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People released from prison are at risk of adverse health outcomes in the weeks after release. This article describes cases that illustrate the complexity of caring for this population. It is important to address medical and psychological needs as well as factors that contribute to social determinants of health.

Background Post-hospitalization transition interventions remain a priority in preventing rehospitalization. However, not all patients referred for readmission prevention interventions receive them. We sought to 1) define patient characteristics associated with non-receipt of readmission prevention interventions (among those eligible for them), and 2) determine whether these same patient characteristics are associated with hospital readmission at the state level. Methods We used state-wide data from the Maryland Health Services Cost Review Commission to determine patient-level factors associated with state-wide readmissions. Concurrently, we conducted a retrospective analysis of discharged patients referred to receive 1 of 3 post-discharge interventions between January 2013 and July 2019—a nurse transition guide, post-discharge phone call, or follow-up appointment in our post-discharge clinic—to determine patient-level factors associated with not receiving the intervention. Multivariable generalized estimating equation logistic regression models were used to calculate the odds of not accepting or not receiving the interventions. Results Older age, male gender, black race, higher expected readmission rate, and lower socioeconomic status were significantly associated with 30-day readmission in hospitalized Maryland patients. Most of these variables (age, sex, race, payer type [Medicaid or non-Medicaid], and socioeconomic status) were also associated with non-receipt of intervention. Conclusions We found that many of the same patient-level characteristics associated with the highest readmission risk are also associated with non-receipt of readmission reduction interventions. This highlights the paradox that patients at high risk of readmission are least likely to accept or receive interventions for preventing readmission. Identifying strategies to engage hard-to-reach high-risk patients continues to be an unmet challenge in readmission prevention.

Background Adults with sickle cell disease (SCD) on chronic transfusion therapy are exposed to a large volume of blood products, thus increasing their risk of transfusion-associated human immunodeficiency virus (HIV), hepatitis C (HCV), and hepatitis B (HBV). Methods We performed a systematic chart review of chronically transfused SCD subjects at the Johns Hopkins Sickle Cell Center for Adults between October 2014 and September 2019 to determine our Center's adherence to the 2014 National Heart, Lung and Blood Institute (NHLBI) SCD guidelines for annual screening for Transfusion Transmitted infections (TTI) and assessed HBV immunity and HBV vaccination rates. Results The study included 85 subjects with a median age of 34 years (23-63); 52% were female. No subject received annual screening; 68 subjects (80%) were screened for HIV, 60 subjects (71%) for HCV and 53 subjects (62%) for HBV infections at least once in the study period. Of those screened, one patient was newly diagnosed with HCV infection, and none with HIV or HBV infection. Among 31 subjects tested for anti-Hepatitis B surface antibody, 16 subjects (52%) tested negative. Nineteen (20%) subjects had HBV vaccination documented. Conclusions Low adherence to the NHLBI TTI screening guidelines, especially for HBV, highlights the resource intensiveness of this patient population. The low rates of anti-Hepatitis B surface antibody positivity highlight the need to confirm vaccination, provide boosters as indicated, and investigate the adults with SCD's immune response to HBV vaccination.

1. Lindy Zhang, MD*,† 2. Caroline DeBoer, MD†† 3. Alejandra Ellison-Barnes, MD‡ 4. Jessica Berger, MD‡‡ 5. Courtney E. Lawrence, MD*,¶ 6. Rosalyn W. Stewart, MD MS MBA‡,§ 7. Lydia H. Pecker, MD** 1. *Departments of Pediatric Hematology, 2. †Pediatric Oncology, 3. ‡Internal Medicine, and 4. §Pediatrics and 5. ¶Division of Transfusion Medicine, Department of Pathology, and 6. **Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD; 7. ††Advocate Aurora Healthcare, Milwaukee WI; 8. ‡‡Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 1. Address correspondence to Lindy Zhang, MD, Charlotte R. Bloomberg Children’s Center, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287. E-mail: lindyzhang{at}jhmi.edu A term boy was born via elective, repeat cesarean delivery to a mother whose prenatal laboratory tests were positive for group B Streptococcus genital infection and negative for human immunodeficiency virus, syphilis, gonorrhea, and chlamydia infections, and showed immunity for rubella. He was the third child born to this mother. The mother had no other diagnosed illnesses, including autoimmune diseases. The cesarean delivery was complicated by extensive adhesions from previous deliveries, but the delivery was atraumatic for the infant. The infant weighed 3.81 kg (82nd percentile for age), and had ABO mismatch with his mother (mother’s blood type was O+, infant’s blood type was A+). By 20 hours of age, the infant developed indirect hyperbilirubinemia (total bilirubin, 7.9 mg/dL). This elevation in bilirubin levels was attributed to ABO isoimmunization. He received 12 hours of phototherapy delivered by a fiberoptic mattress and fluorescent bulbs on an overhead lamp. On postnatal day 2, he had a circumcision, which was complicated by bleeding and required cauterization with silver nitrate. The remainder of his hospital course was uneventful. He was discharged without any ongoing evidence of easy bruising or bleeding and was scheduled for close follow-up with his pediatrician. On postnatal day 6, the infant was presented for his first newborn visit to his pediatrician with jaundice. His total bilirubin level was 19.3 mg/dL. The pediatrician sent the infant to the emergency department for additional evaluation and treatment. There, the infant was found to have severe thrombocytopenia (platelet count, 35 K/mm3) and indirect hyperbilirubinemia (total bilirubin, 20.2 mg/dL; direct bilirubin, 0.3 mg/dL). Mild anemia was present (hemoglobin, 13.8 …

