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Effective educational strategies to train and assess residents' skills in behavioral health competencies have been limited. We hypothesized that a training curriculum using virtual reality (VR) simulations would enhance residents' evidence-based skills related to behavioral health anticipatory guidance (BHAG) and motivational interviewing (MI).We conducted a randomized controlled pilot trial of our curriculum within an urban academic clinic. Intervention and control groups received four 15-minute, monthly didactics on BHAG and MI followed by VR simulations to 1) deliberately practice delivering BHAG by verbally counseling avatars, who responded real-time (intervention group) or 2) assessing pediatric respiratory distress (control group). Two months post-VR training, all residents participated in a unique VR behavioral health scenario which was recorded and coded by pediatric psychologists via an observation instrument to assess residents' skills. Differences in BHAG and MI competencies were assessed via independent samples t tests for continuous variables and Fisher's exact tests for categorical variables.Sixty-six percent (n = 55) of eligible residents completed all study protocols comprising 35 intervention and 20 control participants. Intervention participants demonstrated an increase in BHAG skills (P = .002), percentage of open-ended questions asked (P = .04), and percentage of MI adherent behaviors (P = .04) when compared to the control group.VR may be an effective educational strategy for residents to acquire BHAG and MI skills though deliberate practice. Next steps will focus on assessing the generalizability of the VR curriculum as well as exploring the opportunities to enhance its scalability through artificial intelligence.

Objective To explore fourth-year medical students’ experience with a virtual, near-peer facilitated pediatric boot camp through the lens of self-determination theory (SDT). Methods We developed a virtual pediatric boot camp elective for fourth-year medical students pursuing pediatric residency using Kern’s six steps of curriculum development. The two-week virtual elective consisted of facilitated video conferences and small group discussions led by two senior pediatric residents. Semi-structured focus groups were conducted after elective completion. Using SDT as our conceptual framework, we explored participants’ experience with the near-peer facilitation of the boot camp. Focus group recordings were transcribed and thematically analyzed using deductive coding for SDT, with inductive coding for themes outside the theory’s scope. Saturation was reached after three focus groups. The codebook was iteratively revised through peer debriefing between coders and reviewed by other authors. Credibility was established through member checking. Results Ninety-two percent of eligible medical students (n = 23/25) participated in the boot camp with attendance ranging from 18–21 students per session. Twelve students (52%) participated in three focus groups. Qualitative analysis identified five major themes. Four themes consistent with SDT emerged: competence, autonomy, relatedness to near-peers, and relatedness to specialty/institution. The learning environment, including the virtual setting, emerged as an additional, non-SDT-related theme. Conclusions Medical students’ experience with our virtual boot camp closely aligned with SDT. Near-peer relatedness emerged as a unique theme which could be further investigated in other aspects of medical student education. Future research could evaluate higher-level learning outcomes from near-peer educational opportunities. Supplementary Information The online version contains supplementary material available at 10.1007/s40670-021-01466-w.

Background Vertical transmission of Trypanosoma cruzi infection from mother to infant accounts for a growing proportion of new cases of Chagas disease. However, no systematic reviews of risk factors for T. cruzi vertical transmission have been performed. Methods We performed a systematic review of the literature in PubMed, LILACS, and Embase databases, following PRISMA guidelines. Studies were not excluded based on language, country of origin, or date of publication. Results Our literature review yielded 27 relevant studies examining a wide variety of risk factors, including maternal age, parasitic load, immunologic factors, vector exposure, and more. Several studies suggested that mothers with higher parasitic loads may have a greater risk of vertical transmission, and a meta-analysis of two studies found a significantly higher parasitic load among transmitting than non-transmitting mothers with T. cruzi infection. A second meta-analysis of ten studies demonstrated that maternal age was not significantly associated with vertical transmission risk. Conclusions The current literature suggests that high maternal parasitic load may be a risk factor for congenital Chagas disease among infants of T. cruzi seropositive mothers. Given the considerable heterogeneity and risk of bias among current literature, additional studies are warranted to assess potential risk factors for vertical transmission of T. cruzi infection.

