledge of family medicine (FM) residents. In-training examination (ITE) results were used to compare the MSK knowledge of FM residents with and without SM track participation. Methods A single-center, retrospective study was completed on 85 FM residents from the 2018 to 2024 graduating classes who completed the ITE from 2017 to 2021. Residents were categorized by participation in the SM track, where half a day of FM continuity clinic per week is replaced with an SM clinic, supervised by a fellowship-trained SM physician. ITE scores throughout training were compared between the 2 groups using mixed-effects regression. Results The ITE MSK scores increased among both SM track participants (+77 points/year, p = .001) and nonparticipants (+39 points/year, p = .001) throughout their training. By postgraduate year 3, SM track participants performed significantly better on the MSK portion of the ITE (+87 points compared to non-participants, p = .045). No significant difference in total ITE scores was seen between groups. Conclusions Our data demonstrates that participation in an SM track is associated with an increase in MSK knowledge of ITE, suggesting that an SM track may provide FM residents with a better understanding of MSK conditions.

Background. In regional anesthesia, the efficacy of novel blocks is typically evaluated using randomized controlled trials (RCTs), the findings of which are aggregated in systematic reviews and meta-analyses. Systematic review authors frequently point out the small sample size of RCTs as limiting conclusions from this literature. We sought to determine via statistical simulation if small sample size could be an expected property of RCTs focusing on novel blocks with typical effect sizes. Methods. We simulated the conduct of a series of RCTs comparing a novel block versus placebo on a single continuous outcome measure. Simulation analysis inputs were obtained from a systematic bibliographic search of meta-analyses. Primary outcomes were the predicted number of large trials (empirically defined as N ≥ 256) and total patient enrollment. Results. Simulation analysis predicted that a novel block would be tested in 16 RCTs enrolling a median of 970 patients (interquartile range (IQR) across 1000 simulations: 806, 1269), with no large trials. Among possible modifications to trial design, decreasing the statistical significance threshold from p

Introduction Delays in acute treatment of ischemic stroke have been associated with worse outcomes [1]. Women are more likely to present with atypical stroke symptoms than men, causing delay in pre‐hospital diagnosis and seeking medical attention [2‐3]. Additionally, women tend to be older at stroke onset and more likely to be living alone [4‐5]. Among patients presenting with acute stroke, women experience longer emergency department (ED) door‐to‐doctor and door‐to‐imaging (DIT) times, resulting in fewer interventions [6]. It is unclear if gender disparities in the timeliness of ED arrival and stroke assessment are compounded by gender differences in timeliness of treatment after patient arrival in the ED. Therefore, we sought to identify, if gender and marital status were associated with faster door‐to‐needle (DTN) and door‐to‐puncture (DTP) times. We hypothesized that married men would have the fastest DTN and DTP times, associated with female spouses being quicker to recognize traditional signs of stroke, calling 911 who can activate stroke alert, and therefore avoiding delay in acute care. Methods Our single‐center stroke database was queried for adults presenting to the ED with acute stroke between 1/1/2018‐1/30/2023. Patients were excluded if they had missing data on marital status or covariates. DTN and DTP times, as well as National Institutes of Health Stroke Scale (NIHSS) at discharge, were analyzed using quantile regression on sex, marital status (dichotomized as married vs. single), age, intervention (TPA alone, or thrombectomy±TPA), and NIHSS score at presentation. Results We identified 674 patients meeting inclusion criteria, of whom 31 were excluded due to missing data. In the remaining sample (N=643, median age 66yr), 25%/18% of patients were married men/women, respectively, and 22%/35% were single men/women. Median DTN time, DTP time, and discharge NIHSS were 36min, 79min, and 4, respectively. On multivariable analysis (Table), none of the outcomes were improved among married men relative to any other combination of sex and marital status. Conclusion Gender differences in knowledge of warning signs of stroke in community‐based studies and gender disparities in ED assessment did not translate into faster treatment “after” ED arrival based on gender or marital status. More work is needed to find out ways to accelerate care “after” ED arrival to have faster DTN and DTP time.