COVID-19 restructured the health care delivery process, catapulting telemedicine to the mainstream. The Johns Hopkins After Care Clinic (JHACC) continued transprofessional health care delivery in the telemedicine space by shifting to remote, asynchronous collaboration and a triage system. In 1 month after starting telemedicine, the JHACC had 907 encounters for 376 unique patients. Most patients reported satisfaction with their visits. Telemedicine lengthened visit completion times. Providers encountered many failed call attempts and limited access to videoconferencing. Barriers to sustainable interprofessional telemedicine include poor social determinants of health, limited reimbursement for nonphysician health professionals, and increased clinical and administrative time.

Background Mauriac syndrome is a rare consequence of poorly controlled insulin-dependent diabetes, characterized by hepatomegaly, growth failure, delayed onset of puberty, and cushingoid features. Case reports of patients with Mauriac syndrome are found infrequently in the literature given historic improvements in diabetes management due to readily available insulin therapy. Methods We describe a case of a 14-year-old girl who presented with acute onset abdominal pain, distention, and orthopnea. Results She had a history of poorly controlled insulin-dependent diabetes as well as short stature. Abdominal imaging revealed impressive hepatomegaly. Laboratory testing showed markedly elevated triglycerides and cholesterol. Mauriac syndrome was suspected and diagnosed by liver biopsy, which demonstrated significant glycogenic hepatopathy. Conclusions This case provides an illustrative example of Mauriac syndrome in a child who did not experience delayed onset of puberty and continued to have regular menses unlike what has been previously described. Furthermore, this case highlights the important consideration for significant dyslipidemia in patients with Mauriac syndrome and discusses the challenges of controlling insulin-dependent diabetes in the adolescent population.

Objective This case addresses the issue of surreptitious adulteration of cannabis. Many with opioid and substance use disorders use cannabis while receiving office-based opioid treatment (OBOT), making it valuable to understand the rationale for its use. Further study of the effects that cannabis use has on OBOT success or failure is necessary. Case summary A 50-year-old man receiving OBOT continually tested positive in urine drug screenings (UDSs) for fentanyl, while abstaining from all opiates, but he endorsed smoking cannabis 2-3 times weekly as a self-reported headache reliever and a sleep aid. After changing the source from which he bought cannabis, his UDS became negative for fentanyl. He was maintained on a stable dose of buprenorphine with a consistent UDS after this intervention and was able to make many positive lifestyle changes as a result (i.e., maintaining a relationship with his girlfriend, continuing attendance at support groups, and pursuing employment opportunities). Practice implications The consequences of cannabis use on OBOT success are highly variable and dependent on many factors. Although the concern regarding adulteration of cannabis exists, there is no systematic monitoring or reliable data on its frequency or the magnitude of its effect, which generates a demand for further research and exploration. Depending on state-specific regulations, patients may be able to obtain cannabis from reliable, regulated (nonadulterated) sources. However, providers must thoroughly consider the barriers to patients obtaining medicinal or legalized cannabis.

