Carey Roth Bayer

Retrospective analysis of the prognostic value of electroencephalography patterns obtained in pediatric in-hospital cardiac arrest survivors during three years*

Objective: To test the hypothesis that electroencephalography has prognostic value in children after in-hospital cardiac arrest. Design: Single-center, retrospective chart review. Setting: Urban tertiary care childrens hospital, January 2001 to July 2004. Patients: Thirty-four consecutive children were identified from a registry of all patients resuscitated for cardiac arrest. Inclusion criteria were age >44 wks postmenstrual age to 18 yrs, survival after in-hospital cardiac arrest >24 hrs, and undergoing electroencephalography within 7 days after the cardiac arrest. Interventions: None. Measurements and Main Results: Prearrest, event, cardiopulmonary resuscitation, and postresuscitation variables were collected. Neurologic outcome was assessed by Pediatric Cerebral Performance Category (PCPC). Prearrest PCPC was estimated from chart review. Change in PCPC >1 or death between prearrest and time of hospital discharge was defined as poor neurologic outcome. Experts blinded to PCPC outcomes scored electroencephalographs from 1 (normal) to 5 (isoelectric). Sensitivity/specificity analysis and receiver operating characteristic curve were developed with each electroencephalography grade cutoff. Of 184 consecutive patients who had cardiac arrests in our registry, 107 survived >24 hrs, and 83 met study criteria. Thirty-four patients had electroencephalography within the first 7 days after the cardiac arrest. Among those, 16 (47%) patients had good neurologic outcome defined as no change in PCPC, and 18 (53%) died or had poor neurologic outcome. Univariate analysis showed that a higher electroencephalography score performed within 7 days was associated with poor neurologic outcome (p < .05). Positive predictive value of electroencephalography grade 4–5 for poor neurologic outcome was 90%, and negative predictive value of electroencephalography grade 1–2 for poor neurologic outcome was 91%. Conclusions: In a single-center consecutive case series, electroencephalography background patterns during the initial 7 days after in-hospital cardiac arrest were associated with neurologic outcome in children.

Neuron-specific enolase and S-100B are associated with neurologic outcome after pediatric cardiac arrest.

Objective: To characterize the pattern of serum biochemical markers of central nervous system injury (neuron-specific enolase [NSE], S-100B, plasminogen activator inhibitor-1 [PAI-1]) after pediatric cardiac arrest and determine whether there is an association between biomarker concentrations and neurologic outcome. Design: Prospective, observational study. Setting: Urban, tertiary care childrens hospital. Patients: Cardiac arrest survivors, n = 35. Interventions: Serial blood sampling, pediatric cerebral performance category, and standardized neurologic examination. Measurements and Main Results: Serial serum NSE and S-100B concentrations over 96 hrs and PAI-1 at 24 hrs were measured in children (age <18 yrs) who had return of spontaneous circulation following cardiac arrest. Neurologic outcome was prospectively categorized as poor if the change in pre- to postarrest pediatric cerebral performance category was ≥2. Biomarker concentrations were compared between outcome groups and between survival groups using longitudinal analysis correcting for multiple comparisons. Median levels (25th, 75th percentiles) are reported. Receiver operating characteristic analyses were performed at all time points. Biomarker concentrations showed statistically significant differences. Of the 35 patients, neurologic outcomes were poor in 19, with 15 deaths. Median NSE concentrations differed by outcome when measured at ≥48 hrs, and by survival at ≥24 hrs. S-100B concentrations were not significantly associated with neurologic outcome. S-100B levels were associated with survival outcome at ≥48 hrs. PAI-1 levels were not significantly associated with either neurologic or survival outcomes. Conclusions: The timing, intensity, and duration of serum NSE and S-100B biomarker concentration patterns are associated with neurologic and survival outcomes following pediatric cardiac arrest. Serum NSE concentrations at ≥48 hrs are associated with neurologic outcome, whereas serum S-100B levels at ≥48 hrs are associated with survival. Prospective analysis of these markers may help to predict outcomes and guide postresuscitative therapies.

