Improved documentation of wound care with a structured encounter form in the pediatric emergency department.

OBJECTIVE: Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital. METHODS: The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care. RESULTS: Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting. DISCUSSION: In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.     

Associations of Neighborhood and School Socioeconomic and Social Contexts With Body Mass Index Among Urban Preadolescent Students

Objectives. We examined independent and synergistic effects of school and neighborhood environments on preadolescent body mass index (BMI) to determine why obesity rates nearly double during preadolescence.Methods. Physical measures and health surveys from fifth and sixth graders in 12 randomly selected schools in New Haven, Connecticut, in 2009 were matched to student sociodemographics and school- and residential census tract–level data, for a total of 811 urban preadolescents. Key independent variables included school connectedness, neighborhood social ties, and school and neighborhood socioeconomic status. We estimated cross-classified random-effects hierarchical linear models to examine associations between key school and neighborhood characteristics with student BMI.Results. Greater average connectedness felt by students to their school was significantly associated with lower BMI. This association was stronger among students living in neighborhoods with higher concentrations of affluent neighbors.Conclusions. How schools engage and support students may affect obesity rates preferentially in higher-income neighborhoods. Further research should explore the associations between multiple environments to which children are exposed and obesity-related behaviors and outcomes. This understanding of the multiple social–spatial contexts that children occupy has potential to inform comprehensive and sustainable child obesity prevention efforts.Approximately 17% of the children in the United States aged 2 to 19 years are obese.1 Obesity has both short- and long-term health consequences through adulthood.2–5 A vast field of research has struggled to identify factors contributing to this epidemic that are most amenable to change. Recent research has used ecological frameworks to explore risks for childhood obesity at multiple levels,6 including school7 and neighborhood8 contexts, yet few studies have explored these contexts simultaneously.9–11 Despite the fact that obesity rates nearly double during preadolescence,12 few studies have explored contextual effects specific to this age group.13     

Serving Veterans in their Communities: Evaluation of an Online Resource for Behavioral Health Care Providers

Many veterans receive behavioral health care services from providers in their communities. The Community Provider Toolkit (the Toolkit) is a website developed by the National Center for PTSD and the Department of Veterans Affairs intended to provide community mental health care providers with key veteran-focused educational resources. This mixed-methods study examined the potential impact of the Toolkit on provider knowledge and behaviors. Sixty-four clinicians in the community who currently or plan to provide services to veterans were surveyed. The majority of providers found the website useful and easy to navigate. After visiting the site, many providers found additional online and educational resources that they would add to a hypothetical treatment plan. Forty-five providers completed a 1-month follow-up survey focused on use of the Toolkit. Results indicate that the Toolkit may be a valuable tool for increasing provider knowledge about veteran-specific resources.

     

In vivo 3D morphology of astrocyte–vasculature interactions in the somatosensory cortex: implications for neurovascular coupling

Astrocytes are increasingly believed to play an important role in neurovascular coupling. Recent in vivo studies have shown that intracellular calcium levels in astrocytes correlate with reactivity in adjacent diving arterioles. However, the hemodynamic response to stimulation involves a complex orchestration of vessel dilations and constrictions that spread rapidly over wide distances. In this work, we study the three-dimensional cytoarchitecture of astrocytes and their interrelations with blood vessels down through layer IV of the mouse somatosensory cortex using in vivo two-photon microscopy. Vessels and astrocytes were visualized through intravenous dextran-conjugated fluorescein and cortically applied sulforhodamine 101 (SR101), respectively. In addition to exploring astrocyte density, vascular proximity, and microvascular density, we found that sheathing of subpial vessels by astrocyte processes was continuous along all capillaries, arterioles, and veins, comprising a highly interconnected pathway through which signals could feasibly be relayed over long distances via gap junctions. An inner SR101-positive sheath noted along pial and diving arterioles was determined to be nonastrocytic, and appears to represent selective SR101 staining of arterial endothelial cells. Our findings underscore the intimate relationship between astrocytes and all cortical blood vessels, and suggest that astrocytes could influence neurovascular regulation at a range of sites, including the capillary bed and pial arterioles.     

Functional and anatomical correlates of impaired velocity storage

Velocity storage (VS), a brainstem function, extends the low-frequency response of the vestibular system. To better understand VS mechanisms and characteristics in humans, we analyzed retrospectively functional measures of gait, electrophysiological measures of vestibular function, and imaging studies in an attempt to determine clinical, electrophysiological, and anatomical correlates of abnormalities in VS. Two cohorts of patients referred to our Risk of Falls Assessment Clinic participated in this investigation. Group 1 (control) patients demonstrated normal caloric and rotary chair tests. Group 2 patients with impaired velocity storage (experimentals) differed clinically from Group 1 only by demonstrating abnormal multifrequency vestibulocular reflex phase measures on rotational testing. Results showed that Group 2 patients had greater impairments in postural stability and gait than Group 1 patients. Additionally, 80% of patients in Group 2 and none in Group 1 showed pontine hyperintense lesions on MRI.     

Detection of ophthalmic impairments indirectly with electronystagmography

The objective was to develop, from a pool of clinical electronystagmography (ENG) data, normal lower limits for the corneo-retinal potential (CRP). The CRP evaluated in the present study was derived as a byproduct of eye movement calibration with a computerized ENG system. The data set was collected from a cohort of patients without history of ophthalmic disease. This normative study was designed to develop upper and lower limits for the CRP recorded indirectly from ENG testing. Subjects were 107 consecutive patients (41 males, mean age 57 years). Subject age did not, but gender did affect significant changes in the CRP. Specifically women showed larger CRP values than men. Case studies are presented that support the contention that the dark-adapted CRP may be helpful in the identification of patients with ophthalmic diseases known to affect the CRP and, thus, augment information normally obtained in the course of the ENG examination.     

Low calcium-induced release of glutamate results in autotoxicity of cerebellar granule cells

Primary cultures of cerebellar rat granule neurons were grown for 18-22 days in vitro in the absence of antibiotics. When the cultures were placed in a low calcium (no EGTA) balanced salt solution at room temperature, rapid cell death occurred usually within 30 min of placing cells in the buffer. Changes in the cells were evident within 10 min and included an apparent cellular granulation with a partial loss of cell body birefringence at 10 x magnification which was complete by 30 min. This rapid death was prevented by (1) replacing chloride in the buffer with acetate; (2) increasing the osmolarity of the buffer by 30% with sucrose; (3) the addition of the selective excitatory amino acid (EAA) antagonist, 2-amino-7-phosphonoheptanoic acid (APH, 200 microM) but not by the selective kainate-quisqualate antagonist, glutamylaminomethylsulfonic acid (GAMS, 400 microM); or (4) the addition of one of the following calcium channel antagonists, verapamil (400 microM) diltiazem (150 microM) or lanthanum (5 microM). Placing cells in low calcium buffer resulted in a 3.7- and 3.2-fold increase in the non-selective secretion of aspartate and glutamate (as well as other amino acids) over baseline secretion (same buffer except containing 2.5 mM calcium). This increase was partially prevented by verapamil, but not by APH or chloride deletion. Verapamil only partially prevented the efflux of glutamate in buffer containing 1 mM EGTA. These results indicate that placing cells in low calcium buffer results in neurotoxicity secondary to both the influx of chloride and water in conjunction with the efflux of amino acids, some of which stimulate an excitatory amino acid receptor.(ABSTRACT TRUNCATED AT 250 WORDS)