Buprenorphine is a life-saving treatment for opioid use disorder (OUD). Low-dose initiation (LDI) is an emerging buprenorphine initiation strategy that circumvents barriers associated with standard initiation. This study aims to describe tolerability and completion of LDI using intravenous (IV) buprenorphine and to define dosing protocols in a cohort of patients hospitalized in an urban academic hospital.Data was collected via retrospective chart review for IV buprenorphine LDI cases initiated between September 1, 2020 and February 28, 2021. Cases were excluded if diagnostic criteria for OUD was not met, Clinical Opiate Withdrawal Scale (COWS) scores were not recorded, or sublingual (SL) buprenorphine was given within 24 h before IV buprenorphine. Completion of LDI and COWS data were assessed for all cases. Cases were categorized based on adherence to a dosing strategy and LDI indication, including OUD and acute pain, non-prescribed fentanyl exposure, and transition from methadone.Seventy-two cases were identified, and thirteen cases were excluded, leaving 59 cases in the population. Of these cases, 72.9% (43/59) tolerated LDI, and 91.5% (54/59) completed buprenorphine initiation. Forty-four (44/59, 75%) cases were adherent. Median duration of LDI within the adherent group was 23.7 h (IQR 22.8-27.0), 37.1 h (IQR 36.2-40.9), and 48.8 h (IQR 47.0-52.4) for the "rapid," "moderate," and "slow" dosing strategies, respectively.IV buprenorphine LDI was tolerated and completed in a majority of patients. Dosing protocols allowed for rapid transition to sublingual buprenorphine. Acute pain or recent methadone or fentanyl exposure may inform IV LDI dosing strategy selection.

The authors argue that university-engagement research benefits the communities as well as HEIs, however, such research, and especially the process of community engagement has been less frequently described in the literature. Recognizing the variation within community-based participatory research (CBPR) practices and processes, as well as that research has employed cross-disciplinary mixed methods (MM) designs to create outcomes that are meaningful to communities, the purpose of their chapter is to report on a cross-disciplinary collaborative university-engagement MM research of the character of CBPR for healthier and safer communities in Baltimore, Maryland, funded by Johns Hopkins University. The authors, first, familiarize readers with CBPR, then provide details about the project’s backdrop, MM design, and conclude with lessons learned and suggestions for future research to improve collaboration within scholars in different academic departments (social science, public health, and medicine) as well as with community leaders and residents.

Background While significant racial inequities in health outcomes exist in the United States, these inequities may also exist in healthcare processes, including the Emergency Department (ED). Additionally, gender has emerged in assessing racial healthcare disparity research. This study seeks to determine the association between race and the number and type of ED consultations given to patients presenting at a safety-net, academic hospital, which includes a level-one trauma center. Method Retrospective data was collected on the first 2000 patients who arrived at the ED from 1/1/2015–1/7/2015, with 532 patients being excluded. Of the eligible patients, 77% (74.6% adults and 80.7% pediatric patients) were black and 23% (25.4% adults and 19.3% pediatric patients) were white. Results White and black adult patients receive similar numbers of ED consultations and remained after gender stratification. White pediatric males have a 91% higher incidence of receiving an ED consultation in comparison to their white counterparts. No difference was found between black and white adult patients when assessing the risk of receiving consultations. White adult females have a 260% higher risk of receiving both types of consultations than their black counterparts. Black and white pediatric patients had the same risk of receiving consultations, however, white pediatric males have a 194% higher risk of receiving a specialty consultation as compared to their white counterparts. Discussion Future work should focus on both healthcare practice improvements, as well as explanatory and preventive research practices. Healthcare practice improvements can encompass development of appropriate racial bias trainings and institutionalization of conversations about race in medicine.

Background Patient engagement is an important aspect in improving patient outcomes. However, there is a paucity of literature regarding patient engagement in a nonresearch health care setting and the impacts of ambulatory clinical pharmacist interventions. Patient engagement has several definitions making it challenging to assess, but attendance to initial primary care provider (PCP) visits is an important aspect of patient engagement. Objective The study objective was to assess if improved patient engagement, defined as attendance to an initial PCP visit, was associated with differences in services provided or pharmacist participation during postdischarge clinic appointments. Practice description The site of this study was the Johns Hopkins After Care Clinic (JHACC), an interdisciplinary postdischarge, safety net clinic in Baltimore, MD. Practice innovation Through an interdisciplinary health care team including pharmacists, patients received comprehensive care to assist with postacute disease-state management and transitions of care. Evaluation methods Initial PCP visit attendance after a postacute visit in a high-risk population was evaluated for differing service delivery factors between groups who attended and did not attend their initial PCP visit. Descriptive statistics and chi-square tests were used for analysis. Results Patients were statistically significantly more likely to engage in primary care when clinical pharmacy specialists participated in their JHACC appointment (P = 0.02). Medication education and disease-state counseling improved initial PCP visit attendance, both of which are key pharmacist activities. Conclusion This study suggests ambulatory clinical pharmacy specialists’ roles in an interdisciplinary clinic model correlates with increased attendance to initial PCP visits, a surrogate for patient engagement. Disease-state education and medication education are both important activities in improving this measure; however, additional research is necessary to determine specific pharmacist interventions associated with patient engagement. As research in patient engagement continues, the positive effects of pharmacist involvement in this area could support their value in ambulatory care services.

