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Medico-legal complaints against physicians are a significant source of anxiety and could be associated with defensive medical practices that may correlate with poor patient outcomes. Little is known about patient concerns brought to regulatory bodies and courts against dermatologists in Canada.To characterize factors contributing to medico-legal complaints brought against dermatologists in Canada.The Canadian Medical Protective Association (CMPA) repository was queried for all closed cases involving dermatologists over the past decade. Aggregate, anonymized data was reviewed and case outcomes, patient harm, and contributing factors were extracted.Nearly one-fifth of all dermatologists who are CMPA members have been named in at least one medico-legal case between 2013 to 2022. A total of 396 civil-legal actions or College complaint cases involving dermatologists were closed at the CMPA during this timeframe. The most common patient allegations were deficient assessment (34%), diagnostic error (28%), and unprofessional manner (22%). Nearly half of patients experienced a harmful event, the majority of which were asymptomatic or mild. The most frequently identified contributing factors related to providers were poor clinical decision making (n = 73), lack of situational awareness (n = 67), and conduct and boundary issues (n = 59). Team factors included a breakdown of communication with patients (n = 124).Improved communication with patients for informed consent, treatment plans, clinical follow-up, and documentation of thorough clinical patient assessments can improve patient satisfaction and health outcomes, and mitigate dermatologists’ medico-legal risk. [ABSTRACT FROM AUTHOR]

Abstract Background Shoulder muscle fatigue has been proposed as a possible link to explain the association between repetitive arm use and the development of rotator cuff disorders. To our knowledge, no standardized clinical endurance protocol has been developed to evaluate the effects of muscle fatigue on shoulder function. Such a test could improve clinical examination of individuals with shoulder disorders. Therefore, the purpose of this study was to establish a reliable protocol for objective assessment of shoulder muscle endurance. Methods An endurance protocol was developed on a stationary dynamometer (Biodex System 3). The endurance protocol was performed in isotonic mode with the resistance set at 50% of each subject's peak torque as measured for shoulder external (ER) and internal rotation (IR). Each subject performed 60 continuous repetitions of IR/ER rotation. The endurance protocol was performed by 36 healthy individuals on two separate occasions at least two days apart. Maximal isometric shoulder strength tests were performed before and after the fatigue protocol to evaluate the effects of the endurance protocol and its reliability. Paired t-tests were used to evaluate the reduction in shoulder strength due to the protocol, while intraclass correlation coefficients (ICC) and minimal detectable change (MDC) were used to evaluate its reliability. Results Maximal isometric strength was significantly decreased after the endurance protocol (P < 0.001). The total work performed during the last third of the protocol was significantly less than the first third of the protocol (P < 0.05). The test-retest reliability of the post-fatigue strength measures was excellent (ICC >0.84). Conclusions Changes in muscular performance observed during and after the muscular endurance protocol suggests that the protocol did result in muscular fatigue. Furthermore, this study established that the resultant effects of fatigue of the proposed isotonic protocol were reproducible over time. The protocol was performed without difficulty by all volunteers and took less than 10 minutes to perform, suggesting that it might be feasible for clinical practice. This protocol could be used to induce local muscular fatigue in order to evaluate the effects of fatigue on shoulder kinematics or to evaluate changes in shoulder muscle endurance following rehabilitation.

Background: Rituximab is associated with high infection rates, but studies of infections following rituximab in youth with childhood-onset SLE (cSLE) are limited. We conducted a retrospective longitudinal cohort study to assess the incidence of hospitalised infections following rituximab among children with cSLE and to assess changes in hospital-based rituximab administration over time., Methods: Youth ages 2-21 years with an International Classification of Diseases (ICD) code for SLE who received rituximab during admission to a Pediatric Health Information System hospital from 2009 to 2021 were included. Incidence rates for infections requiring hospitalisation over the 12 months following first rituximab administration were calculated. Rituximab use by year of hospital discharge was tabulated., Results: We identified 1567 children with cSLE who received rituximab. 219 children were admitted with an infection within 1 year after first rituximab administration, for an incidence rate of 140 cases per 1000 patient-years. Seven children (0.44%) died during a hospitalisation with an infection in the year following rituximab administration. The most common hospitalised infections were bacterial pneumonia, sepsis and cellulitis. 12 children were hospitalised with COVID-19, none of whom died. Hospitalisations with rituximab administered decreased from 2019 to 2021., Conclusions: In this cohort of patients with cSLE who received inpatient treatment with rituximab, we observed a 14% rate of hospitalisation with infection in the year following rituximab administration among youth with cSLE. Rituximab use declined during the COVID-19 pandemic. No fatalities with COVID-19 were observed. Given the lack of outpatient data, including doses of concomitant medications and disease activity measures, further research is needed to identify risk factors for infection following rituximab among children with cSLE., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We aimed to determine the frequency and types of infections in hospitalized children with childhood-onset systemic lupus erythematosus (cSLE), and to identify risk factors for intensive care unit (ICU) admission and mortality., Methods: We conducted a retrospective study of youth aged 2 to 21 years using International Classification of Diseases (ICD) codes for SLE assigned during admission to a hospital participating in the Pediatric Health Information System, a database of United States children's hospitals, from 2009 to 2021. Generalized linear mixed effects models were used to identify risk factors for ICU admission and mortality among children hospitalized with infection., Results: We identified 8588 children with cSLE and ≥ 1 hospitalization. Among this cohort, there were 26,269 hospitalizations, of which 13% had codes for infections, a proportion that increased over time ( P = 0.04). Bacterial pneumonia was the most common hospitalized infection. In-hospital mortality occurred in 0.4% (n = 103) of cSLE hospitalizations for any indication and 2% of hospitalizations for infection (n = 60). The highest mortality rates occurred with Pneumocystis jirovecii pneumonia (21%) and other fungal infections (21%). Lupus nephritis (LN) and endstage renal disease (ESRD) were associated with increased odds of ICU admission (odds ratio [OR] 1.47 [95% CI 1.2-1.8] and OR 2.40 [95% CI 1.7-3.4]) among children admitted for serious infection. ESRD was associated with higher mortality (OR 2.34 [95% CI 1.1-4.9])., Conclusion: Hospitalizations with ICD codes for infection comprised a small proportion of cSLE admissions but accounted for the majority of mortality. The proportion of hospitalizations for infection increased over time. LN and ESRD were risk factors for poor outcomes., (Copyright © 2024 by the Journal of Rheumatology.)

