Faculty Bibliography

OBJECTIVE: Given the prevalence of mental health (MH) conditions (MHC) in children, pediatricians should initiate treatment alone or in collaboration with a specialist for children with MHC. However, the majority of pediatricians do not manage or comanage common MHC even with an on-site MH provider. We examined which physician, practice, and training characteristics are associated with pediatricians' comanaging at least half of their patients with MHC. METHODS: We analyzed responses of general pediatricians (n = 305) from the American Academy of Pediatrics 2013 Periodic Survey. Practice characteristics include presence of an on-site MH provider and perceived access to services. Independent variables included sociodemographics, training experiences, and interest in further training. The outcome was comanagement of >/=50% of patients with MHC. Weighted univariate, bivariate, and multivariable analyses were performed. RESULTS: Of the pediatricians who reported comanaging >/=50% of their patients with MHC, logistic regression analysis showed that pediatricians who completed >/=4 weeks of developmental behavioral pediatrics training had 1.8 increased odds (95% confidence interval 1.06, 3.08, P = .03) of comanagement, those very interested in further education in managing/treating MHC had 2.75 increased odds (95% confidence interval 1.63, 3.08, P < .001), and those with more training in MH treatment with medications had 1.4 increased odds (95% confidence interval 1.12, 1.75, P = .004) of comanaging children with MHC. CONCLUSIONS: Specific educational experiences and interest in further education in managing or treating MHC were significantly associated with comanaging >/=50% of patients, suggesting that enhanced MH training among pediatricians could increase the comanagement of children with MHC.

OBJECTIVE:The Eating Disorder Examination (EDE) was originally developed and validated in primarily white female samples. Since data indicate that eating pathology impacts black youth, elucidating the psychometric appropriateness of the EDE for black youth is crucial. METHODS:A convenience sample was assembled from seven pediatric obesity studies. The EDE was administered to all youth. Confirmatory factor analyses (CFA) were conducted to examine the original four-factor model fit and two alternative factor structures for black and white youth. With acceptable fit, multiple-group CFAs were conducted. For measurement invariant structures, the interactive effects of race with sex, BMIz, adiposity, and age were explored (all significance levels p < .05). RESULTS:For both black and white youth (N = 820; 41% black; 37% male; 6-18 years; BMIz -3.11 to 3.40), the original four-factor EDE structure and alternative eight-item one-factor structure had mixed fit via CFA. However, a seven-item, three-factor structure reflecting Dietary Restraint, Shape/Weight Overvaluation, and Body Dissatisfaction had good fit and held at the level of strict invariance. Girls reported higher factor scores than boys. BMIz and adiposity were positively associated with each subscale. Age was associated with Dietary Restraint and Body Dissatisfaction. The interactional effects between sex, BMIz, and age with race were not significant; however, the interaction between adiposity and race was significant. At higher adiposity, white youth reported greater pathology than black youth. CONCLUSION:An abbreviated seven-item, three-factor version of the EDE captures eating pathology equivalently across black and white youth. Full psychometric testing of the modified EDE factor structure in black youth is warranted.

BACKGROUND: Annexin A5 (A5) is a potent anticoagulant protein that shields anionic phospholipids from availability for coagulation reactions. Previous studies showed that antibodies from patients with antiphospholipid (aPL) syndrome (APS) interfere with A5 crystallization and anticoagulant activity. OBJECTIVE: The purpose of this study was to investigate whether reduction of the Annexin A5 Anticoagulant Ratio (A5R) assay (i.e. 'A5 resistance') is associated with adverse clinical events in aPL antibody-positive patients. PATIENTS/METHODS: In an initial discovery phase group of 679 patient samples from a 'real world' tertiary care hospital population who were tested for A5R. This was followed by a validation phase cohort of 71 asymptomatic patients with aPL antibodies and no prior history for an adverse clinical event whose baseline samples were tested for A5R then subsequently observed for up to 4 years. RESULTS: In the discovery phase group, we found a reduction of A5R in aPL antibody-positive patients with thrombosis and/or pregnancy complications compared to aPL antibody-negative patients and controls. In addition, reduced A5R values in both the discovery and validation phase cohorts correlated with the extent of multipositivity for standard APS tests, which has also been shown to be associated with risk for adverse clinical outcomes. CONCLUSION: Reduction of A5R levels was associated with a multipositivity profile in aPL antibody-positive patients within both groups and with the development of adverse clinical events