Objective To determine whether racial disparities occurred among specialty and allied health inpatient consultations for patients admitted to adult hospital services at an academic hospital. Methods A retrospective data analysis of the first 2000 patients, ages 18 years or older, admitted to an academic hospital. Results No regression model demonstrated any statistically significant relation between race and type of inpatient consultation received. No statistically significant difference in the number of inpatient consultations was found. Conclusions Processes within the healthcare setting studied did not contribute to racial differences in consultation services. Our findings suggest that implicit racial bias may not be a factor when ordering consultations, but the findings are more likely affected by more appropriate factors such as the patient's age, length of stay, and complexity/severity of illness score.

Millions of adults in the United States are currently living with what is termed chronic childhood conditions-childhood-onset conditions, about which adult providers often receive minimal training-and another half million youths with special health care needs enter adulthood each year and will undergo transition from pediatric to adult care. Here, the authors review the important otolaryngologic manifestations of several of these chronic childhood conditions, including autism spectrum disorder, cerebral palsy, and Down syndrome, as well as the primary care providers' role in caring for transitioning tracheostomy-dependent patients.

As part of a cultural competence needs assessment study at a large academic health care system, we conducted a survey among 1,220 practicing physicians to assess their perceptions of the organization's cultural competence climate and their skills and behaviors targeting patient-centered care for culturally and socially diverse patients. Less than half of providers reported engaging in behaviors to address cultural and social barriers more than 75% of the time. In multivariable logistic regression models, providers who reported moderate or major structural problems were more likely to report low skillfulness in identifying patient mistrust (aOR: 2.01; 95% CI: 1.23-3.28, plt;0.01), how well patients read and write English (aOR: 1.63; 95% CI: 1.03-2.57, p=0.03), and socioeconomic barriers (aOR: 2.14; 95% CI: 1.14-4.01, p=0.01), than providers who reported only small or no structural problems. Improved structural support for socially and culturally complex medical encounters is needed to enhance care for socially at-risk patients.

Since Dr. Kubler-Ross’s seminal publication in 1969, we have seen significant growth in palliative and hospice care. We have also learned that palliative care can decrease medical costs and the tim...

1. Chetna K. Pande, MD, MPH* 2. Amanda O’Halloran, MD* 3. Rosalyn W. Stewart, MD, MS, MBA* 4. Angela Nguyen, MD* 5. Therese Canares, MD* 1. *Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD A 14-year-old boy with attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, and astrocytoma (status-post resection in infancy, no residual deficits) presents to the emergency department (ED) with 2 days of abnormal movements: facial twitching, jaw stiffness, and torticollis, progressing to whole-body tremors, agitation, diaphoresis, and altered mental status. Medications include fluoxetine 60 mg daily and lisdexamfetamine 60 mg daily, started 1 year ago. He recently gained independence with taking medications but took no medications in the past week. Two days ago his mother discovered his noncompliance and restarted his medications at the prescribed doses. Since symptom onset, he was seen in community EDs twice, received diphenhydramine for dystonia and lorazepam for agitation, and was discharged. Vital signs are temperature, 98.8°F (37.1°C); blood pressure, 121 to 149/64 to 76 mm Hg; heart rate, 70 to 90 beats/min, with episodes of 170 beats/min when tremulous; respirations, 18 to 24 breaths/min; and oxygen saturation, 97% to 99% on room air. He is diaphoretic and agitated; his eyes are closed, but he opens them on command. He responds to questions verbally and follows commands. He has rotary and horizontal nystagmus, …

Many clinicians have limited training preparing them for delivery of bad or uncertain news to new or expectant parents. Pediatric and Women’s Health educators at the Johns Hopkins University School of Medicine developed a simulation-based education module for clinical clerks focused on addressing medical uncertainty and delivering bad news along the antenatal-neonatal care continuum. In this article, we highlight how this curriculum improved self-perceived student confidence when encountering difficult discussions with parents or parents-to-be. Additionally, this activity emphasized the shared medical care continuum between obstetricians and pediatricians in these clinical scenarios.

This review will give a general overview of the impact of breast cancer, as well as breast cancer risk factors, identification of high-risk groups, screening modalities, and guidelines for screening average-risk and high-risk individuals, including a case discussion of the primary care provider's approach to screening.

This review will comprise a general overview of colorectal cancer (CRC) screening. We will cover the impact of CRC, CRC risk factors, screening modalities, and guideline recommendations for screening in average-risk and high-risk individuals. Based on this data, we will summarize our approach to CRC screening.

