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Background and Objectives: Residency programs are expected to meet many requirements in training their residents, including providing adequate numbers of pediatric visits and procedures opportunities. In the residency program studied here, these numbers were inadequate, despite the efforts of faculty members over the years. A self-designated faculty champion (with traits including vision, persuasiveness, proactivity, and tenacity) launched a series of clinical initiatives to combat these problems., Methods: The number of pediatric visits in the Family Medical Center (FMC) were tracked and compared from 2012, prior to the intervention led by the faculty champion, through 2023. The number of procedures performed in the FMC were tracked and compared from 2015, when the procedures-only clinic was launched by the faculty champion, through 2023., Results: The number of pediatric visits in the FMC in 2012-2013 was a total of 12. By 2022-2023, that number had grown to 1,454. The number of procedures in the FMC was four in 2015-2016, but by 2022-2023 had grown to 470. The improved numbers support competency-based medical education, with increased faculty observation, teaching, and evaluation. For procedures training, the improved numbers support faculty members in using the Procedural Competency Assessment Tools to evaluate resident performance., Conclusions: A faculty champion who is interested, self-motivated, persistent, and focused on leading the project from beginning to end can bring about significant improvements in a residency program, despite the program's track record of difficulty in making such improvements.

Introduction: One out of four parents reported HPV vaccine hesitancy; however, little is known about HPV vaccine-hesitant parents who vaccinate their children (e.g., hesitant adopters)., Method: We use individual interviews (n = 8) to explore hesitancy and facilitators for overcoming hesitancy among hesitant adopter parents. We drew a priori codes from the Increasing Vaccination Model domains and identified seven emergent secondary themes., Results: Understandable information about safety, side effects, and effectiveness could address HPV vaccine hesitancy. Health care professionals, family, friends, and coworkers were trusted vaccine and vaccination information sources. The study documents the lack of access to HPV vaccines with established health care providers as a barrier to vaccination., Discussion: This is the first study of hesitant adopter parents that expands our understanding of factors driving HPV vaccination among them. Study insights can inform future efforts to increase HPV vaccine uptake among the hesitant., Competing Interests: CONFLICTS OF INTEREST None to report., (Copyright © 2023 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Introduction: COVID-19 vaccination coverage among children remains low, and many parents report being hesitant to get their children vaccinated. This study explores factors influencing hesitancy and the facilitators that helped hesitant adopter parents choose to vaccinate their children against COVID-19 despite their hesitancy., Method: We use a qualitative descriptive design with individual interviews (n = 20) to explore COVID-19 vaccine hesitancy and facilitators of vaccination among hesitant adopter parents. The Increasing Vaccination Model domains (thoughts and feelings, social processes, and practical issues) provided the framework for initial coding, and the research team identified nine emergent themes., Results: Findings document the factors influencing hesitancy and the facilitators motivating COVID-19 vaccination among hesitant adopter parents., Discussion: Findings fill the gap in the literature by providing hesitant adopters' lived experience, perspectives on vaccine hesitancy, and the influential factors that helped participants overcome their hesitancy and choose to vaccinate their children against COVID-19., Competing Interests: CONFLICTS OF INTEREST None to report., (Copyright © 2024 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

COVID-19 vaccine coverage remains low for US children, especially among those living in rural areas and the Southern/Southeastern US. As of 12 September 2023, the CDC recommended bivalent booster doses for everyone 6 months and older. Emerging research has shown an individual may be vaccine hesitant and also choose to receive a vaccine for themselves or their child(ren); however, little is known regarding how hesitant adopters evaluate COVID-19 booster vaccinations. We used an exploratory qualitative descriptive study design and conducted individual interviews with COVID-19 vaccine-hesitant adopter parents (n = 20) to explore COVID-19 parental intentions to have children receive COVID-19 boosters. Three primary themes emerged during the analysis: risk, confidence, and intent, with risk assessments from COVID-19 and COVID-19 vaccine confidence often related to an individual parent's intent to vaccinate. We also found links among individuals with persistent concerns about the COVID-19 vaccine and low COVID-19 vaccine confidence with conditional and/or low/no intent and refusal to receive recommended boosters for children. Our findings suggest that healthcare providers and public health officials should continue making strong recommendations for vaccines, continue to address parental concerns, and provide strong evidence for vaccine safety and efficacy even among the vaccinated.