The onset of the coronavirus disease 2019 (COVID-19) pandemic had far-reaching economic and social consequences, affecting economic well-being, health, mobility, relationships, and daily routines. What effect did the COVID-19 pandemic have on neighborhood social cohesion? Drawing on data from the National Survey of Children’s Health, the authors examine trends in neighborhood social cohesion as reported by caregivers of U.S. children from 2016 to 2021. Despite the substantial changes spurred by the COVID-19 pandemic, the authors find that the pandemic did not lead to a significant change in perceived neighborhood social cohesion. These findings reveal the durability of perceived neighborhood social cohesion, showing that it appears to be unaffected even by sizable changes in social and economic contexts. Moreover, the findings provide additional evidence of disparities in perceived neighborhood social cohesion across social groups and contribute to ongoing debates related to potential declines in neighborhood relationships.

Following the 2016 US Presidential election, immigration enforcement became more aggressive, with variation by state and region depending on local policies and sentiment. Increases in enforcement created an environment of risk for decreased use of health care services among especially among Latino families. of Hispanic ethnicity and/or from Latin American origin (as a group subsequently referred to as Latino). For Latino children with chronic health conditions, avoidance of routine health care can result in significant negative health consequences such as disease progression, avoidable use of acute health care services, and overall increased costs of care. To investigate for changes in visit attendance during the periods before and since increased immigration enforcement, we extracted data on children followed by subspecialty clinics of one healthcare system in the US state of North Carolina during 2015–2019. For each patient, we calculated the proportion of cancelled visits and no-show visits out of all scheduled visits during the 2016–2019 follow-up period. We compared patient characteristics (at the 2015 baseline) according to whether they cancelled or did not show to any visits in subsequent years by clinic and patient factors, including ethnicity. Data were analyzed using multinomial logistic regression of attendance at each visit, including an interaction between visit year and patient ethnicity. Among 852 children 1 to 17 years of age (111 of Latino ethnicity), visit no-show was more common among Latino patients, compared to non-Latino White patients; while visit cancellation was more common among non-Latino White patients, compared to Latino patients. There was no significant interaction between ethnicity and trends in visit no-show or cancellation. Although differences in pediatric specialty clinic visit attendance by patient ethnicity were seen at study baseline, changing immigration policy and negative rhetoric did not appear to impact use of pediatric subspecialty care.

Background: The use of cuffed endotracheal tubes (ETT) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. Methods: In this retrospective study, the ETT cuff position was examined on the sagittal plane images of neck and chest CT scans of 44 children. The position of the proximal and the distal aspect of the ETT cuff inside the trachea was recorded in relation to the vertebral levels. The vertebral levels were used to estimate the location of the cricoid ring and its relationship to the cuff. Results: The vertebrae were used as the primary landmarks to define the position of the cricoid and its relationship to the cuff of the ETT. Correlating vertebral levels with the cricoid for different age groups, the proximal (cephalad) edge of the ETT cuff was below the cricoid in 41 of 44 patients (93%). The ETT cuff was deep in 6 patients, below the 1st thoracic vertebra, with 2 ETTs in the right mainstem bronchus. Conclusion: This is the first study demonstrating that the cuff of the ETT and its position in the trachea can be identified on CT imaging in children. The ETT cuff was below the level of the cricoid in the majority of patients irrespective of the patient's age as well as the size, make, and type of ETT.

Abstract Background Increasing the number of primary care physicians is critical to overcoming the shortage of healthcare providers. Primary care physicians are increasingly called upon to address not only medical concerns but also behavioral health needs and social determinants of health which requires ongoing research and innovation. This paper evaluated scholarly productivity of faculty in tenure versus non-tenure tracks in primary care roles, defined as family medicine, internal medicine, internal medicine/pediatrics and pediatrics. Methods The study included physician faculty in the clinical departments of Brody School of Medicine serving between the 2014–2015 and 2018–2019 academic years. Department, track, and rank at the beginning of each academic year (e.g., 2014–2015) were correlated with having any publications in the following calendar year (e.g., 2015), as determined from a search of the Scopus database. Results A total of 1620 observations and 542 unique faculty were included in the analysis. As of 2018–2019, 19% percent of primary care faculty were either tenured or on tenure track, as compared to 41% of faculty in other departments (p