This review will comprise a general overview of the epidemiology of lung cancer, as well as lung cancer risk factors, screening modalities, current guideline recommendations for screening, and our approach to lung cancer screening.

Introduction The 2014 NHLBI Sickle Cell Expert Panel recommends that young adults with sickle cell disease (SCD) be supported to develop a reproductive life plan, but little data about implementing this recommendation exists and reproductive health behaviors or knowledge is not assessed in existing SCD transition readiness forms. Young adults with SCD confront typical age-related reproductive challenges and require additional support due to SCD-related complexities. For men and women, there are questions about the effect of SCD and its treatments on fertility and reproductive lifespan and the problem of genetic risk for SCD in offspring. For men, priapism and erectile dysfunction may be problems, while women face contraception choices and complicated pregnancy care. In our young adult clinic, we assess young adults' reproductive history, intentions and knowledge using a clinical survey and standard intake questions. The purpose of this study was to describe young adult responses to our family planning survey. Methods This is a retrospective analysis of patients who established care at the Johns Hopkins Sickle Cell Center for Adults' Young Adult Clinic (YAC), which serves young adults with SCD Results Fifty patients who established care in the YAC over its first 15 months (April 2019-July 2020) completed the survey. They were 66% female with a median age of 23.5 (IQR 21,25). Most (74%) had sickle cell anemia (SCA); 60% had education beyond high school. Most (78%) were either students (34%) or employed full time (44%). Forty-two percent lived with a parent. Most (68%) were sexually active, and 45% reported contraception use. Condoms were commonly used by both sexes (41%); forty percent of women used depot-medroxyprogesterone acetate (DMPA). Half of women (58%) had a gynecologist. One third of women reported dysmenorrhea. Forty-one percent of men reported priapism. Twenty-four percent of respondents had a history of pregnancy or of impregnating a partner and 14% had children. The median age of parents at the birth of the first child was 21 (IQR 16,22). Survey results are in Table 1. The response rate was 98% for eight questions and 50% for two questions. Few (8%) reported desire to have a child in the next year, and 27% wished to discuss contraception. Among sexually active respondents, 29% knew their partner's sickle cell trait status and 35% of them wanted testing. Few respondents wanted to meet with a genetics counselor (12%) or reported knowledge of preimplantation genetic testing (PGT) (11%). Thirty-eight percent of respondents were interested in learning how to identify if a fetus has SCD. Ninety-two percent of respondents indicated they do not desire pregnancy in the next year, and 38% of them were using contraception - 33% used condoms, 22% used DMPA, and 11% had an intrauterine device (IUD). Those interested in contraception were young (68% under 26), female (77%), and, of those women, most did not have a gynecologist (60%). Most women with dysmenorrhea (63%) were not interested in discussing contraception. Of the 14% of respondents with children, 29% knew their partner's trait status; and of those who did not, 20% wanted testing. Among 10 patients interested in genetic counseling or who knew of PGT, half had more than high school education; most (70%) were women with SCA who had never been pregnant. Among 82% who had not heard of PGT, 17% identified interest in more information. Most (70%) of this group was 22-25 years old, 14% wanted a child in the next year, all were either students (43%) or employed full time (57%); most (57%) had education beyond high school. Conclusions Clinic administration of a family planning survey is feasible. Many young adults transition to adult care and are parents or interested in becoming parents. Ninety-two percent of respondents do not desire pregnancy in the near future but 67% of them are not using reliable birth control. Genetic counseling interest, knowledge of PGT, and knowledge of partner sickle trait status is low. Current transition readiness documents for SCD do not adequately address reproductive health. These results suggest a discordance between the reproductive health priorities of young adults with SCD and providers that should be further examined. Disclosures Stewart: HRSA: Research Funding. Lanzkron:GBT: Research Funding; HRSA: Research Funding; Ironwood: Research Funding; NHLBI: Research Funding; PCORI: Research Funding; Pfizer: Research Funding; Pharmacy Times Continuing Education: Honoraria; Prolong: Research Funding. Pecker:Forma Therapeutics: Consultancy.

Community health workers are increasingly recognized as useful for improving health care and health outcomes for a variety of chronic conditions. Community health workers can provide social support, navigation of health systems and resources, and lay counseling. Social and cultural alignment of community health workers with the population they serve is an important aspect of community health worker intervention. Although community health worker interventions have been shown to improve patient-centered outcomes in underserved communities, these interventions have not been evaluated with sickle cell disease. Evidence from other disease areas suggests that community health worker intervention also would be effective for these patients. Sickle cell disease is complex, with a range of barriers to multifaceted care needs at the individual, family/friend, clinical organization, and community levels. Care delivery is complicated by disparities in health care: access, delivery, services, and cultural mismatches between providers and families. Current practices inadequately address or provide incomplete control of symptoms, especially pain, resulting in decreased quality of life and high medical expense. The authors propose that care and care outcomes for people with sickle cell disease could be improved through community health worker case management, social support, and health system navigation. This report outlines implementation strategies in current use to test community health workers for sickle cell disease management in a variety of settings. National medical and advocacy efforts to develop the community health workforce for sickle cell disease management may enhance the progress and development of “best practices” for this area of community-based care.