Many families seek medical care at pediatric urgent care centers. The objective of this study was to determine social and unintentional injury risks reported by these families.This cross-sectional study surveyed a convenience sample of guardians of patients 1 to 5 years of age presenting to our pediatric urgent care, 9/10/21 to 2/25/22. Outcomes were the number of reported social and unintentional injury risks. Predictors and covariates included child and parent demographic characteristics and a neighborhood socioeconomic deprivation index. Chi-square, Student's t test, Pearson's correlation tests, and multinominal regression were used.A total of 273 guardians (and children) were included; 245 of guardians (89.7%) were female; 137 (50.2%) of included children identified as Black. Approximately 60% reported ≥1 social risk; 31.5% reported ≥3. Approximately 90% reported ≥1 unintentional injury risk; 57.9% reported ≥3. There were significant associations between social risk presence and Black race, public/no insurance, and neighborhood deprivation (all P.05). There were no significant associations between unintentional injury risks and assessed predictors. Black guardians were more likely than those of other races to report a greater number of social risks (adjusted odds ratio [AOR] 2.90, 95% confidence interval [CI] 1.50, 5.58 for ≥3 vs 0 risk). Children with public/no insurance compared to private insurance were more likely to experience a greater number of social risks (AOR 3.34, 95% CI 1.42, 7.84 for ≥3 vs 0 risks).Many presenting to pediatric urgent cares experience social and unintentional injury risks. Risk identification may guide equitable responses.

Although the strongest predictor of human papillomavirus (HPV) vaccination is a high-quality recommendation, physicians often provide weak recommendations. Thus, the authors developed Virtual Immersive Communication Training on Recommending Immunizations (VICTORI), a virtual reality (VR)‒based intervention that provided physicians the opportunity to deliberately practice recommendation behaviors. VICTORI included VR simulations during which participants counseled caregiver avatars hesitant to vaccinate. Before participation in VICTORI, participants reviewed a smartphone application on recommendation behaviors. A nonrandomized control trial of VICTORI was conducted with licensed and resident physicians. The intervention group completed the application and VICTORI simulations, whereas a comparison group completed only the application. The hypothesis was that HPV vaccination rates would increase for patients in the intervention group. The preintervention period was defined as the 6 months before allocated training (February 1, 2020-July 31, 2020), and the postintervention period was the 6 months after (October 1, 2020-March 31, 2021). The primary outcome was a change in the rates of human papillomavirus vaccine initiation among eligible patients presenting to clinic before and after. Of 142 eligible physicians, 134 (94%) chose to participate, with 93 of /97 (96%) intervention and 30 of 37 (81%) comparison participants completing study protocols. There was a statistically significant increase in patients' HPV vaccine initiation rates after training within the intervention group (54.3%‒72.4%; 18.1% difference [95% CI=11.0, 25.8]; p0.001) but not within the comparison group (59.5%‒63.4%; 3.9% difference [95% CI= -11.0, 19.0]; p=0.609). In conclusion, HPV vaccine initiation increased after VR training, and further study is warranted.

Although cardiovascular death is a growing source of mortality for people living with human immunodeficiency virus (HIV), the risk factors and circumstances surrounding sudden death in this population are poorly understood. We compared 399 adult sudden death victims reported by Emergency Medical Services in North Carolina to 1,114 controls. Sudden death was more common among HIV-positive than HIV-negative individuals (OR: 2.59, 95% CI: 1.15-5.83). In a multivariable model of sudden death victims including Black race, BMI, and history of divorce, incarceration, substance abuse, and respiratory disease, HIV-positive individuals were more likely to be Black (adjusted OR [aOR]: 6.04, 95% CI: 1.08-33.7) or divorced (aOR: 4.71, 95% CI: 1.04-21.3), adjusted for all other variables in the model. Compared to controls with HIV, sudden death victims with HIV were more likely to have a history of incarceration, divorce, respiratory disease, alcohol abuse, or dyslipidemia. A qualitative assessment of victims suggested that many died in isolation, suffering from past and current substance abuse and depression. HIV infection appears to be an important risk factor for sudden death, and incarceration history, social isolation, and medical comorbidities contribute to sudden death risk for HIV-positive individuals.