Objectives: Urinary tract infections (UTIs) are the most common bacterial infections in young infants and are traditionally treated with longer intravenous (IV) antibiotic courses. A growing body of evidence supports shorter IV antibiotic courses for young infants. Our primary aim was to decrease the IV antibiotic treatment to 3 days over 2 years for neonates aged 0 to 28 days who have been hospitalized with UTIs., Methods: Using quality improvement methods, our primary intervention was to implement a revised clinical pathway recommending 3 (previously 7) days of IV antibiotics. Our primary outcome measure was IV antibiotic duration, and the secondary outcomes were length of stay (LOS) and costs. The balancing measure was readmission within 30 days of discharge. Neonates were identified by using International Classification of Diseases diagnosis codes and excluded if they were admitted to the ICU or had a LOS >30 days. We used statistical process control to analyze outcome measures for 4 years before (baseline) and 2 years after the pathway revision (intervention) in February 2020., Results: A total of 93 neonates were hospitalized with UTIs in the baseline period and 41 were hospitalized in the intervention period. We found special cause variation, with a significant decrease in mean IV antibiotic duration from 4.7 (baseline) to 3.1 days (intervention) and a decrease in mean LOS from 5.4 to 3.6 days. Costs did not differ between the baseline and intervention periods. There were 7 readmissions during the baseline period, and 0 during the intervention period., Conclusions: The implementation of a revised clinical pathway significantly reduced IV antibiotic treatment duration and hospital LOS for neonatal UTIs without an increase in hospital readmissions., (Copyright © 2024 by the American Academy of Pediatrics.)

Aims: To undertake a survey of the prevalence of tail deviations, trauma and shortening on a representative selection of New Zealand dairy farms, and to assess whether sampling based on milking order could be used instead of random sampling across the herd to estimate prevalence., Methods: This was a cross-sectional observational study, with 200 randomly selected farms enrolled across nine regions of New Zealand via selected veterinary practices (one/region). Veterinary clinics enrolled 20-25 farms each depending on region, with 1-2 trained technicians scoring per region. All cows (n = 92,348) present at a milking or pregnancy testing event were tail scored using a modified version of the New Zealand Veterinary Association Industry Scoring System. Palpated lesions were recorded as deviated (i.e. non-linear deformity), shortened (tail shorter than normal) or traumatic (all other lesions). The location of lesions was defined by dividing the tail into three equal zones: upper, middle and lower. A cow could have more than one lesion type and location, and/or multiple lesions of the same type, but for the prevalence calculation, only the presence or absence of a particular lesion was assessed. Prevalence of tail damage calculated using whole herd scoring was compared to random sampling across the herd and sampling from the front and back of the milking order. Bootstrap sampling with replacement was used to generate the sampling distributions across seven sample sizes ranging from 40-435 cows., Results: When scoring all cows, the median prevalence for deviation was 9.5 (min 0.9, max 40.3)%; trauma 0.9 (min 0, max 10.7)%, and shortening was 4.5 (min 1.3, max 10.8)%. Deviation and trauma prevalence varied between regions; the median prevalence of deviations ranged from 6% in the West Coast to 13% in Waikato, and the median prevalence of all tail damage from 7% in the West Coast to 29% in Southland. Sampling based on milking order was less precise than random sampling across the herd. With the latter and using 157 cows, 95% of prevalence estimates were within 5% of the whole herd estimate, but sampling based on milking order needed > 300 cows to achieve the same precision., Conclusions and Clinical Relevance: The proportion of cows identified as having damaged tails was consistent with recent reports from New Zealand and Ireland, but at 11.5%, the proportion of cows with trauma or deviation is below acceptable standards. An industry-wide programme is needed to reduce the proportion of affected cows.

Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose.