Giving Context to the Physician Competency Reference Set: Adapting to the Needs of Diverse Populations.

Delineating the requisite competencies of a 21st-century physician is the first step in the paradigm shift to competency-based medical education. Over the past two decades, more than 150 lists of competencies have emerged. In a synthesis of these lists, the Physician Competency Reference Set (PCRS) provided a unifying framework of competencies that define the general physician. The PCRS is not context or population specific; however, competently caring for certain underrepresented populations or specific medical conditions can require more specific context. Previously developed competency lists describing care for these populations have been disconnected from an overarching competency framework, limiting their uptake. To address this gap, the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development adapted the PCRS by adding context- and content-specific qualifying statements to existing PCRS competencies to better meet the needs of diverse patient populations. This Article describes the committee’s process in developing these qualifiers of competence. To facilitate widespread adoption of the contextualized competencies in U.S. medical schools, the committee used an established competency framework to develop qualifiers of competence to improve the health of individuals who are lesbian, gay, bisexual, transgender; gender nonconforming; or born with differences in sexual development. This process can be applied to other underrepresented populations or medical conditions, ensuring that relevant topics are included in medical education and, ultimately, health care outcomes are improved for all patients inclusive of diversity, background, and ability.

Health Policy Training: A Review of the Literature

The context within which health care and public health systems operate is framed by health policies. There is growing consensus about the need for increased health policy leadership and a health professional workforce prepared to assume these leadership roles. At the same time, there is strong evidence supporting the need for a broader policy lens and the need to intentionally target health disparities. We reviewed the published literature between 1983 and 2013 regarding health policy training. From 5124 articles identified, 33 met inclusion criteria. Articles varied across common themes including target audience, goal(s), health policy definition, and core curricular content. The majority of articles were directed to medical or nursing audiences. Most articles framed health policy as health care policy and only a small number adopted a broader health in all policies definition. Few articles specifically addressed vulnerable populations or health disparities. The need for more rigorous research and evaluation to inform health policy training is compelling. Providing health professionals with the knowledge and skills to engage and take leadership roles in health policy will require training programs to move beyond their limited health care-oriented health policy framework to adopt a broader health and health equity in all policies approach.

Eight Spheres of Intimacy.

Intimacy can be a complex subject. However, holistic and healthy intimacy exists in many forms and can be achieved not only with a romantic other but also with ones friends, family, professional colleagues, and self. As part of lifespan development, it is ideal to build a knowledge base and skill set to comprehend the multiple facets of intimacy. It is hypothesized that intimacy skills can also act as a protective factor for the primary prevention of dating violence, sexual violence, unintended pregnancy, HIV/AIDS, and sexually transmitted diseases.

Moving Medical Education and Sexuality Education Forward

Despite well-documented sexual health disparities, medical school training in human sexuality remains limited. Our intents with this paper are to deconstruct the successes and challenges in including sexuality education in medical education and to pose critical questions for moving medical education and sexuality education forward. We offer future systematic level strategies for consideration, including the role of health policy in addressing this problem in training. It is imperative that all physicians are well equipped to address sexual health with patients in order to help eliminate sexual health disparities. Finding solutions to bridge the patient realities with the medical training realities is one step in creating sexually healthy societies.

Understanding health policy leaders’ training needs

Purpose We assessed the training needs of health policy leaders and practitioners across career stages; identified areas of core content for health policy training programs; and, identified training modalities for health policy leaders. Methods We convened a focus group of health policy leaders at varying career stages to inform the development of the Health Policy Leaders’ Training Needs Assessment tool. We piloted and distributed the tool electronically. We used descriptive statistics and thematic coding for analysis. Results Seventy participants varying in age and stage of career completed the tool. “Cost implications of health policies” ranked highest for personal knowledge development and “intersection of policy and politics” ranked highest for health policy leaders in general. “Effective communication skills” ranked as the highest skill element and “integrity” as the highest attribute element. Format for training varied based on age and career stage. Conclusions This study highlighted the training needs of health policy leaders personally as well as their perceptions of the needs for training health policy leaders in general. The findings are applicable for current health policy leadership training programs as well as those in development.