Purpose To identify associations between age of onset of overweight/obesity, a child’s sociodemographic characteristics, and characteristics of a child’s home census tract. Design Retrospective electronic health record review of children with overweight/obesity. Setting Three primary care centers associated with a free-standing, tertiary-care pediatric institution in Cincinnati. Subjects Patients born between August 1, 2013 and July 31, 2014, who had a body mass index (BMI) ≥85th percentile before 5 years of age (n = 794). Measures Primary outcome was the patient’s age at the first encounter when BMI was ≥85th percentile. Patient-level predictors were sex, age, race/ethnicity, health insurance, and number of moves captured in the health record. Census tract-level predictors were density of bus stops, presence of grocery stores, and a Socioeconomic Deprivation Index. Analysis Multivariable linear regression models assessed for independent associations between age of onset of overweight/obesity and predictors. Results Patients were 55.8% female, 73.6% black, and 79.1% publicly insured. Each additional move per year was associated with onset of overweight/obesity occurring 4.05 months earlier ( P < .0001). No significant associations between age of onset of overweight/obesity and census tract-level density of bus stops ( P = .82), presence of grocery stores ( P = .39), and socioeconomic deprivation ( P = .53) were demonstrated. Conclusion Public policy efforts toward improving access to grocery stores or public transportation may not be sufficient to prevent childhood obesity. Population-level interventions related to improving housing may also reduce obesity.

Purpose To evaluate the frequency and clinical impact of switches in antiplatelet therapy following implementation of CYP2C19 genotyping after percutaneous coronary intervention (PCI). Methods The frequency of escalation (clopidogrel switched to prasugrel/ticagrelor) and de-escalation (prasugrel/ticagrelor switched to clopidogrel) was evaluated in 1063 PCI patients who underwent CYP2C19 genotyping. Risk of major adverse cardiovascular or cerebrovascular (MACCE) and bleeding events over one-year was evaluated. Results Antiplatelet therapy switches were common (19%), with escalation (101/115: 88%) and de-escalation (77/84: 92%) occurring predominantly in patients with and without a CYP2C19 nonfunctional allele, respectively. Nonfunctional allele carriers initiated and continued on clopidogrel had a significantly higher risk of experiencing either a MACCE or bleeding event compared to those escalated to prasugrel/ticagrelor (52 vs. 19 events/100 patient-years; adjusted hazard ratio [HR] 2.89 [1.44–6.13], p=0.003). Patients without a nonfunctional allele de-escalated to clopidogrel had no difference in risk compared to those initiated and continued on prasugrel/ticagrelor (21 vs. 19 events/100 patient-years; adjusted HR 1.13 [0.51–2.34], p=0.751). Conclusions CYP2C19-guided escalation and de-escalation is common in a real-world setting. Continuation of clopidogrel in nonfunctional allele carriers is associated with adverse outcomes. De-escalation to clopidogrel in patients without a nonfunctional allele appears safe and warrants prospective study.