Background and Objectives: Multisystem inflammatory syndrome in children (MIS-C) is a novel, severe condition following severe acute respiratory syndrome coronavirus 2 infection. Large epidemiologic studies comparing MIS-C to Kawasaki disease (KD) and evaluating the evolving epidemiology of MIS-C over time are lacking. We sought to understand the illness severity of MIS-C compared with KD and evaluate changes in MIS-C illness severity over time during the coronavirus disease 2019 pandemic compared with KD., Methods: We included hospitalizations of children with MIS-C and KD from April 2020 to May 2022 from the Pediatric Health Information System administrative database. Our primary outcome measure was the presence of shock, defined as the use of vasoactive/inotropic cardiac support or extracorporeal membrane oxygenation. We examined the volume of MIS-C and KD hospitalizations and the proportion of hospitalizations with shock over time using 2-week intervals. We compared the proportion of hospitalizations with shock in MIS-C and KD patients over time using generalized estimating equations adjusting for hospital clustering and age, with time as a fixed effect., Results: We identified 4868 hospitalizations for MIS-C and 2387 hospitalizations for KD. There was a higher proportion of hospitalizations with shock in MIS-C compared with KD (38.7% vs 5.1%). In our models with time as a fixed effect, we observed a significant decrease in the odds of shock over time in MIS-C patients (odds ratio 0.98, P < .001) but not in KD patients (odds ratio 1.00, P = .062)., Conclusions: We provide further evidence that MIS-C is a distinct condition from KD. MIS-C was a source of lower morbidity as the pandemic progressed., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: We sought to confirm, refute, or modify a 4-step process for implementing shared decision-making (SDM) in pediatrics that involves determining 1) if the decision includes >1 medically reasonable option; 2) if one option has a favorable medical benefit-burden ratio compared to other options; and 3) parents' preferences regarding the options; then 4) calibrating the SDM approach based on other relevant decision characteristics., Methods: We videotaped a purposive sample of pediatric inpatient and outpatient encounters at a single US children's hospital. Clinicians from 7 clinical services (craniofacial, neonatology, oncology, pulmonary, pediatric intensive care, hospital medicine, and sports medicine) were eligible. English-speaking parents of children who participated in inpatient family care conferences or outpatient problem-oriented encounters with participating clinicians were eligible. We conducted individual postencounter interviews with clinician and parent participants utilizing video-stimulated recall to facilitate reflection of decision-making that occurred during the encounter. We utilized direct content analysis with open coding of interview transcripts to determine the salience of the 4-step SDM process and identify themes that confirmed, refuted, or modified this process., Results: We videotaped 30 encounters and conducted 53 interviews. We found that clinicians' and parents' experiences of decision-making confirmed each SDM step. However, there was variation in the interpretation of each step and a need for flexibility in implementing the process depending on specific decisional contexts., Conclusions: The 4-step SDM process for pediatrics appears to be salient and may benefit from further guidance about the interpretation of each step and contextual factors that support a modified approach., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic., Methods: We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling., Findings: Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168., Conclusions: Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children., (© 2023 National Rural Health Association.)

Background: Individual children's hospitals care for a small number of patients with multisystem inflammatory syndrome in children (MIS-C). Administrative databases offer an opportunity to conduct generalizable research; however, identifying patients with MIS-C is challenging., Methods: We developed and validated algorithms to identify MIS-C hospitalizations in administrative databases. We developed 10 approaches using diagnostic codes and medication billing data and applied them to the Pediatric Health Information System from January 2020 to August 2021. We reviewed medical records at 7 geographically diverse hospitals to compare potential cases of MIS-C identified by algorithms to each participating hospital's list of patients with MIS-C (used for public health reporting)., Results: The sites had 245 hospitalizations for MIS-C in 2020 and 358 additional MIS-C hospitalizations through August 2021. One algorithm for the identification of cases in 2020 had a sensitivity of 82%, a low false positive rate of 22%, and a positive predictive value (PPV) of 78%. For hospitalizations in 2021, the sensitivity of the MIS-C diagnosis code was 98% with 84% PPV., Conclusion: We developed high-sensitivity algorithms to use for epidemiologic research and high-PPV algorithms for comparative effectiveness research. Accurate algorithms to identify MIS-C hospitalizations can facilitate important research for understanding this novel entity as it evolves during new waves., (Copyright © 2023 by the American Academy of Pediatrics.)

The purpose of this observational study was to compare the performance of a novel on-farm culture (OFC) test with the reference method (RM) in identifying pathogens, and in particular Staphylococcus aureus , associated with subclinical mastitis (SCM) in dairy cattle. The OFC test (Mastatest HiSCC; Mastaplex Limited) for SCM uses a cartridge with 2 × 12 wells allowing 1 sample to be analyzed in duplicate (24 wells) or 2 samples analyzed simultaneously, each in 12 wells. Results of the milk analyses are reported hierarchically ( Staph. aureus → coagulase-negative staphylococci (CNS) → other gram positive or coliform/gram negative → no bacteria present) and emailed within 24 h. Milk samples (617 quarter level from 158 cows and 70 cow level) were collected from 288 cows [individual cow somatic cell count (ICSCC) ≥150,000 cells/mL] on 9 purposefully selected farms known to have a high prevalence of clinical and subclinical Staph. aureus mastitis in Southland New Zealand. Quarter samples were analyzed individually (617 samples) and after animal-level pooling, providing 228 (158 + 70) cow-level samples. Samples were analyzed by the OFC test (in duplicate) and the RM (culture agar medium and latex test based on the recommendation by the National Mastitis Council) and identifications confirmed with MALDI-TOF mass spectrometry. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) for detection of Staph. aureus were all ∼90% with tight 95% confidence limits, and Cohen's kappa (κ) for agreement between the OFC test and RM was 0.81. Kappa for agreement between the OFC test duplicates was 0.93. About 35% of cows had only one quarter infected with Staph. aureus and all these animals could still be identified when pooled cow-level milk was analyzed. Although the high prevalence of Staph. aureus in the herds used in this study does not affect the Se and Sp values, it does elevate the PPV value (and decrease the NPV) and therefore use of PPV to extrapolate to a population with lower prevalence is not appropriate. For CNS, Sp, PPV, and NPV were all >0.8, κ was ≥0.6, and Se was >0.7. Kappa for agreement between the OFC test duplicates was 0.83. A result of "no bacteria detected" was reported in 13% of the cows with 93% agreement between OFC test and RM. We conclude that the OFC test provides a reliable method for detecting Staph. aureus in pooled cow-level milk even if only one quarter is infected; in the absence of Staph. aureus in the milk, it reliably identified CNS in pooled cow-level milk; it reliably identified cows with <10 cfu/10 µL of their milk. Compared with the RM, the method was rapid with results returned in 24 h of loading the cartridge., (© 2023.)