Although the provision of immunoprophylaxis to children has become routine in the practice of pediatric preventive care, the same is not true in adult primary care. Contributing to this problem is a lack of knowledge among providers of adult preventive care. This review aimed to bolster providers' understanding of adult vaccinations by highlighting changes in vaccination recommendations and addressing common knowledge gaps. This is not a comprehensive list of vaccination recommendations, but rather the "top 10" common misconceptions, advancements, and updates we have found in our reading of the vaccination literature and in our own experience in a training institution.

The physical examination in the outpatient setting is a valuable tool. Even in settings where there is lack of evidence, such as the annual physical examination of an asymptomatic adult, the physical examination is beneficial for the physician-patient relationship. When a patient has specific symptoms, the physical examination-in addition to a thorough history-can help narrow down, or in many cases establish, a diagnosis. In a time where imaging and laboratory tests are easily available, but are expensive and can be invasive, a skilled physical examination remains an important component of patient evaluation.

Introduction The Johns Hopkins Pediatrics Clerkship developed this growth module as part of the PRECEDE (preclerkship educational exercises) curriculum, with the primary goal of providing students with experiential, explicit, and standardized instruction in essential pediatric clinical skills to better prepare them to utilize these skills during their clerkship. Methods This 2-hour growth module begins with a 45-minute didactic overview of growth, including discussion of normal growth, normal variants of growth, and disorders that affect growth, and contains interactive elements to engage the students. Students then divide into groups of four to six, each with a faculty facilitator to work through three cases in a guided discussion to explore specific aspects of growth that may be encountered in a pediatric evaluation. Results In a survey of 238 students, 97–100% agreed or strongly agreed with eight positive assessments of the module. Likewise, 79% of students rated the module as excellent, the remainder rating the module as good. Discussion From the perspectives of students and instructors, the implementation of this new module was very successful in its delivery of educational content. These cases were designed to give the students experience in plotting growth parameters against normative data and to gain familiarity with pediatric growth curves in order to identify growth abnormalities. The cases also aimed to reinforce the importance of using growth data in pediatric patients in order to both generate a differential diagnosis for a growth disorder and to modify a differential diagnosis generated by a chief complaint based on growth data.

BACKGROUND: Although residency programs are well situated for developing a physician workforce with knowledge, skills, and attitudes that incorporate the strengths and reflect the priorities of community organizations, few curricula explicitly do so. AIM: To develop urban health primary care tracks for internal medicine and combined internal medicine-pediatrics residents. SETTING: Academic hospital, community health center, and community-based organizations. PARTICIPANTS: Internal medicine and combined internal medicine-pediatrics residents. PROGRAM DESCRIPTION: The program integrates community-based experiences with a focus on stakeholder engagement into its curriculum. A significant portion of the training (28 weeks out of 3 years for internal medicine and 34 weeks out of 4 years for medicine-pediatrics) occurs outside the hospital and continuity clinic to support residents’ understanding of structural vulnerabilities. PROGRAM EVALUATION: Sixteen internal medicine and 14 medicine-pediatrics residents have graduated from our programs. Fifty-six percent of internal medicine graduates and 79% of medicine-pediatrics graduates are seeking primary care careers, and eight overall (27%) have been placed in community organizations. Seven (23%) hold leadership positions. DISCUSSION: We implemented two novel residency tracks that successfully placed graduates in community-based primary care settings. Integrating primary care training with experiences in community organizations can create primary care leaders and may foster collective efficacy among medical centers and community organizations. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-017-4272-y) contains supplementary material, which is available to authorized users.

