Patricia Keefer

Use of simulated electronic mail (e-mail) to assess medical student knowledge, professionalism, and communication skills.

Background Physicians communicate with patients using electronic mail (e-mail) with increasing frequency. Communication skills specific to e-mail do not appear to be taught explicitly in medical school. Therefore, the effect of an instructive session on effective e-mail communication was examined. Method Four simulated e-mails from a parent were developed. Students responded to an initial e-mail and then participated in a session on effective e-mail communication. Responses to a final e-mail were assessed using a rubric with subscores for medical knowledge, communication, and professionalism. Results Performance improved from the first to final e-mail response in the overall score and in each subscore. Improvement was sustained over the course of the academic year. Interrater reliability revealed good agreement. Conclusions Communicating effectively with patients via e-mail is not intuitive but can be taught. It is feasible to introduce responses to a simulated e-mail case in a clinical clerkship as an assessment tool.

Continuous Lidocaine Infusions to Manage Opioid-Refractory Pain in a Series of Cancer Patients in a Pediatric Hospital.

Research on the safety and efficacy of continuous lidocaine infusions (CLIs) for the treatment of pain in the pediatric setting is limited. This article describes a series of pediatric oncology patients who received lidocaine infusions for refractory, longstanding, cancer‐related pain.

Use of Intravenous Acetaminophen (Paracetamol) in a Pediatric Patient at the End of Life: Case Report

BACKGROUND For the better part of 100 years, acetaminophen (or paracetamol as it is known outside of the United States) has been a common first-line analgesic in pediatrics and is typically well tolerated with minimal side effects. Its use as an anti-pyretic is also well-documented and thus it is used broadly for symptom control in the general pediatric population. DISCUSSION In pediatric palliative care, acetaminophen is also used as an adjuvant to opioid therapy for pain as well as an anti-pyretic. For many pediatric patients near end-of-life, however, the ability to tolerate oral intake is diminished and rectal suppository administration can be distressing or contraindicated as in the setting of neutropenia, thus limiting use of acetaminophen by its usual routes. In Europe and Australia, an intravenous formulation of acetaminophen has been used for many years and has only recently become available in the United States. CONCLUSION Here, we describe a case using intravenous acetaminophen in a pediatric patient at the end of life.

Neonatal Circumcision: Is Feeding Behavior Altered?

BACKGROUND The effect of circumcision on feeding behavior in the newborn period is unknown. We hypothesized that circumcision would not have a significant effect on newborn feeding. METHODS This prospective study analyzed the effect of circumcision on neonatal feeding behavior. Inclusion criteria were healthy male infants WHO were exclusively bottle-fed and underwent a circumcision before discharge from the newborn nursery. We collected data (N = 42) on gestational age, birth weight, Apgar scores, maternal age, gravid status, anesthesia used during delivery, analgesia used after circumcision, time of circumcision, and volume and frequency of feeding before and after circumcision. Data were analyzed by using paired t tests, multivariable regression analysis, and analysis of variance (with SPSS version 18). Significance was P < .05 (2-tailed α). RESULTS Descriptive statistics for the entire group (N = 42) are as follows: mean ± SD gestational age: 38.7 ± 1.2 weeks; mean birth weight: 3.3 ± 0.4 kg; maternal age: 26.7 ± 6.3 years; baseline feeding (mean of first 2 feedings before circumcision): 24.5 ± 9.9 mL; mean first feeding after circumcision: 21.7 ± 11.9 mL; and mean second feeding: 26.7 ± 13.5 mL. Forty-eight percent of patients increased their feeding volume after circumcision compared with baseline, and 52% of patients decreased their feeding volume, which persisted with the second feeding. There was no statistical difference between the baseline and first feeding (P = .11) or second feeding (P = .22). CONCLUSIONS Our data suggest that circumcision does not alter feeding after circumcision. This information will be useful in counseling families regarding circumcision in the newborn period.

National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings

BACKGROUND Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management. METHODS In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondents respective hospital. RESULTS Responses were obtained from 38 North American academic childrens hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management. CONCLUSION Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.

Using the LACE Score as a Predictor of Clinical Outcomes in Patients Referred for Inpatient Palliative Care Consultation: A Single-Center Experience

BACKGROUND Readmissions and death for palliative care patients are common and costly outcomes for hospitals, patients, and/or caregivers. Predicting which patients are likely to be readmitted or die within 30 days would help allocate resources and aid in patient disposition planning. Few factors have been strongly correlated with predicting which patients will be readmitted or die within 30 days of hospital discharge. The LACE (Length of Stay, Acuity of admission, Charlson comorbidity index, Emergency department use) score has been validated in medical/surgical patients; however, it has not been evaluated in the palliative care population. OBJECTIVE To evaluate the LACE score in palliative care population. DESIGN This study was a single-center retrospective cohort design. SETTING/PATIENTS Patients were identified based on their consultation to an inpatient palliative care service. MEASUREMENTS Thirty-day readmissions, 30-day mortality, length of stay, acuity of admission, Charlson comorbidity index, emergency department utilization, and demographic information. RESULTS The LACE score was not an accurate predictor of clinical outcomes in the palliative care population. Patients who were readmitted or died within 30 days tended to be younger. Patients who were readmitted within 30 days tended to have increased emergency department use in the previous 6 months. CONCLUSIONS Our study demonstrates the LACE score may not be a sensitive predictor of clinical outcomes in our institutions palliative care patients. This may be due to the complexity of the required care in this population; thus, other factors should be investigated to determine accurate predictors of patient outcomes to better allocate resources.