Objective: To examine whether exposure to safe sleep recommendations using a blog format changed infant sleep practices., Methods: We conducted a pilot randomized controlled trial via Qualtrics, a web-based platform, with a national sample of parents of children < 1 year old. Survey questions about infant sleep practices included: bed-sharing, location, position and objects present. Safe sleep was defined as not bed-sharing, in a crib, bassinet or playard, back positioning, and no other objects present except pacifiers. Participants were randomized to read one of the following: (1) pediatrician blog post, (2) parent blog post, or (3) no blog post. The blog posts contained the same content about infant sleep but varied by identified authorship. All participants received links to online content about safe sleep. Participants received a follow-up survey 2-4 weeks later with the same questions about infant sleep practices. We compared responses in pre- and post-surveys by type of blog post exposure using multivariable logistic regression models., Results: The average infant age (n = 1500) was 6.6 months (Standard Deviation 3.3). Most participants (74%) were female; 77% were married; 65% identified as white Non-Hispanic, 12% were black and 17% were Hispanic. 47% (n = 711) completed both surveys. We identified no differences in the odds of any of the four safe sleep practices after exposure to safe sleep recommendations in blog post format., Conclusion: Although in-person advice has been associated with improved safe sleep practices, we did not identify changes in infant sleep practices after exposure to safe sleep advice using blog posts., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aim: To explore factors associated with the frequency of tail damage in dairy cows on 29 New Zealand farms participating in an animal welfare monitoring programme., Materials and Methods: Herd-level tail score data were collected at the cow level and then summarised at the herd level as counts for each lactation over the period 1 June 2014 to 31 May 2018. A cow's tail was considered damaged if there was evidence of any injury that deformed the anatomical structure involving either bone or soft tissue and could include loss of use. There were four categories for tail scoring. Fracture or dislocation of tail bones was considered as a deviation (score 1). When the tail had been docked above the top of the cow's udder, this was considered as docked short tail (score 2). When there was evidence of soft tissue trauma (score 3) or bone damage but no fracture (score 4), this was recorded as damaged (other). Tails were scored for each whole dairy herd. Tail scoring was performed by trained veterinarians or veterinary technicians. The primary outcome variable was counts of deviated tails (DT). Other outcome variables were docked short, damaged (other), and total tail injuries (TTI) which was a summation of all tail injuries. The potential predictor variables were area, season, farm, region, replacement rate, and herd size. A mixed-effects negative binomial or Poisson regression was fitted to the count data., Results: A total of 29 farms contributed data for tail scoring, with 54,831 cows individually scored. The unadjusted regional prevalence of TTI ranged from 3.5% (64/1,835) in Taranaki in 2014-2015 to 28.7% (1,434/4,988) in Southland/Otago in 2017-2018. The unadjusted regional herd prevalence of DT ranged from 2.1% (280/6,862) in Taranaki (2014-2015) to 13.2% (4,627/30,165) in Southland/South Otago (2017-2018). The incident rate ratio (IRR) of DT in 2015-2016 was 1.74 (95% CI = 1.20-2.53; p = 0.003) times the incident rate for the reference group (2014-2015). The IRR for TTI in 2015-2016 was 1.70 (95% CI = 1.60-1.81; p = 0.001) times the incident rate for the reference group (2014-2015)., Conclusions and Clinical Relevance: This is the first quantitative study of the frequency of tail damage within New Zealand dairy farms and whilst variable between regions, it indicates that the frequency is increasing. Opportunities exist to better understand the causes of tail injuries and to improve animal welfare.

This secondary analysis examined relationships between pain severity and interference and substance use among patients filling opioid prescriptions in Indiana and Ohio community pharmacies (n = 1,461). We likewise sought to explore the moderating role of gender in pain-substance use relations. We used patient-reported data from a cross-sectional health survey linked with controlled substance dispensing data from statewide prescription drug monitoring programs. Multivariable logistic regression estimated associations between pain severity and interference and various indices of risky prescription opioid use and non-opioid substance use. Exploratory analyses examined whether gender moderated associations. Increased pain severity was associated with increased odds of moderate- to high-risk opioid use (OR: 1.23; 95% CI: 1.16-1.31) and opioid-benzodiazepine co-use (OR: 1.20; 95% CI: 1.03-1.40). Increased pain interference was associated with greater odds of receiving opioids from multiple pharmacies or providers (OR: 1.15; 95% CI: 1.01-1.31). Increased pain severity and interference were associated with higher odds of any tobacco use (severity: OR: 1.13; 95% CI: 1.06-1.21; interference: OR: 1.07; 95% CI: 1.01-1.12) and weekly to daily sedative use (severity: OR: 1.13; 95% CI: 1.03-1.25; interference: OR: 1.13; 95% CI: 1.04-1.22). Increased pain severity was associated with decreased odds of any alcohol use (OR: 0.93; 95% CI: 0.88-0.99). Gender was a significant effect modifier in associations between pain and alcohol, tobacco, and cannabis use. The study was registered in the database of clinicaltrials.gov (register number NCT03936985). Perspective: This study suggests that pain severity and interference are associated with increased use of non-medical prescription opioids, sedatives, and tobacco and decreased use of alcohol, in ways that are different between women and men. Findings may guide the development of gender-sensitive evidence-based strategies to ameliorate or prevent substance misuse among patients living with pain., (Copyright © 2022 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the prevalence and safety of infant second-sleep practices., Methods: A cross-sectional online survey of parents with infants ≤12 months assessed parent-reported sleep practices: position, use of a separate sleep surface, and sleep location at 2 time points (sleep onset and after nighttime waking). A composite score examined if all 3 safe sleep practices were used at each time point. Safe sleep was defined as: supine position, sleeping in a separate space, and in a crib, bassinet, cradle, or playard. Wilcoxon sign rank test was used to examine changes between the time points. Poisson regression models compared parents who reported a second-sleep location with those who did not., Results: Of participants (n = 1500), 74% were female, 65% were White, 12% were Black, and 17% were of Hispanic ethnicity. Thirty-nine percent (n = 581) reported a second-sleep practice. Of parents who reported a second-sleep practice, 28% (n = 137) met all 3 safe sleep criteria at sleep onset; 9% (n = 42) met all 3 safe sleep criteria at both time points. A higher proportion of changes in sleep practices were to less-safe practices (P <.001). Factors associated with a second-sleep practice were parental age <25 years, parental race and ethnicity, first-time parents, homes with smoke exposure, and infants born at <37 weeks., Conclusions: Less than 10% of infants met all 3 safe sleep criteria at sleep onset and after nighttime waking. Interventions focused on safe sleep should highlight the importance of safe sleep practices after nighttime waking., (Copyright © 2022 by the American Academy of Pediatrics.)