Background: Unsecured debt — debt not tied to an asset — is a financial stressor that undermines health, but prior research has not investigated relationships between group-based trajectories of unsecured debt and pain and disability at midlife. Methods: US respondents of the National Longitudinal Study of Youth-1979 cohort reported unsecured debt and income between ages 28–40. We used these measures to identify group-based trajectories of unsecured debt and unsecured debt-to-income ratio. We then used trajectory membership to predict three pain and disability-related health outcomes at age 50, adjusting for lagged health and other covariates. Results: Group-based trajectory models divided the sample of 7850 respondents into 6 unsecured debt trajectories and 5 unsecured debt-to-income trajectories. In fully adjusted unsecured debt models, compared to people with constant low debt, those who paid down debt over time, carried constant debt, experienced debt cycling, or accumulated debt later in life were more likely to report pain interference with activities or joint pain or stiffness at age 50 (pain interference ORs ranging from 1.33 to 1.76; joint pain or stiffness ORs ranging from 1.27 to 1.45). In fully adjusted unsecured debt-to-income models, compared to those with constant low debt, those with constant high debt or accumulating debt later in life were more likely to report pain interference or joint pain or stiffness (pain interference ORs ranging from 1.30 to 1.91; joint pain or stiffness ORs ranging from 1.19 to 1.33). Conclusion: The amount, timing, and duration of unsecured debt accumulation and repayment have important health implications and may exacerbate midlife health inequalities.

Background and Aims: Sugammadex is a novel agent for reversal of steroidal neuromuscular blocking agents (NMBAs) with potential advantages over acetylcholinesterase inhibitors. In preclinical trials, there have been rare instances of bradycardia with progression to cardiac arrest. To better define this issue, its incidence and mitigating factors, we prospectively evaluated the incidence of bradycardia after sugammadex administration in adults. Material and Methods: Patients ≥ 18 years of age who received sugammadex were included in this prospective, open label trial. After administration, heart rate (HR) was continuously monitored. HR was recorded every minute for 15 minutes and then every five minutes for the next 15 minutes or until patient was transferred out of the operating room. Bradycardia was defined as HR less than 60 beats/minute (bpm) or decrease in HR by ≥ 10 beats per minute (bpm) if the baseline HR was

Background: Several studies have attempted to estimate the approximate distance from the skin-to-epidural space using different imaging modalities (computed tomography [CT], ultrasound, and magnetic resonance imaging [MRI]) and direct needle measurements. The objective of our study was to compare the distance from the skin to the epidural space (SED) at multiple levels, focusing on T6-7, T9-10, and L2-3using MRI. Methods: After institutional review board (IRB) approval, sagittal T2-weighted MRI images of the spine of 108 children in the age group ranging from 3 months to 8 years undergoing radiological evaluation in the supine position at our institution were analyzed. The SED at T6-7and T9-10levels (straight and inclined) and SED at L2-3 (straight) were determined and compared using repeated-measures ANOVA and paired t-tests with a Bonferroni correction for 10 pairwise comparisons (P < 0.005 was considered statistically significant). Results: The average SED (measured straight and inclined) was 18.2 mm and 21.6 mm at T6-7; 18.3 mm and 20.5 mm at T9-10; and 21.8 mm (straight) at L2-3. The repeated-measures ANOVA F-test indicated significant variability in SED (P < 0.001) among the 5 measurements obtained. At the P < 0.005 significance level, corrected for multiple comparisons, the SED (straight) at T9-10 straight was shorter than the other measured distances. Conclusion: The distance from the skin to the epidural space is not constant at various vertebral levels. At the levels measured, it was greatest at the lumbar level and at least at the thoracic level of T9-10. A single predictive formula was not applicable for calculating the approximate SED at all vertebral levels.

