Esophageal Surveillance Practices in Esophageal Atresia Patients: A Survey by the Eastern Pediatric Surgery Network

IntroductionEndoscopic surveillance guidelines for patients with repaired esophageal atresia (EA) rely primarily on expert opinion. Prior to embarking on a prospective EA surveillance registry, we sought to understand EA surveillance practices within the Eastern Pediatric Surgery Network (EPSN).MethodsAn anonymous, 23-question Qualtrics survey was emailed to 181 physicians (surgeons and gastroenterologists) at 19 member institutions. Likert scale questions gauged agreement with international EA surveillance guideline-derived statements. Multiple-choice questions assessed individual and institutional practices.ResultsThe response rate was 77%. Most respondents (80%) strongly agree or agree that EA surveillance endoscopy should follow a set schedule, while only 36% claimed to perform routine upper GI endoscopy regardless of symptoms. Many institutions (77%) have an aerodigestive clinic, even if some lack a multi-disciplinary EA team. Most physicians (72%) expressed strong interest in helping develop evidence-based guidelines.ConclusionsOur survey reveals physician agreement with current guidelines but weak adherence. Surveillance methods vary greatly, underscoring the lack of evidence-based data to guide EA care. Aerodigestive clinics may help implement surveillance schedules. Respondents support evidence-based protocols, which bodes well for care standardization. Results will inform the first multi-institutional EA databases in the United States (US), which will be essential for evidence-based care.Level of EvidenceThis is a prognosis study with level 4 evidence.     

The impact of California's staffing mandate and the economic recession on registered nurse staffing levels: A longitudinal analysis

BackgroundDespite the importance of adequate hospital nurse staffing, California is the only state with minimum nurse-to-patient ratio mandates. The health care workforce is historically “countercyclical”—exhibiting growth during economic recessions when employment in other sectors is shrinking.PurposeThis study was to examine how staffing mandates impact hospital nurse staffing during economic recessions.MethodWe compared hospital nurse staffing in California and in other states over 20 years to examine differences before and after the California mandate and, within the postmandate period, before, during, and after the Great Recession of 2008.FindingsStaffing differences increased during the postmandate period due to faster growth in California staffing compared to other states, except during the Great Recession, when staffing remained stable in California but declined in other states.DiscussionState legislators deliberating staffing mandates should consider the protective factor such policies provide during economic recessions and the implications for the quality and safety of care.     

Medical Devices Made Into Weapons by Prisoners: An Unrecognized Risk

Study objective: The alteration of a knee immobilizer into a sharp weapon by a prisoner prompted us to survey neighboring penal institutions to determine the frequency of such events. Design: We mailed a nine-item survey to all detention facilities in Tennessee, Arkansas, and Mississippi. A second survey was sent to nonresponding institutions 6 weeks after the initial mailing. Setting: The Regional Medical Center at Memphis, the designated facility for evaluation and treatment of prisoners from the county jail and state penitentiary. Participants: Survey respondents included 25 state penitentiaries, 31 county jails, 1 state minimum-security facility, 1 state maximum-security facility, 1 work-release center, 1 county detention center for drunken-driving offenders, and 1 federal penitentiary. Results: Of the 81 institutions surveyed, 77% responded to one of the two mailings. Forty percent responded in the affirmative when asked whether stolen or unauthorized medical equipment from outside their institutions had been discovered among inmates. When respondents were questioned as to whether medical equipment, prescribed or not, had been used or altered in a criminal manner, 34% responded "yes." Medications and medical appliances were listed in the responses. Conclusion: A survey of 81 local and neighboring penal institutions in a three-state area revealed that the illicit use of medicine and medical devices by prisoners is a legitimate safety concern of prison personnel and health care workers when medical care for inmates must be sought outside the security of their institutions. The modification of medical equipment into weapons by incarcerated patients, although clearly recognized as a security and safety problem by police authorities, appears to be unappreciated by health care workers providing episodic care to inmates. [Hayden JW, Laney C, Kellermann AL: Medical devices made into weapons by prisoners: An unrecognized risk. Ann Emerg Med December 1995;26:739-742.]     

Epidemiology of Travelers— Diarrhea: Details of a Global Survey

Background Recent epidemiologic data on travelers— diarrhea (TD) are essential for the evaluation of conventional and future prophylactic and therapeutic measures.
Methods To determine the epidemiology, including risk factors, impact and quality-of-life evaluation of TD, a cross-sectional survey was conducted over 12 months at the airports of Mombasa (Kenya), Goa (India), Montego Bay (Jamaica) and Fortaleza (Brazil) by distributing questionnaires to visitors just prior to their flying home. The study period was March 1996 to July 1998.
Results Overall, 73,630 short-term visitors completed a questionnaire. The total diarrhea attack rate varied between a high of 54.6% in Mombasa and a low of 13.6% in Fortaleza, but only between 31.5% and 5.4% of all travelers had classic TD. The 14-day incidence rates varied between 19.5% and 65.7%. Few travelers meticulously avoided potentially dangerous food items, although in India and Kenya most travelers avoided those considered most dangerous. Risk factors were stays exceeding 1 week, age between 15 and 30 years, and residence in the UK. The impact, measured as incapacity or quality-of-life scores, was very considerable.
Conclusions TD continues to affect vacationers and business travelers as frequently as it did some 20 years ago. Compliance with recommendations to reduce exposure to pathogens by avoiding dangerous food items is poor among travelers from all countries. Implementation of food safety education programs may be difficult to achieve.