Objectives: To examine inpatient vaccine delivery across a national sample of children's hospitals., Methods: We conducted a retrospective cohort study examining vaccine administration at 49 children's hospitals in the Pediatric Health Information System database. Children <18 years old admitted between July 1, 2017, and June 30, 2019, and age eligible for vaccinations were included. We determined the proportion of hospitalizations with ≥1 dose of any vaccine type administered overall and by hospital, the type of vaccines administered, and the demographic characteristics of children who received vaccines. We calculated adjusted hospital-level rates for each vaccine type by hospital. We used logistic and linear regression models to examine characteristics associated with vaccine administration., Results: There were 1 185 667 children and 1 536 340 hospitalizations included. The mean age was 5.5 years; 18% were non-Hispanic Black, and 55% had public insurance. There were ≥1 vaccine doses administered in 12.9% (95% confidence interval: 12.8-12.9) of hospitalizations, ranging from 1% to 45% across hospitals. The most common vaccines administered were hepatitis B and influenza. Vaccine doses other than the hepatitis B birth dose and influenza were administered in 1.9% of hospitalizations. Children had higher odds of receiving a vaccine dose other than the hepatitis B birth dose or influenza if they were <2 months old, had public insurance, were non-Hispanic Black race, were medically complex, or had a length of stay ≥3 days., Conclusions: In this national study, few hospitalizations involved vaccine administration with substantial variability across US children's hospitals. Efforts to standardize inpatient vaccine administration may represent an opportunity to increase childhood vaccine coverage., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: A central facet of the popular understanding of mindfulness practice is the non-judgmental observation of all thoughts and feelings. Savoring is a cognitive practice developed out of economics and positive psychology, which involves the conscious mental engagement with positively-valenced interoceptive and exteroceptive stimuli, which in turn amplifies the derived pleasure experience. Results: When incorporated into mindfulness-based interventions (MBIs), savoring holds promise in improving outcomes related to reward processing, such as positive affect and well-being. The growing body of mindfulness literature also suggests that the inclusion of savoring in MBIs may be key in treating disorders of reward dysregulation, such as addiction. If savoring does indeed reduce craving, this phenomenon offers a point of union for divergent neurobiological theories of addiction. Conclusion: In this commentary, we explore the existing literature on savoring and mindfulness practices as it relates to addictive disorders, posit underlying neurocognitive mechanisms, and present future areas of research.

Background: Health care professionals (HCPs) play an important role in opioid misuse and opioid use disorder (OUD) screening/identification, mitigation, and referral to treatment. This study compared attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation among pregnancy and non-pregnancy HCPs in rural communities. Methods: We conducted a secondary analysis of cross-sectional, self-report survey data of HCPs in two rural counties in southern Utah. Pregnancy HCPs were identified by a question asking whether they provide care to pregnant patients. HCPs' attitudes toward their patients with opioid misuse/OUD were measured using the Survey of Attitudes and Perceptions questionnaire. Self-efficacy and practices related to opioid risk assessment and mitigation were captured with questions asking about assessment and screening of opioid use, advisement to change opioid use behavior, and referral to treatment for OUD. We used linear regression analyses to estimate associations between HCPs' attitudes toward patients with opioid misuse/OUD and their self-efficacy and use of opioid risk assessment and mitigation practices. Results: This sample included a total of 132 HCPs, including 82 pregnancy HCPs and 50 non-pregnancy HCPs. Attitudes domains were similar among pregnancy and non-pregnancy HCPs. Among pregnancy HCPs, role adequacy ( β = .48, 95% CI = .16-.80), role legitimacy ( β = .72, 95% CI = .21-1.22), motivation ( β = .68, 95% CI = .14-1.21), and positive task-specific self-esteem ( β  = 1.52, 95% CI = .70-2.35) were positively associated with more frequent use of opioid risk assessment and mitigation practices, while attitudes were not associated with these practices among non-pregnancy HCPs. Conclusions: Training initiatives that lead to improved HCP attitudes could improve opioid care management among rural pregnancy HCPs. More research is needed to determine approaches to increase the use of opioid risk assessment and mitigation practices among rural non-pregnancy HCPs.