BACKGROUND Behavioral health disorders have steadily increased and been exacerbated by the COVID-19 pandemic. Though behavioral health disorders can be successfully mitigated with early implementation of evidence-based parent management strategies, education for pediatric residents on behavioral health anticipatory guidance has been limited to date, with training challenges compounded by the physical distancing requirements of the COVID-19 pandemic. Virtual reality (VR) simulations provide an opportunity to train residents on this complex competency by allowing deliberate practice of necessary skills while adhering to current social distancing guidelines. OBJECTIVE This study explored the usability of a VR-based behavioral health anticipatory guidance curriculum for pediatric residents. METHODS This mixed methods study included 14 postgraduate third-year pediatric residents who completed the behavioral health anticipatory guidance VR curriculum. Residents completed the MEC Spatial Presence Questionnaire to assess immersion in the virtual environment. Semistructured interviews were used to elucidate residents’ perspectives on the curriculum’s content and format. The interviews were analyzed using conventional content analysis. RESULTS Quantitatively, residents reported a high degree of immersion, spatial presence, and cognitive involvement. Most residents (11/14, 79%) agreed or strongly agreed that it seemed as though they took part in the action of the simulation. Qualitatively, two themes emerged from the data: (1) the curriculum expands behavioral health anticipatory guidance and motivational interviewing knowledge and skills and (2) VR technology is uniquely positioned to develop competence. These themes revealed that the curriculum expanded their current level of knowledge and skill, addressed training gaps, and was applicable to all residents. Additionally, residents experienced VR as immersive, feasible, realistic to the clinic setting, and a safe space to practice and learn new skills. CONCLUSIONS Pilot data indicates that VR may be an effective tool to teach pediatric residents behavioral health anticipatory guidance, meeting a current gap in medical education training. This VR curriculum is particularly relevant in the context of the COVID-19 pandemic given the increased behavioral health concerns of families.

BACKGROUND Sickle cell anemia (SCA) is a genetic blood disorder that puts children at a risk of serious medical complications, early morbidity and mortality, and high health care utilization. Until recently, hydroxyurea was the only disease-modifying treatment for this life-threatening disease and has remained the only option for children younger than 5 years. Evidence-based guidelines recommend using a shared decision-making (SDM) approach for offering hydroxyurea to children with SCA (HbSS or HbS/β0 thalassemia) aged as early as 9 months. However, the uptake remains suboptimal, likely because caregivers lack information about hydroxyurea and have concerns about its safety and potential long-term side effects. Moreover, clinicians do not routinely receive training or tools, especially those that provide medical evidence and consider caregivers’ preferences and values, to facilitate a shared discussion with caregivers. OBJECTIVE The aim of this study is to understand how best to help parents of young children with sickle cell disease and their clinicians have a shared discussion about hydroxyurea (one that considers medical evidence and parent values and preferences). METHODS We designed our study to compare the effectiveness of two methods for disseminating hydroxyurea guidelines to facilitate SDM: a clinician pocket guide (ie, usual care) and a clinician hydroxyurea SDM toolkit (H-SDM toolkit). Our primary outcomes are caregiver reports of decisional uncertainty and knowledge of hydroxyurea. The study also assesses the number of children (aged 0-5 years) who were offered and prescribed hydroxyurea and the resultant health outcomes. RESULTS The Ethics Committee of the Cincinnati Children’s Hospital Medical Center approved this study in November 2017. As of February 2021, we have enrolled 120 caregiver participants. CONCLUSIONS The long-term objective of this study is to improve the quality of care for children with SCA. Using multicomponent dissemination methods developed in partnership with key stakeholders and designed to address barriers to high-quality care, caregivers of patients with SCA can make informed and shared decisions about their health. CLINICALTRIAL ClinicalTrials.gov NCT03442114; https://clinicaltrials.gov/ct2/show/NCT03442114 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/27650

Hepatitis C virus (HCV) is a chronic infection that can lead to severe liver damage if left untreated. With increased availability and affordability of curative treatments, screening for HCV has become an important first step in reducing morbidity and mortality. At a rural federally qualified health center (FQHC) in North Carolina, two quality improvement initiatives—an electronic health record (EHR) prompt and educational flyers—were implemented to improve HCV screening rates. We compared the proportion of eligible patients born from 1945 to 1965 who received HCV screening before, during, and after the initiatives. HCV screening rates were highest during the two initiatives (30% and 39%, respectively). Screening rates fell in the six-month period following the initiatives’ conclusion (12%) but remained higher than at baseline (6%). While HCV screening can increase with simple interventions, more durable solutions are needed to maintain screening coverage.