The coronavirus disease (COVID-19) was the third leading cause of death in 2021 in the United States and has led to historic declines in life expectancy for Americans. While vaccination is an effective mitigation strategy for COVID-19, vaccine hesitancy remains a major barrier to individual and population-level protection. An emerging literature on hesitant adopters of COVID-19 vaccines highlights co-occurrence of hesitancy and vaccine uptake as an understudied phenomenon, with the potential to provide insight into factors that lead hesitant individuals to become vaccinated despite their hesitancy. We use qualitative interviews among hesitant adopters in Arkansas to examine vaccine hesitancy among this understudied group. Drawing on the Increasing Vaccination Model, we find that the most frequently reported motivations of hesitant adopters were within the domain of social processes, pointing to a critical focal point for targeted health communications intervening in this domain (e.g. social norms, social networks, and altruistic behavior). We find that recommendations from health care workers (HCWs) other than physicians/providers may serve as an effective influence to vaccinate. We also demonstrate negative effects of low provider and HCW confidence and weak recommendations on motivations to vaccinate among individuals expressing vaccine hesitancy. Additionally, we find individual information-seeking behaviors among hesitant adopters bolstered confidence in the efficacy of the COVID-19 vaccine. Based on these findings, clear, accessible, and authoritative health communication has a role in combatting the COVID-19 misinformation/disinformation infodemic.

Background and objectives Medical residents may work from home for various reasons, including study electives, isolation due to exposure to illness, or during parental leave when they choose to work at home instead of taking extended time off. The University of Arkansas for Medical Sciences (UAMS) Little Rock Family Medicine residency program recognized the need for a tool that provided residents with a list of resources and approved activities for at-home work and a means of tracking their performance in those activities. Methods The administration team at the UAMS Little Rock Family Medicine residency program custom-designed a Daily Activities Log that served multiple purposes. Family medicine residents used it to choose what activities to participate in from a comprehensive list of activities and resources including virtual conferences, recorded didactics, modules, and other online materials. The program provided the framework on the log, while residents used it to document time spent on those activities. The log also gave the program a daily update on the resident's health, as one question specifically asked about well-being. Since it was built in an electronic survey format already owned by the residency program, it was completely customizable and available at no additional cost. Results In the two years covered by this project, residents logged a total of 593 hours of at-home work. In response to a survey, 76% of participating residents (N=14) rated the log as extremely or very easy to use; 64% indicated that it was a helpful resource; and 50% said that it simplified the reporting of their daily status. The residency program faculty found that having one source to track all off-site residents was an efficient means of monitoring their well-being and their work. Conclusions The Daily Activities Log is a versatile tool that provides comprehensive information, resources, and approved activities for residents, documents their work, and provides updates to residency management. It can be readily modified for use in other programs that have residents working at home., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Jarrett et al.)

Few studies have investigated the relationship between influenza vaccination and health care access. Furthermore, despite the well-documented disparities in vaccine coverage for communities of color, few studies have examined how experiences of discrimination may influence vaccine uptake. To fill this gap in the literature, this study examined associations between 5-year influenza vaccination rates and sociodemographic characteristics, health care access, and racial discrimination. Age, race/ethnicity, education, health care coverage, primary care provider, no medical care due to cost, and routine doctor checkups were significant correlates of 5-year influenza vaccination. In contrast to previous studies, discrimination scores were not a significant correlate of regular influenza vaccination. Respondents who reported forgoing care due to cost were less likely to report vaccination every year out of the last 5 years compared to all of the less frequent categories combined, demonstrating a more complex association between sometimes not being able to afford medical care and influenza vaccination. Future research should examine the relationship between influenza vaccination uptake, racial discrimination, and forgone care due to cost to enhance resources and messaging for influenza vaccination uptake.