Background: Individuals with pain prescribed opioids experience high rates of comorbid depression. The aim of this study was to characterize pain, substance use, and health status as a function of depressive symptom level in individuals filling an opioid prescription at a community pharmacy. Methods: Participants ( N  = 1268) filling an opioid prescription enrolled in a study validating a prescription drug monitoring metric completed an online survey assessing sociodemographics, depressive symptoms, substance use, prescription opioid misuse, overdose history, general health, and pain severity and interference. Results: Approximately one-fifth (19.3%) had a positive depression screen result. In covariate-adjusted logistic regression analyses, individuals with a positive depression screen result were more likely to have moderate/high substance use risk scores for prescription opioids (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI], 1.51-2.79); street opioids (AOR = 7.18; 95% CI, 2.57-20.01); cannabis (AOR = 2.00; 95% CI, 1.34-3.00); cocaine (AOR = 3.46; 95% CI, 1.46-8.22); tobacco (AOR = 1.59; 95% CI, 1.18-2.15); methamphetamine (AOR = 7.59; 95% CI, 2.58-22.35); prescription stimulants (AOR = 2.95; 95% CI, 1.59-5.49); and sedatives (AOR = 3.41; 95% CI, 2.43-4.79). Individuals with a positive depression screen were more likely to misuse prescription opioids (AOR = 3.46; 95% CI, 2.33-5.15), experience a prior overdose (AOR = 2.69; 95% CI, 1.76-4.11), report poorer general health (AOR = 0.25, 95% CI, 0.18-0.35), and report moderate/severe pain severity (AOR = 4.36, 95% CI, 2.80-6.77) and interference (AOR = 6.47, 95% CI, 4.08-10.26). Conclusions: Individuals prescribed opioids with heightened depression were more likely to report other substance use, prescription opioid misuse, prior overdose, greater pain, and poorer health.

The opioid epidemic continues to affect pregnant women with opioid use disorder adversely in unique and enduring ways. The onset of the coronavirus disease 2019 (COVID-19) pandemic and the necessary public health measures implemented to slow the transmission have increased barriers to care for these same women. This commentary explores the implications of these measures and discusses strategies we have developed to manage these challenges based on our work in a clinical trial providing patient navigation to pregnant mothers with OUD. We believe these solutions can be applied in medical, behavioral health, and research settings through the pandemic and beyond to increase the quality of care and resources to this vulnerable population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 American Society of Addiction Medicine.)

Objectives: Evaluate the association between dexamethasone dosing and outcomes for children hospitalized with croup., Methods: This study was nested within a multisite prospective cohort study of children aged 6 months to 6 years admitted to 1 of 5 US children's hospitals between July 2014 and June /2016. Multivariable linear and logistic mixed-effects regression models were used to examine the association between the number of dexamethasone doses (1 vs >1) and outcomes (length of stay [LOS], cost, and 30-day same-cause reuse). All multivariable analyses included a site-specific random effect to account for clustering within hospital and were adjusted for age, sex, race and ethnicity, presenting severity, medical complexity, insurance, caregiver education, and hospital. In cost analyses, we controlled for LOS., Results: Among 234 children hospitalized with croup, patient characteristics did not differ by number of doses. The proportion receiving >1 dose varied by hospital (range 27.9%-57.1%). In adjusted analyses, >1 dose was not associated with same-cause reuse (odds ratio 0.87 [95% confidence interval (CI): 0.26 to 2.95]) but was associated with 45% longer LOS (relative risk = 1.45 [95% CI: 1.30 to 1.62]). When we controlled for LOS, >1 dose was not associated with differential cost ($-31.2 [95% CI $-424.4 to $362.0]). Eighty-two (35%) children received dexamethasone before presentation., Conclusions: We found significant interhospital variation in dexamethasone dosing and LOS. When we controlled for severity on presentation, >1 dexamethasone dose was associated with longer LOS but not reuse. Although incomplete adjustment for severity is one possible explanation, some providers may routinely keep children hospitalized to administer multiple dexamethasone doses., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Prescription drug monitoring programs (PDMPs) are critical for pharmacists to identify risky opioid medication use. We performed an independent evaluation of the PDMP-based Narcotic Score (NS) metric., Methods: This study was a one-time, cross-sectional health assessment within 19 pharmacies from a national chain among adults picking-up opioid medications. The NS metric is a 3-digit composite indicator. The WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was the gold-standard to which the NS metric was compared. Machine learning determined optimal risk thresholds; Receiver Operating Characteristic curves and Spearman (P) and Kappa (K) coefficients analyzed concurrent validity. Regression analyses evaluated participant characteristics associated with misclassification., Results: The NS metric showed fair concurrent validity (area under the curve≥0.70; K=0.35; P = 0.37, p < 0.001). The ASSIST and NS metric categorized 37% of participants as low-risk (i.e., not needing screening/intervention) and 32.3% as moderate/high-risk (i.e., needing screening/intervention). Further, 17.2% were categorized as low ASSIST risk but moderate/high NS metric risk, termed false positives. These reported disability (OR=3.12), poor general health (OR=0.66), and/or greater pain severity/interference (OR=1.12/1.09; all p < 0.05; i.e., needing unmanaged-pain screening/intervention). A total of 13.4% were categorized as moderate/high ASSIST risk but low NS metric risk, termed false negatives. These reported greater overdose history (OR=1.24) and/or substance use (OR=1.81-12.66; all p < 0.05)., Conclusions: The NS metric could serve as a useful initial universal prescription opioid-risk screener given its: 1) low-burden (i.e., no direct assessment); 2) high accuracy (86.5%) of actionable data identifying low-risk patients and those needing opioid use/unmanaged pain screening/intervention; and 3) broad availability., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Contrast-associated acute kidney injury (CA-AKI) is a potentially preventable complication of coronary angiography and intervention. Relatively little research has been done to determine how knowledge on CA-AKI prevention can be translated into clinical practice., Methods: We developed, implemented, and surveyed end-users about the usability, acceptability, and utility of an audit and feedback process for CA-AKI prevention in Alberta, Canada. The audit and feedback reported on amount of radiocontrast dye used, hemodynamic optimization of intravenous fluids, and CA-AKI incidence for each cardiologist practicing coronary angiography or percutaneous coronary intervention, compared with peers at their site and across the province. Reports were developed through an iterative process involving interventional cardiologists throughout the design process and usability testing., Results: Cardiologists participating in usability testing indicated a preference for the visual displays of data and summarizing indicators on the front page, and endorsed the value of peer-to-peer comparisons of performance measures. Of 31 eligible cardiologists from across Alberta, 17 responded to a survey evaluating the audit and feedback process. Fifteen respondents (88.2%) agreed that the data presented in the audit and feedback report were understandable; 17 respondents (100%) agreed or strongly agreed that the presentation of the report helped them better understand their performance compared with that of their peers; and 14 (82.4%) agreed that the audit and feedback process helped them identify ways to reduce the risk of AKI for their patients., Conclusions: Conducting an audit and providing feedback was an understandable and acceptable intervention to help cardiologists identify ways to improve prevention of CA-AKI during coronary angiography or intervention., (© 2021 The Authors.)