Increasing enrollment of students who are underrepresented in medicine has been a priority of United States (US) medical schools. The authors sought to compare how increasing minority student representation factors into mission statements, statements of values, and strategic action plans at top research-oriented US medical schools and US medical schools with a social mission. A Web search was performed to locate three documents for each medical school: the mission statement; a statement of values; and a strategic plan. Data were retrieved on the number of underrepresented minority graduates and total graduates from each school in the graduating classes of 2015-2019. The number and percentage of graduates during this period were compared according to schools' mission statements using rank-sum tests. Other quantitative study data were compared by school mission using Fisher's exact tests. Five of the schools with a social mission (25%) and none of the schools with a research mission had a mission statement that addressed increasing representation of underrepresented minority students in the medical school (p = 0.047). Schools with a mission statement that addressed this group had a higher proportion of those graduates during 2015-2019 (median 66%; IQR 28%, 68%) compared to schools that did not address this in their mission statement (median 10%; IQR 6%, 13%; p = 0.003). More research is needed to explore the association between US medical school mission statements and the representation of underrepresented students in medical education, especially at research-oriented medical schools.

AbstractObjectiveWe implemented a parent–teacher Vanderbilt agreement program to increase return rates of Vanderbilt assessment scales for children in our primary care practice, and compared the assessment return rate before and after agreement signature.MethodsWe retrospectively reviewed children diagnosed with attention-deficit/hyperactivity disorder (ADHD) who had a signed Vanderbilt agreement and were under continuous care at our clinic. Return rates were compared 1 year before and 1 year after the agreement date.ResultsAmong 195 children, prior to the agreement, 71% returned teacher assessments, and 59% returned parent forms; after the intervention, assessment rates were not significantly different (76%, p = .255; and 65%, p = .185, respectively). The median number of returned assessments increased after the agreement.ConclusionsLack of documented parent and teacher Vanderbilt assessments remain a barrier to appropriate management of ADHD. Improving the rate of assessments returned is an important outcome for treating ADHD in the primary care setting.

Introduction: Primary care physicians serve on the front lines of care and provide comprehensive care to patients who may have difficulty accessing subspecialists. However, not enough students are entering residency in primary care fields to meet the primary care physician shortage. The authors sought to compare primary care match rates among graduates of medical schools in the state of North Carolina from 2014 to 2018. Methods: The 4 allopathic medical schools in the state of North Carolina were selected for this study: East Carolina University (ECU) Brody School of Medicine, University of North Carolina (UNC) Chapel Hill, Duke School of Medicine, and Wake Forest School of Medicine. Primary care specialties were defined as family medicine, internal medicine, pediatrics, and internal medicine/pediatrics. The proportion of students matching to a residency in any of these fields, and in each specific field, was compared across schools. Results: Over 2014-2018, 214 ECU Brody School of Medicine graduates, 386 UNC graduates, 165 Duke graduates, and 196 Wake Forest graduates matched to a primary care specialty. ECU had the highest proportion of its graduates match in a primary care specialty (53%, compared with 34% to 45% at other schools; P < .001), and was particularly distinguished by having the highest proportions of graduates match to residencies in family medicine (18%) and pediatrics (16%). Conclusion: During the study period of 2014-2018, the ECU Brody School of Medicine matched more medical students into primary care specialties than the other medical schools in the state. This school’s community-driven mission and rural location, among other characteristics facilitating sustained student commitment to primary care careers, can inform the development of new medical schools in the United States to overcome the primary care physician shortage.

The peer review process provides a foundation for the credibility of scientific findings in medicine. The following article discusses the history of peer review in scientific and medical journals, the process for the selection of peer reviewers, and how journal editors arrive at a decision on submitted manuscripts. To aid authors who are invited to revise their manuscripts for further consideration, we outline steps for considering reviewer comments and provide suggestions for organizing the author's response to reviewers. We also examine ethical issues in peer review and provide recommendations for authors interested in becoming peer reviewers themselves.

Purpose: Income inequality has been implicated as a potential risk to population health due to lower provision of healthcare services in deeply unequal countries or communities. We tested whether county economic inequality was associated with individual self-report of unmet healthcare needs using a state health survey data set. Methods: Adults residents of Ohio responding to the 2015 Ohio Medicaid Assessment Survey were included in the analysis. Ohio's 88 counties were classified into quartiles according to the Gini coefficient of income inequality. The primary outcome was a composite of self-reported unmet dental care, vision care, mental healthcare, prescription medication, or other healthcare needs within the past year. Unmet healthcare needs were compared according to county inequality quartile using weighted logistic regression. Results: The analytic sample included 37,140 adults. The weighted proportion of adults with unmet healthcare needs was 28%. In multivariable logistic regression, residents of counties in the highest (odds ratio [OR]=1.13, 95% confidence interval [CI]: 1.01?1.26; p=0.030) and second-highest (OR=1.16, 95% CI: 1.04?1.30; p=0.010) quartiles of income inequality experienced more unmet healthcare needs than residents of the most equal counties. Conclusion: Higher county-level income inequality was associated with individual unmet healthcare needs in a large state survey. This finding represents novel evidence for an individual-level association that may explain aggregate-level associations between community economic inequality and population health outcomes.