Objective Although 25% of primary care complaints are otolaryngology related, otolaryngology instruction is not required in most medical schools. Our aim was to systematically review existing literature on the inclusion of otolaryngology in undergraduate medical education. Data Sources PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Education Resources Information Center. Study Design/Review Methods Our search encompassed all indexed years through December 29, 2014. Inclusion criteria were English language, original human data, and a focus on medical student education. Data regarding study design, teacher, educational topic, educational methods, and setting were extracted from each article. Two investigators independently reviewed all articles. Results Our initial search yielded 436 articles; 87 underwent full-text evaluation and 47 remained in the final review. The majority of studies were conducted in the United States (40%), United Kingdom (23%), and Canada (17%) and represented a single institutional experience. Studies were classified as needs assessments (36%), curriculum descriptions (15%), educational methods (36%), and skills assessments (32%); 81% were levels of evidence 3 or 4. Most reports indicated that otolaryngology rotations are not compulsory. Conclusions Studies indicated the need for increased exposure to otolaryngology. Educational methods such as team-based learning, simulation, online learning, and clinical skills assessments may offer ways to increase exposure without overburdening clinical faculty and require further study. Data suggest that a universal otolaryngology medical student curriculum would be valuable and aid in resource sharing across institutions. We recommend that an assessment be performed to determine topics and skills that should comprise this curriculum. Level of Evidence NA Laryngoscope, 125:2695–2708, 2015

Background The American Pain Society recommends that individuals experiencing sickle cell crisis receive parenteral pain medication within 30 minutes of assessment. We examined factors affecting achievement of this standard at the Johns Hopkins Sickle Cell Infusion Center. Methods Baseline patient care time intervals and data on variables affecting the ability to achieve the American Pain Society goal were measured. Time to first parenteral opiate administration was modeled using simple and multivariable linear regression. Results Mean time from initial assessment to first dose was initially 41 minutes. Increased nurse to patient ratio decreased time to first dose. Conclusions Of the factors associated with improved times to first dose, only nurse to patient ratio is amenable to process change, suggesting it as a potential target for future interventions.

The aim of this study was to identify the factors associated with delays in treatment of sickle pain crisis in the pediatric emergency department with the goal of discerning whether earlier pain management is correlated with better clinical outcome.This retrospective study examined data collected from clinical records of patients, aged 21 years or younger, who was treated for sickle cell pain crisis between January and June 2012. Demographic and clinical characteristics were extracted from electronic records, as well as time of registration, triage, initial pain assessment, analgesic administration, and pain reassessment.A total of 160 sickle cell pain crises visits by 67 unique patients were identified. Opiates were the most common initial pain medication prescribed and administered. The mean time to initial analgesic administration and pain reassessment was 89 and 60 minutes, respectively. Patients with orders for imaging studies experienced significant delays in time to initial analgesic medication and pain reassessment. In addition, higher triage pain score correlated with shorter time to first dose of pain medication. However, age, sex, and final disposition did not affect time to administration of analgesic medications.Earlier pain management resulted in shorter ED length of stay for all patients regardless of disposition. However, earlier pain management did not affect the total length of hospitalization for patients admitted to the inpatient services.Pediatric patients with sickle cell pain crises experienced significant delays to initial analgesic medication. A standardized approach to pain management may improve ED management of SCD crises.

Background Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. Methods One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). Results Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing ‘a’ from ‘v’ waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. Conclusions A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

Hospital readmission rates are increasingly used as a measure of healthcare systems’ quality and effectiveness and a tool for reimbursement or penalization if rates are excessive.[1][1] Patients with chronic conditions and patients without a primary care provider often seek care in the emergency

We are concerned that providing insurance for the previously uninsured will be seen as a panacea for resolving health disparities, for the social environment makes a tremendous difference in health outcomes. A careful examination of the factors involved in the social determinants of health shows that health insurance plays only a small role in alleviating health disparities. In this commentary, we highlight the complexity of the problem of the social determinants of health and health disparities in the United States by comparing two neighborhoods in Baltimore City and by examining hypertension and mental health disorders.

OBJECTIVE: More effective transitions and transfers of young people with sickle cell disease (SCD) into the adult healthcare setting is a focus of both primary care and specialty care medical organizations. Effective transition and transfer requires six core elements: establishing a policy, tracking progress, administering transition readiness assessments, planning for adult care, transferring to adult care, and integrating into an adult practice. We developed a program using these six core elements. The objective of our report was to assess the development and implementation of this program. METHODS: We used the six core elements to develop and implement a program at Virginia Commonwealth University for children and adolescents with SCD to transition to adult health care. RESULTS: We assessed individuals’ differences by age and grade, their independent living skills, their feelings about moving to adult care, tallied and analyzed several assessment scales, and assessed transfer success and patient retention. CONCLUSIONS: The principles and lessons we learned in developing and implementing this program over 5 years, accompanied by caring, flexible, and dedicated care team members, often can overcome even severe barriers to care transitions.