Background: Many children are undervaccinated at the time of hospital admission. Our objective was to explore the facilitators and barriers to vaccinating during hospitalization., Methods: We conducted qualitative interviews of parents, primary care pediatricians, emergency department (ED) physicians, and pediatric hospitalists. Parents of undervaccinated hospitalized children who were admitted through the ED were invited to participate. We used purposive sampling to identify physician participants. Semistructured interviews querying participants' perspectives on hospital-based vaccination were audiorecorded and transcribed. Parent demographics and physician practice characteristics were collected. Transcripts were analyzed for facilitators and barriers to vaccinating during acute hospital visits by using inductive content analysis. A conceptual framework was developed on the basis of the social ecological model., Results: Twenty-one parent interviews and 10 physician interviews were conducted. Of parent participants, 86% were female; 76% were white. Physician participants included 3 primary care pediatricians, 3 ED physicians, and 4 hospitalists. Facilitators and barriers fell under 4 major themes: (1) systems-level factors, (2) physician-level factors, (3) parent-provider interactional factors, and (4) parent- and child-level factors. Parent participants reported a willingness to receive vaccines during hospitalizations, which aligned with physician participants' experiences. Another key facilitator identified by parent and physician participants was the availability of shared immunization data. Identified by parent and physician participants included the availability of shared immunization data. Barriers included being unaware that the child was vaccine-eligible, parental beliefs against vaccination, and ED and inpatient physicians' perceived lack of skills to effectively communicate with vaccine-hesitant parents., Conclusions: Parents and physicians identified several key facilitators and barriers to vaccinating during hospitalization. Efforts to provide inpatient vaccines need to address existing barriers., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Cannabis use is common among individuals with pain who are prescribed opioids, occurring in approximately 10% of this population. This study aims to explore the relationship between non-medical cannabis use and other health risks among individuals filling opioids at community pharmacies., Methods: This study was an exploratory secondary data analysis of a National Drug Abuse Treatment Clinical Trials Network (CTN)-sponsored study, Validation of a Community Pharmacy-Based Prescription Drug Monitoring Program Risk Screening, examining the relationship between risky cannabis use and depressive symptoms, pain, overdose, and other substance misuse among individuals filling opioid prescriptions in community pharmacies (N = 1440)., Results: Participants reporting moderate- to high-risk compared to low-risk cannabis use were more likely to report depressive symptoms (adjusted OR = 1.67, 95% CI = 1.11-2.56), history of overdose (adjusted OR = 2.15, 95% CI = 1.34-3.44), and moderate- to high-risk use of alcohol (adjusted OR = 2.10, 95% CI = 1.28-3.45), opioids (adjusted OR = 2.50, 95% CI = 1.67-3.76), sedatives (adjusted OR = 2.58, 95% CI = 1.72-3.86), stimulants (adjusted OR = 4.79, 95% CI = 2.83-8.01), and tobacco (adjusted OR = 3.60, 95% CI = 2.47-5.24)., Conclusions: Community pharmacies may be valuable sites for identifying, studying, and intervening with substance use problems.

Aim: To describe the use of antimicrobial drugs for food animals in New Zealand, based on sales data reported to government for 2005-2018, to provide a baseline to determine the success of measures to reduce antimicrobial use for food animals and to compare usage to selected European countries., Methods: Data were sourced from official government and industry reports to update previous estimates of use (as amount sold) of antimicrobial products applied to animals in New Zealand. The data included antimicrobial sales and animal populations, weighted where appropriate by breed and age class. Antimicrobial use was estimated based on the amount of active ingredient sold, per kg of animal biomass standardised to the probable weight at time of treatment or lifetime average but not slaughter weight (population correction unit; PCU). New Zealand data for 2017 and 2018 were adjusted to account only for antimicrobials used for farm animals by discounting horticulture use, companion animal use and export., Results: Between 2014 and 2018 the estimated usage of antimicrobials in animals flattened to a 5-year rolling average of 10.40 mg/PCU. New data on use for companion animals and on exports of zinc bacitracin and tylosin, included previously in the gross New Zealand values, allow a more refined estimate of use of antimicrobials in food animals of 10.21 mg/PCU in 2018, the third lowest rate of use for countries reporting by the same methodology. The intensive industries of pigs and poultry combined use more than 500 mg/PCU whereas the extensive red meat and dairy industries use an estimated 6.25 mg/PCU. New Zealand uses proportionally more cephalosporins and macrolides, two of the critically important antimicrobial groups, when compared with European countries, but less quinolones. The most obvious difference is the extensive use of zinc bacitracin and tylosin fed to pigs and poultry in New Zealand but not in the European Union., Conclusions: Use of antimicrobials in food animals has stabilised to a rate of approximately 10.2 mg/PCU. This baseline should be used by the animal health industry to measure future success in its efforts to reduce and make more refined use of antimicrobial drugs as New Zealand works to deliver the government's Antimicrobial Resistance Action Plan. High rates of use of zinc bacitracin and some critically important macrolides represent clear targets in attempts to reduce usage.