Treatment of obstructive sleep apnea improves daytime sleepiness, but does it improve other outcomes?

Background and Objectives: Untreated maternal depression negatively impacts both the mother and her children's health and development. We sought to assess family medicine program directors' (PDs) knowledge and attitudes regarding maternal depression management as well as resident training and clinical experience with this disorder., Methods: Data were gathered through the Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) national survey of family medicine PDs in US and Canadian programs, from January through February, 2018., Results: Surveys were completed by 298 PDs (57.1% response rate) who were majority male (58.9%) and white (83.8%). Nearly all (90.2%) PDs agreed that family physicians should lead efforts to minimize the impact of maternal depression on child well-being. According to PD report, in the family medicine clinics where residents train, most (77.3%) have a clinic process that ensures that routine screening for depression occurs, and 54.4% do some screening of mothers during pediatric visits. Only 18.2% report routinely taking steps to minimize the impact of the mothers' depression on child well-being. Finally, 41.3% of PDs reported being familiar with the literature on the impact of maternal depression on children; self-reported familiarity was significantly associated with more comprehensive resident training on this topic., Conclusions: Family medicine residency program directors are supportive of training in maternal depression, though their current knowledge is variable and there are opportunities to enhance care of mothers and children impacted by this common and serious disorder.

Excessive television (TV) viewing by children can lead to negative health and developmental outcomes. Using structural equation modeling, this study tests a conceptual model to understand social and familial factors associated with TV exposure among a sample of 767 Head Start families with children between the ages of 3 and 5 years. Fit statistics suggested that the overall model provided an acceptable fit to the observed data. Specifically, significant structural paths suggest that parents' social support affects child TV exposure. Additionally, lower levels of social support were associated with significantly greater parental stress, which also predicted child TV exposure. Findings suggest that physicians and other team members of the patient-centered medical home may benefit from broad-based interventions that address familial factors to combat excess TV exposure among children. Urging parents to turn off the TV could fail to address the underlying causes of child TV exposure.

Introduction: Adverse childhood experiences (ACEs) have lifetime consequences for health and development. This study examined whether there is evidence to support a screening approach that assesses children's current exposures to risks that act as proxies for ACEs, measured in a way that falls below a threshold of explicit abuse, neglect, or illegal behavior., Method: We used data collected during routine home visitations of at-risk children aged 0-5. Home visitors used the Family Map Inventories (FMI; Whiteside-Mansell et al., 2007) to screen ACEs and measure health outcomes, and the Ages and Stages Questionnaire (3rd ed.; ASQ-3; Squires, Twombly, Bricker, & Potter, 2009) to screen child development. Parents (N = 2,004) were 28 years of age on average and most were White (60%). Children were 32 months of age on average and equally divided on gender (51% male)., Results: Children were exposed at rates of 27%, 17%, 11%, and 11% to 1, 2, 3, and 4 or more FMI-ACEs, respectively. Logistic regressions revealed significant associations between FMI-ACE scores and health environments and outcomes for children, including health risks in the home (e.g., safety and secondhand smoke exposure), underuse of preventive health care, and overuse of emergency medical treatment. In terms of development, having four or more FMI-ACEs was associated with the child having a chronic health condition and screening at risk for delay in at least one area of development., Discussion: Findings highlight the potential use of questionnaires and in-home observations to measure and intervene in potentially developing ACEs. Further, our screening was associated with children whose health was at risk very early in development. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Type 2 diabetes mellitus (T2DM) is a global pandemic, as evident from the global cartographic picture of diabetes by the International Diabetes Federation (http://www.diabetesatlas.org/). Diabetes mellitus is a chronic, progressive, incompletely understood metabolic condition chiefly characterized by hyperglycemia. Impaired insulin secretion, resistance to tissue actions of insulin, or a combination of both are thought to be the commonest reasons contributing to the pathophysiology of T2DM, a spectrum of disease originally arising from tissue insulin resistance and gradually progressing to a state characterized by complete loss of secretory activity of the beta cells of the pancreas. T2DM is a major contributor to the very large rise in the rate of non-communicable diseases affecting developed as well as developing nations. In this mini review, we endeavor to outline the current management principles, including the spectrum of medications that are currently used for pharmacologic management, for lowering the elevated blood glucose in T2DM.