Developing Health Leaders to Combat Sexual Health Disparities

Health disparities, including sexual health disparities, remain pervasive in our society. The Satcher Health Leadership Institute at Morehouse School of Medicine, through its Sexual Health Scholars and Health Policy Leadership Fellowship Programs, is preparing the next generation of health leaders with the necessary knowledge and skills to combat health disparities.

The Missing Links: Understanding the Role of Motivations and Power Differentials in the Sexual Behaviors of Young Gay and Bisexual Males

In their article, entitled ‘‘Age-Concordant and Age-Discordant Sexual Behavior among Gay and Bisexual Male Adolescents,’’ Bruce, Harper, Fernández, and Jamil (2012) presented descriptive and exploratory research by assessing the range of sexual behaviors and identifying partner age-specific trends of gay and bisexual male adolescents. Research on adolescent sexual behavior has focused on the sexual behavior of heterosexual females with older male partners, claiming increased HIV risk for females who have sex with older men (Miller, Clark, & Moore, 1997). Bruce et al. moved beyond the adolescent female-older male focus into research addressing the risks for HIV in the sexual behaviors of young gay and bisexual men. Bruce et al. assessed the sexual behavior of 200 gay and bisexual males, ages 15–22 years, in Chicago and South Florida. Key findings from their work indicate age-concordant sexual behavior among the study sample—participants reported more oral, receptive anal, and insertive anal sex with partners of the same age than with partners of younger, slightly older, and much older ages—and sexual initiation for oral sex, receptive anal, and insertive anal sex at ages 15, 16.5, and 17 years, respectively. The research is particularly important because 13–29 year-old males who have sex with men (MSM) accounted for 69 % of new HIV infections in 2009 (CDC, 2012a, b). Adolescent MSM (age 13–19 years) experienced a 51 % increase in HIV infections and young adult MSM (age 20–24 years) experienced a 52 % increase in HIV infections between 2006 and 2009 (CDC, 2012a). While Bruce et al. help expand our understanding, descriptively, of young gay and bisexual males, motivations behind partner selection based on age were not addressed and may provide greater insight into partner age patterns and power differentials for various sexual acts. Furthermore, replicating the research in additional geographic areas, such as Baltimore, San Francisco, New York City, Dallas, and Houston, where HIV prevalence is high among MSM (CDC, 2010) may reveal more statistically significant trends in sexual behaviors. Bruce et al. used data from the Adolescent HIV Medicine Trials Network, a multiphase and multi-site mixed methods study. Yet, the participants’ motivations for engaging in specific sexual behaviors were not illuminated in the article. Mustanski, Newcomb, and Clerkin (2011) conducted qualitative interviews using audio computer assisted self-interview (ACASI) technology to assess the characteristics of MSM relationships and related sexual behaviors. Perhaps ACASI may be used to investigate the motivating factors for certain sexual behaviors and for selecting a partner of a particular age, whether older, younger, or same age. Moreover, determining sexual motivation may help explain the trend Bruce et al. identified where young gay and bisexual males engaged in receptive anal sex while under the influence of drugs or alcohol with much older partners. Power differentials play a role in sexual relationships between adolescent girls and adult men, increasing the risk of these girls acquiring HIV (Miller et al., 1997). Understanding power differentials in relationships between young males and older males may provide insight into relationship dynamics and HIV risks for young MSM. Bruce et al. suggested that J. Eugene Medical Education, Morehouse School of Medicine, Atlanta, GA, USA

A Review of 99 Things Parents Wish They Knew Before® … Having “THE” Talk

Numerous books exist on parent-teen communication related to sex, sexuality, and sexual health. However, Chris Fariello and Pierre-Paul Tellier take a new, question-and-answer approach to reaching todays busy parents in their book 99 Things Parents Wish They Knew Before® … Having “THE” Talk. The concept behind the book is innovative, but the execution needs improvement. A revised, second edition is needed to address the clinical/colloquial language confusion, definitions of key words and concepts, and copy editing challenges.