Introduction: Although the Nuss procedure provides excellent cosmetic results for the correction of pectus excavatum, the provision of analgesia following such procedures can be challenging. Methods: The current study retrospectively reviews our experience over a 2.5 year period with thoracic epidural analgesia (TE), paravertebral blockade (PVB), and intravenous opioids delivered via patient-controlled analgesia (PCA) to provide postoperative analgesia. Results: The study cohort included 30 patients (mean age = 15.6 ± 1.5 years), 15 of whom were treated with PCA, 8 with TE, and 7 with PVB. There were no significant differences in pain scores between the 3 groups at any time point during the first 3 postoperative days. Compared to PCA, the PVB group had lower opioid consumption over the first 24 hours of hospitalization by 1.7 mg/kg morphine equivalents (95% CI of difference: 0.1, 3.3; p=0.035); but had higher opioid consumption by 2.0 mg/kg morphine equivalents than the TE group (95% CI of difference: 0.3, 3.7; p=0.024). There were no differences in opioid consumption between PVB and PCA or between PVB and TE at 48 or 72 hours. The number of intraoperative hypotension episodes was significantly lower in the PCA group when compared to the PVB group (p=0.001), with no difference between the PVB and TE groups. Conclusions: The use of regional anesthesia should be considered a viable option for the relief of postoperative pain in pediatric patients following the Nuss procedure albeit with a higher incidence of intraoperative hemodynamic effects. A randomized, prospective, study powered to compare all 3 techniques against one another would be necessary to confirm the significance of these findings.

There is a paucity of literature examining recipient-donor obesity matching on liver transplantation outcomes. The United Network for Organ Sharing database was queried for first-time recipients of liver transplant whose age was ≥18 between January 2003 and September 2013. Outcomes including patient and graft survival at 30 days, 1 year, and 5 years and overall, liver retransplantation, and length of stay were compared between nonobese recipients receiving a graft from nonobese donors and obese recipient-obese donor, obese recipient-nonobese donor, and nonobese recipient-obese donor pairs. 51,556 LT recipients were identified, including 34,217 (66%) nonobese and 17,339 (34%) obese recipients. The proportions of patients receiving an allograft from an obese donor were 24% and 29%, respectively, among nonobese and obese recipients. Graft loss (HR: 1.27; 95% CI: 1.09–1.46; p=0.002) and mortality (HR: 1.38; 95% CI: 1.16–1.65; p

Background: Field of study may influence the timing of transitions to the labor market, marriage, and parenthood among college graduates. Research to date has yet to study how field of study is associated with the interweaving of these transitions in the USA. Objective: The current study examines gendered influences of college field of study on transitions to a series of adult roles, including full-time work, marriage, and parenthood. Methods: We use Cox proportional hazards models and multinomial logistic regression to examine gendered associations between field of study and the three transitions among college graduates of the NLSY97 (National Longitudinal Survey of Youth) cohort. Results: Men majoring in STEM achieve early transitions to full-time work, marriage, and parenthood; women majoring in STEM show no significant advantage in finding full-time work and delayed marriage and childbearing; women in business have earlier transitions to full-time work and marriage than women in other fields, demonstrating an advantage similar to that of men in STEM. Conclusions: The contrast between men and women in STEM shows that transition to adulthood remains gendered; the contrast between women in STEM and women in business illustrates that a prestigious career may not necessarily delay family formation. Contribution: The paper shows how stratification by field of study creates gendered demographic outcomes for college graduates. It also demonstrates that women's decisions regarding marriage and parenthood do not uniformly respond to the economic prospect of their work.