Objective: To describe a patient who developed acute interstitial nephritis, hepatitis and serum sickness-like syndrome after receiving piperacillin-tazobactam (zosyn) therapy., Case Summary: A 30-year-old woman received a 7-day course of piperacillin-tazobactam as empiric treatment for pneumonia. The patient's kidney function worsened and she turned anuric needing dialysis. She also developed fever and a rash. Laboratory analysis showed elevated liver function and leukocytosis. Kidney biopsy showed acute interstitial nephritis. The patient responded well to steroids; white blood cell count normalized and her liver and kidney function improved over a period of one month., Discussion: Piperacillin-tazobactam is one of the most commonly used antibiotics in the hospital setting. It has rarely been associated with acute interstitial nephritis, hepatic injury, or serum sickness-like reactions. Steroids have improved the outcome in most of the cases of interstitial nephritis., Conclusion: Clinicians should be aware of piperacillin-tazobactam as a drug capable of causing interstitial nephritis, hepatitis and serum sickness-like syndrome. It is essential that we monitor for these rare but severe complications.

Objectives: Examine the association between mothers' low- and high-level depressive symptoms in early childhood and children's behavior problems in middle childhood., Methods: We used data from 1844 families in a multi-site, longitudinal study beginning when children were 14 months and continuing to age 11 years. Children's internalizing and externalizing behavior problems at age 11 were assessed using the child behavior checklist for ages 6-18. Mothers' scores on the Center for Epidemiological Studies-Depression Scale when children were 14 months were used to classify them into three groups: 'no depressive symptoms', 'low-level depressive symptoms (below the clinical cut-off)' and 'clinically significant depressive symptoms (above the clinical cut-off).', Results: Mothers were racially/ethnically diverse, including Caucasian (38.9 %), African-American (34.4 %), Hispanic (21.6 %), or other (5.1 %). More than one-third (39.2 %) were teenaged mothers, and 46.0 % did not complete high school. Of the 1844 families, 1172 had age 11 child outcome data. Logistic regression analyses controlling for family demographics revealed a significant association between early maternal depressive symptoms and later child behavioral outcomes. Both low level and clinically significant symptoms were associated with internalizing and externalizing behavior problems. For example, children whose mothers had low-level depressive symptoms were twice as likely to have clinically elevated internalizing problems compared with children whose mothers never had symptoms of depression., Conclusions: Children whose mothers experience low-level depressive symptoms early in their development have increased risk for later behavioral problems, suggesting a possible need for new screening and intervention strategies for mothers with lower than clinically elevated symptoms.

Objective: To describe a patient with Budd-Chiari syndrome (BCS) found to have multiple hypercoagulopathies., Case Summary: A 33-year-old man who presented with abdominal distension, hematemesis, shortness of breath was found to have liver cirrhosis, portal hypertension and Budd-Chiari Syndrome. He was evaluated for hypercoagulability and was found to be heterozygous for Factor V Leiden mutation and his protein C level was 38% of normal. He was started on oral anticoagulation and underwent elective liver transplantation within 3 months of diagnosis., Discussion: In patients with Budd-Chiari syndrome, factor V Leiden is the second most commonly identified prothrombotic state after primary myeloproliferative disorders. There may be a coexistence of several thrombophilic states in patients with Budd-Chiari Syndrome., Conclusions: Budd-Chiari syndrome is an uncommon disorder. Outcome is poor in many cases. Therefore, a successful diagnostic and therapeutic approach is of vital importance. A complete thrombophilia screening needs to be requested in all patients diagnosed with Budd-Chiari syndrome. Thorough investigation needs to be performed to identify an underlying process contributing to the hepatic venous outflow obstruction.