Introduction The PRECEDE (preclerkship educational exercises) curriculum was developed by the Johns Hopkins Pediatrics Clerkship with the primary goal of providing students with experiential, explicit, and standardized instruction in essential pediatric clinical skills to better prepare them for their clerkships. This data interpretation workshop is one of a series of modules within the PRECEDE curriculum presented just prior to the clerkship. Methods This 2-hour workshop divides medical students into small groups of four to six students, each group with a faculty facilitator. Three clinical vignettes are presented to the student groups. For each vignette, students participate in a guided discussion to develop an interpretation and understanding of what is often misinterpreted pediatric information, such as developmental milestones, vital signs, and laboratory values. Results From the perspectives of students and instructors, the implementation of this new module was very successful in terms of its delivery of educational content and its organizational structure. Of 229 students who participated in the session and completed surveys, 77% strongly agreed the session was educationally valuable. Discussion By establishing important basic skills of correct pediatric data interpretation, students may be better equipped to develop appropriate differential diagnoses, assessments, and plans of care for patients.

This review comprises a general overview of the impact and risk factors for prostate cancer. Evidenced-based professional society prostate cancer screening guideline recommendations are reviewed, and our approach to a case is presented.

Objectives Poor oral health can have a negative impact on overall health. This is especially concerning for individuals with sickle cell disease (SCD), an inherited blood disorder that affects hemoglobin and can lead to an increased risk of infection and hyperalgesia. Because the majority of individuals with SCD have Medicaid insurance and no dental coverage, we provided free basic dental care to individuals with SCD to determine whether it decreased overall healthcare utilization. Methods Through a contract with a private dental office, we provided free basic dental care (eg, cleanings, fillings, x-rays) to individuals with SCD. We reviewed medical records for the 12 months before and after their initial dental visit to determine whether there were any changes in acute care visits (defined as a visit to the emergency department, sickle cell infusion center, or visits to both in the same day), hospitalizations, and total days hospitalized. We conducted a negative binomial regression to determine any differences in the pre-post periods. Results In our multivariable analysis, there was a statistically significant decrease in hospital admissions. In addition, there was a significant decrease in total days hospitalized if dental work was completed, but an increase in days hospitalized in men. Conclusions Providing dental care to individuals with SCD who did not have dental insurance did not greatly alter acute care visits. A larger sample size may be necessary to observe an effect.

Johns Hopkins University recently implemented two novel urban health residency training programs (UHR). The programs include increased access programs, community health worker-delivered care, substance abuse screening and treatment, community psychiatry/ mental health programs, case and disease management teams, and interprofessional training. These programs are designed to create well-trained physicians who competently provide care for the underserved inner-city patient.

Objectives: The purpose of this study was to assess changes in students’ perceptions of the medical school sense of community and their satisfaction with advising following the initiation of a structured advising program at the Johns Hopkins University School of Medicine. Methods: Participants included School of Medicine graduates from 2006 to 2009. Total sample size was 471. The response rate was 367/471 (81%). A cross-sectional survey design was utilized to assess students’ perceived differences in advising and sense of community. Scales were developed to assess these constructs. Scale scores and responses to individual items were compared by graduation year. Results: Statistically significant increases over time were noted on the Advising Satisfaction (F (3,363) = 6.54; p≤0.001) and the Relational Community (F(3,363) = 2.76; p=0.042) scales. Using simple logistic regression, unadjusted Odds Ratios show that students graduating in 2009 report higher quality of advising during their clinical years (OR 2.87, 95% CI=1.56-5.28), around academics (OR 2.54, 95% CI=1.414.60), career planning (OR 1.87, 95% CI=1.03-3.38), stress management (OR 2.88, 95% CI=1.56-5.30), and an enhanced sense of community (OR 2.55, 95% CI=1.40-4.64), and social integration (OR 2.07, 95% CI=1.15-3.71) compared to 2006 graduates. Conclusions: We found, that students were more satisfied with advising and the medical school environment over the four years of maturation of the Program. A structured advising program that fosters meaningful, longitudinal relationships between students and advisors may enhance students’ experiences during medical school.

Background: In July 2005, a learning community was created at Johns Hopkins University School of Medicine (JHUSOM) to foster camaraderie, networking, advising, mentoring, professionalism, clinical skills, and scholarship—The Colleges. The cultural and structural changes that emerged with the creation of this program have resulted in JHUSOM bearing a resemblance to J. K. Rowling’s fictional Hogwarts School of Witchcraft and Wizardry. Aims: This manuscript will describe the similarities between these two revered schools, and highlight the innovations and improvements made to JHUSOM’s learning environment. Description: The intense, stressful, and lengthy professional training required to achieve competency in the practice of medicine and in the practice of witchcraft (albeit fictional) have meaningful parallels. Conclusion: The supportive learning environment at these two schools should afford the next generation of graduates to have an even more enriching experience than those who have come before them.