Vera Goldberg - Academia.edu (original) (raw)

Papers by Vera Goldberg

Case Reports, May 16, 2017

Pediatrics, Oct 24, 2017

Short bowel syndrome (SBS) is a disease of insufficient intestinal nutritional absorption because... more Short bowel syndrome (SBS) is a disease of insufficient intestinal nutritional absorption because of inadequate bowel length. 1, 2 In a 1992 study, researchers estimated there were 40 000 children nationally with SBS, and although there are no more recent published estimates, the population is thought to be growing in number. 3 In its most severe form, SBS may lead to intestinal failure (IF), defined by the necessity for parenteral nutrition (PN), which must be delivered by an indwelling central venous catheter (CVC). 4 Less commonly, IF may occur in children with adequate bowel length but inadequate absorption or motility. 2 Children with IF are at high risk of bloodstream infection because of poor nutritional status, disrupted intestinal immunity, potential bacterial translocation across the bowel wall, and the presence of the CVC, which provides a locus for bacterial growth. As a result, when children with IF develop fever, they have a high rate of bacteremia. In 1 study, researchers demonstrated that 46% of hospitalized

International Journal for Quality in Health Care, May 9, 2017

Quality issue: Quality improvement (QI) is a key strategy for improving diabetes care in low-and ... more Quality issue: Quality improvement (QI) is a key strategy for improving diabetes care in low-and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients. Initial assessment: Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care. Choice of solution: This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework. Implementation: A bundle of improvement activities were implemented at the home, clinic and institutional level. Evaluation: Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control. Lessons learned: Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.

The Journal of Pediatrics, May 1, 2018

To determine which factors confer the greatest risk of central line-associated bloodstream infect... more To determine which factors confer the greatest risk of central line-associated bloodstream infection (CLABSI) in children with intestinal failure and fever presenting to an emergency department (ED), and to assess whether a low-risk group exists that may not require the standard treatment of admission for 48 hours on intravenous antibiotics pending culture results. This retrospective cohort study included children with intestinal failure and fever presenting to an ED over a 6-year period. Multivariable models were created using risk factors selected a priori to be associated with CLABSI as well as univariate predictors with P < .2. Among 81 patients with 278 ED encounters, 132 (47.5%) CLABSI episodes were identified. Multivariable models showed higher initial temperature in the ED (aOR, 1.99; 95% CI, 1.25-3.17) and low white blood cell count (aOR, 2.65; 95% CI, 1.03-6.79) and platelet count (aOR, 2.65; 95% CI, 1.20-5.87) relative to age-specific reference ranges were strongly associated with CLABSI. Among the 63 encounters in which the patient had none of these risk factors, the rate of CLABSI was 25.4%. Children with intestinal failure who present to the ED with fever have high rates of CLABSI. Although higher temperature in the ED, lower white blood cell count, and lower platelet count are strongly associated with CLABSI, patients without these risk factors frequently have positive blood cultures as well. Antibiotics should, therefore, be given to all children with intestinal failure and fever until CLABSI is ruled out.

PLOS ONE, Sep 1, 2016

Background The burden of chronic, non-communicable diseases such as diabetes is growing rapidly i... more Background The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low-and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings. Program Description We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting. Methods We conduct a retrospective chart review from our electronic medical record to evaluate our program's performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes. Results A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%.

Global Pediatric Health

This study demonstrates the challenges of establishing social determinants of health (SDH) screen... more This study demonstrates the challenges of establishing social determinants of health (SDH) screening at well child visits (WCVs) during the COVID-19 pandemic. We conducted a 6-month pre-intervention retrospective chart review (2/2020-8/2020) and 6-month post-intervention prospective chart review (8/2020-2/2021) of an SDH screening and referral protocol at a single suburban academic pediatric clinic. WCVs were screened for food, financial, and transportation needs. With the new protocol, 46% of eligible WCVs (n = 1253/2729) had documented screening results. Self-report of screened visits found 34.6% with financial strain, 32% with worry about food insecurity, 25.1% with food insecurity, 5.3% with medical transportation difficulties, and 6% with daily living transportation difficulties. There was an increase in resources offered during the post-intervention period (OR = 11.5 [7.1-18.6], P < .001). There was also an increase in resident physician self-reported knowledge in providing...

The Journal of Pediatrics

Pediatrics, 2017

Children with intestinal failure (IF) on parenteral nutrition (PN) are at high risk for bacteremi... more Children with intestinal failure (IF) on parenteral nutrition (PN) are at high risk for bacteremia, and delays in antibiotic administration have been associated with increased morbidity and mortality. We designed an emergency department (ED) quality improvement (QI) initiative to reduce time to administration of intravenous antibiotics in febrile children with IF on PN. Our aim was to decrease the mean time for febrile children with IF on PN to receive intravenous antibiotics by 50% to <60 minutes over a 12-month period. Secondary outcome measures were ED, hospital, and ICU length of stay (LOS). Our process measure was the rate of ordering recommended antibiotics, and our balancing measure was the rate of hypoglycemia. Interventions included increasing provider knowledge of IF, streamlining order entry, providing individualized feedback, and standardizing the triage process. Results were analyzed by using statistical process control methodology and time series analysis. We identi...

The Journal of pediatrics, 2018

International journal for quality in health care : journal of the International Society for Quality in Health Care, Jan 9, 2017

Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income ... more Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients. Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care. This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework. A bundle of improvement activities were implemented at the home, clinic and institutional level. Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important...

Canadian journal of public health = Revue canadienne de santé publique

This paper reports on the implementation and results of a three-year comprehensive worksite healt... more This paper reports on the implementation and results of a three-year comprehensive worksite health promotion program called Take care of your health!, delivered at a single branch of a large financial organization with 656 employees at the beginning of the implementation period and 905 at the end. The program included six educational modules delivered over a three-year period. A global health profile was part of the first and last modules. The decision to implement the program coincided with an overall program of organizational renewal. The data for this evaluation come from four sources: analysis of changes in employee health profiles between the first and last program sessions (n=270); questionnaires completed by participating employees at the end of the program (n=169); organizational data on employee absenteeism and turnover; and qualitative interviews with company managers (n=9). Employee participation rates in the six modules varied between 39% and 76%. The assessment of healt...

BMJ Case Reports, May 16, 2017

We present a female infant with a right-sided facial and neck haemangioma, from a remote, resourc... more We present a female infant with a right-sided facial and neck haemangioma, from a remote, resource-poor community in rural Guatemala. She received first-line treatment, propranolol, with marked reduction in tumour size and erythema. Treatment was stopped after 35 weeks due to recurrent diarrhoea and sustained weight loss. Propranolol can be used to safely treat infants with haemangiomas in remote, rural communities if there is adequate follow-up, education and communication. Periocular haemangiomas should be treated promptly to avoid visual impairment. Infants with large facial haemangiomas should be screened for Posterior fossa anomalies, Hemangioma, Arterial anomalies, Cardiac anomalies, and Eye anomalies (PHACE) syndrome, and specialists should be involved. The case also highlights the difficulty of providing treatment for a complex illness when basic health needs, such as food security and water sanitation, are limited.