Objective: The objective of this study was to examine the relationship between low-level depressive symptoms in mothers and their support for child cognitive development., Methods: Participants included 913 low-income mothers of preschool-age children who were screened for maternal depression and interviewed about support for learning in the child's home environment., Results: Of the 770 mothers in the analysis, 21.5% reported low-level depressive symptoms (below the cutoff on the screening tool indicating clinically elevated symptoms). Logistic regression analyses revealed that children of mothers with low-level depressive symptoms were significantly less likely to experience six of seven types of support for learning compared with children of mothers with no depressive symptoms., Conclusions: Results suggest that children whose mothers experience even low-level depressive symptoms are less likely to receive important supports for cognitive development and school readiness, pointing to the need for screening and interventions to address maternal depression at all levels of severity., (Copyright © 2014 National Association of Pediatric Nurse Practitioners. Published by Mosby, Inc. All rights reserved.)

Objective: To describe a patient who developed pancytopenia and lactic acidosis after receiving linezolid therapy., Case Summary: A 32-year-old man with past medical history of heart failure, hypertension received a 14-day course of linezolid for treatment of empyema with broncho-pleural fistula. During his follow up visit, he was found to be septic and further evaluation showed pancytopenia, acidosis and elevated liver enzymes. With the exclusion of other possible etiologies, the time course to development of these laboratory abnormalities correlated with the use of linezolid. Antibiotics were switched subsequently and the labs improved after reaching a nadir on the fourth day after stopping linezolid., Discussion: Linezolid was noted to cause time and dose-dependent reversible myelosuppression in preclinical studies. There are several case reports of throinbocytopenia occurring with linezolid use, but only few cases of pancytopenia and lactic acidosis are reported. Exact mechanism of toxicity is unknown, but many hypothesize it to be similar to chloramphenicol marrow toxicity because of the cross-reactivity to mitochondrial ribosomes., Conclusions: Clinicians should be aware of linezolid as a drug capable of causing pancytopenia, lactic acidosis and elevated liver enzymes. While recovery is usually complete following withdrawal of the drug, we need to still monitor for these rare but severe complications; and consider treating only for a shorter duration, if possible.

We explore the associations between exposure to conflict and crime in the home and community, and child anxiety and self-control problems among 60 children whose mothers were in treatment for substance abuse problems. Experiences with violence and crime were widespread, with many children exposed to multiple incidents. Approximately one-third (35.5%) of children exhibited clinically elevated anxiety. Controlling for other potential predictors, both children's exposure to violence and the number of years the mother had been using substances predicted higher anxiety in children, while only exposure to violence predicted problems in self-control. Results highlight the importance of screening for violence exposure., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: Our objective was to examine the relationship between low- and high-level depressive symptoms in mothers' and children's risks in the areas of home and car safety, monitoring, and exposure to violence., Methods: Participants included 978 mothers of preschool-age children who were interviewed about their home environment and screened for maternal depression., Results: Whereas only 5.7% scored at high depressive levels on the screen, another 21.3% scored at low depressive levels. Logistic regression analyses controlling for demographics revealed that children were significantly more likely to experience home safety risks in 6 of 7 areas when mothers reported either low or high levels of depressive symptoms., Conclusions: Results suggest that children whose mothers experience even low-level depressive symptoms are at increased risk for safety problems in the home environment, pointing to the need for screening and interventions to reduce the risk of injury.