Purpose: Medication expertise and close patient contact position community pharmacists to make significant contributions to combatting the opioid epidemic. This position facilitated the development and initial implementation of the Brief Intervention Medication Therapy Management (BIMTM) model to detect and address patient opioid misuse. BIMTM is an intervention consisting of 9 sessions. One medication management session is delivered by a pharmacist in a community pharmacy setting, and the remaining sessions are delivered telephonically by a patient navigator to follow up with goals established with the pharmacist and address concomitant health concerns that increase risk for misuse., Methods: We employed the Consolidated Framework for Implementation Research (CFIR) to summarize and present key findings from 4 distinct studies. CFIR domains addressed were (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) process, and (5) characteristics of individuals. The study results show sequential development of evidence for BIMTM., Results: A multistate cross-sectional pharmacist survey (n = 739) demonstrated limited pharmacist training and/or resources to address misuse, suggesting the need for external intervention development. Our multistakeholder intervention planning project showed limitations of current evidence-based models of care and of intervention implementation, which resulted in construction of the BIMTM. A multisite cross-sectional screening survey of patients (n = 333) established an electronic misuse screening protocol within 4 community pharmacies and identified opioid misuse in 15% of screened patients; among those patients, 98% had concomitant health conditions that contribute to the risk of opioid misuse. Presentation of study results to pharmacy leaders produced commitment for intervention implementation and a partnership to develop a grant proposal supporting this action. Our small-scale randomized trial evinced success in recruitment and retention and BIMTM patient benefit. The small-scale randomized trial likewise showed high levels of satisfaction with BIMTM., Conclusion: The establishment of BIMTM supports community pharmacist identification and intervention with patients engaged in misuse. Continued use of this research-based strategy may further empower pharmacists to address the opioid epidemic., (© American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To determine parental perceptions of pediatrician blog posts by narrative voice., Methods: Three blog posts each on 2 topics (vaccines and sleep) were written by an established physician blogger and varied by narrative voice (personal, third person objective and mixed). Topics were chosen to be applicable to all parents. Blog posts were evaluated by a communications expert, 2 research investigators, and 3 parents to confirm differences in narrative voice. We sampled parents of children 0 to 18 years old in 4 primary and subspecialty care clinics, and 1 inpatient medical unit. Participants were randomized to read 2 blog posts (1 per topic) that varied by narrative voice. Participants rated their perceptions of the accuracy, reliability, and appeal for each blog posts on a 5-point Likert Scale. The Kruskal-Wallis test was used to compare the distribution of parental rankings for accuracy, reliability, and appeal., Results: The average participant age (n = 258) was 39.8 (SD 9.7), 83% were female. Blog posts written in the third person objective voice were rated as more accurate and reliable than those in the personal or mixed voice. There was effect modification by topic, with parents rating the sleep blog posts as more accurate than the vaccine blog posts. There was no difference in the appeal of information by narrative voice or topic of blog post., Conclusions: The narrative voice used to convey information on pediatrician blog posts can influence reader perception of accuracy and reliability. Physician bloggers can enhance parental trust of their content using study findings., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Acute kidney injury (AKI) after cardiac catheterization procedures is associated with poor health outcomes. We sought to characterize the experiences of patients after receiving standardized information on their risk of AKI accompanied by instructions for follow-up care after cardiac catheterization., Methods: We implemented an initiative across 3 cardiac catheterization units in Alberta, Canada to provide standardized assessment, followed by guidance for patients at risk of AKI. This was accompanied by communication to primary care providers to improve continuity of care when patients transition from the hospital to the community. A structured survey from a sample of 100 participants at increased risk of AKI determined their perceptions of information provided and experiences with follow-up steps after the initiative was implemented in each cardiac catheterization unit in Alberta., Results: The mean age of participants was 72.4 (SD 10.4) years, 37% were female, and the mean risk of AKI was 8.8%. Most (63%) participants were able to recall the information provided to them about their risk of kidney injury, 68% recalled the education provided on strategies to reduce risk, and 65% believed their primary care practitioner had received enough information to conduct appropriate follow-up care. Eighty-six percent of patients were satisfied with their transition to the community, and 53% were reassured by the information and follow-up care they received., Conclusions: These findings suggest that communicating risk information to patients, in combination with education and collaboration for follow-up with primary care providers, is associated with positive patient experiences and satisfaction with care., (© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc.)

Objectives: To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis., Methods: We prospectively enrolled children with bronchiolitis at 5 children's hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 "overuse" indicators for care that should not occur and 7 "underuse" indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital., Results: We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: -24.3 hours; adjusted mean cost difference: -$731, P < .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, P < .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05)., Conclusions: A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)