Current guidelines recommend dual antiplatelet therapy—a P2Y 12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin—for patients undergoing percutaneous coronary intervention. Although clopidogrel is the most commonly prescribed P2Y 12 inhibitor, it is associated with an increased risk of major adverse cardiovascular events in patients carrying loss-of-function CYP2C19 alleles. In contrast, CYP2C19 genotype does not impact clinical response to prasugrel or ticagrelor. Nevertheless, routine implementation of CYP2C19 genotyping to guide antiplatelet therapy selection has remained controversial because of the lack of large randomized controlled trials evaluating this strategy. Emerging results from registry studies and small clinical trials of CYP2C19 genotype-guided antiplatelet therapy following percutaneous coronary intervention offer new insight and contribute to a growing evidence base that supports the clinical utility of a genotyping strategy to personalize antiplatelet therapy selection.

Members of the Chagas Disease Working Group in Peru and Bolivia include Edith Hinojosa, Clariza Chavez, Jean Karla Velarde, Carla Chavarria, Victoria Serrudo, Roberto Araya, Alcides Buitron, Rita Mendieta, Holger Mayta, Maritza Calderon, Holger Mayta and Yagahira Castro. Background Vertical transmission of Trypanosoma cruzi infection accounts for a growing proportion of new cases of Chagas disease. Congenital infection is curable if treated promptly, but the majority of infected infants do not receive timely diagnosis or treatment. Better risk stratification is needed to predict which women are more likely to transmit the infection. Methods This study enrolled women who presented for delivery and their infants at the Percy Boland Women’s Hospital in Santa Cruz, Bolivia. Pregnant women were screened for Chagas disease by rapid test. The infants of seropositive mothers underwent diagnostic testing with microscopy (“micromethod”) and quantitative polymerase chain reaction (qPCR) as newborns and at one- and nine-month follow-up. Mothers completed surveys about demographics and medical history. Results Among 5,828 enrolled women, 1,271 (21.8%) screened positive for Chagas disease. Of the 1,325 infants of seropositive mothers, 113 (8.5%) were diagnosed with congenital Chagas disease by microscopy or qPCR. Cesarean delivery was significantly associated with lower odds of vertical transmission (adjusted OR: 0.63, 95% CI: 0.41–0.98, p=0.040). Congenital infection was more common in twins (adjusted OR: 3.30, 95% CI: 1.97–5.54, p< 0.001) and male infants (adjusted OR: 1.50, 95% CI: 1.01–1.22, p=0.045). Conclusion Our findings suggest that Cesarean delivery may be protective against vertical transmission of T. cruzi, while twins and male infants may have an increased risk. A better understanding of risk stratification for congenital Chagas disease may help improve regional initiatives to reduce disease burden. Disclosures All Authors: No reported disclosures

It is well established that the CYP2C19 nonfunctional *2 and *3 polymorphisms impair the bioactivation and antiplatelet effects of clopidogrel, and increase the risk of adverse cardiovascular events following percutaneous coronary intervention. In contrast, CYP2C19 genotype does not impact clinical response to prasugrel or ticagrelor. Recent studies have evaluated the impact of CYP2C19 genotype-guided selection of antiplatelet therapy on clinical outcomes and begun to close some of the gaps in knowledge and uncertainty that have impeded widespread clinical implementation of this precision medicine approach. This review will critically evaluate recent data and offer new insight into the potential clinical utility of genotype-guided antiplatelet therapy in the context of current clinical practice guidelines.

The clinical impact of using CYP2C19 genotype to guide dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains unclear. This single center retrospective cohort study included 1193 PCI patients from 2012-14. CYP2C19 genotyping was recommended in high risk patients