We previously defined teaching domains necessary for successful inpatient medicine attending rounds from the trainees' perspective in Role Modeling, Learning Environment, Teaching Process and Team Management. We sought to understand whether trainee characteristics and daily fluctuations in workload influence the prioritization of these domains. We conducted a prospective observational study in general medicine inpatient wards at a university, Veterans Affairs, and a county hospital affiliated with one academic institution over the course of 6 months. All student and resident trainees on internal medicine inpatient wards were eligible to participate. We designed a daily assessment tool on which trainees were asked to identify the teaching domain most important to them, along with information on sex, training level, call-cycle day, patient census, and number of team members absent during rounds. We examined associations between training level and workload factors with the prioritized teaching domain using Pearson's chi-square analysis, adjusted for clustering effects. We collected 1,378 daily assessment cards evaluating 53 (91%) attending physicians. Students valued Teaching Process (𝑃 < 0.001), while senior residents sought Team Management (𝑃 < 0.001). On most days, Teaching Process was prioritized (𝑃 = 0.005). On post-call days and days with a high patient census, Team Management was prioritized (𝑃 < 0.001). Attending physicians may consider tailoring rounds in response to work-related pressures. Days with a high workload are better suited for demonstrating efficient and effective patient care skills.

BACKGROUND:In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow. METHODS:To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program. RESULTS:Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS. CONCLUSION:Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.

BACKGROUND:receptor antagonist icatibant is approved for treatment of attacks of hereditary angioedema. Icatibant has been reported to decrease time-to-resolution of angiotensin-converting enzyme (ACE) inhibitor-associated angioedema in 1 study of European patients. OBJECTIVE:receptor antagonist would shorten time-to-resolution from ACE inhibitor-associated angioedema. METHODS:Patients with ACE inhibitor-associated angioedema (defined as swelling of lips, tongue, pharynx, or face during ACE inhibitor use and no swelling in the absence of ACE inhibitor use) were enrolled at Vanderbilt University Medical Center from October 2007 through September 2015 and at Massachusetts General Hospital in 2012. C1 inhibitor deficiency and patients with bowel edema only were excluded. Patients were randomized within 6 hours of presentation to subcutaneous icatibant 30 mg or placebo at 0 and 6 hours later. Patients assessed severity of swelling using a visual analog scale serially following study drug administration or until discharge. RESULTS:Thirty-three patients were randomized and 31 received treatment, with 13 receiving icatibant and 18 receiving placebo. One patient randomized to icatibant did not complete the visual analog scale and was excluded from analyses. Two-thirds of patients were black and two-thirds were women. Time-to-resolution of symptoms was similar in placebo and icatibant treatment groups (P = .19 for the primary symptom and P > .16 for individual symptoms of face, lip, tongue, or eyelid swelling). Frequency of administration of H1 and H2 blockers, corticosteroids, and epinephrine was similar in the 2 treatment groups. Time-to-resolution of symptoms was similar in black and white patients. CONCLUSIONS:receptor antagonist in ACE inhibitor-associated angioedema.

INTRODUCTION: Accumulating evidence indicates that arsenic (As), a potent environmental toxicant, may increase cardiovascular disease risk and adversely affect endothelial function at high levels of exposure. Pregnancy is a vulnerable time for both mother and child; however, studies examining the association between prenatal As exposure and plasma biomarkers of inflammation and endothelial function in mothers and newborns are lacking. METHODS: We examined maternal urinary As levels at gestational weeks 24-28 and levels of inflammatory biomarkers in plasma from 563 pregnant women and 500 infants' cord blood. We assessed a multiplexed panel of circulating inflammatory and endothelial function markers, including tumor necrosis factor alpha (TNFalpha), monocyte chemoattractant protein 1 (MCP1), intercellular adhesion molecule (ICAM1) and vascular cell adhesion molecule (VCAM1). RESULTS: Compared with the bottom tertile, the highest tertile of maternal urinary As during pregnancy was associated with a 145.2ng/ml (95% CI 4.1, 286.3; p=0.04) increase in cord blood ICAM1 and 557.3ng/ml (95% CI -56.4, 1171.1; p=0.09) increase in cord blood VCAM1. Among mothers, the highest tertile of maternal urinary As during pregnancy was related to a 141.8ng/ml (95% CI 26.1, 257.5; p=0.02) increase maternal plasma VCAM1 levels. Urinary As was unrelated to MCP1 or TNFalpha in maternal plasma and cord blood. In structural equation models, the association between maternal urinary As and infant VCAM was mediated by maternal levels of VCAM (betamediation: 0.024, 95% CI: 0.002, 0.050). CONCLUSION: Our observations indicate that As exposure during pregnancy may affect markers of vascular health and endothelial function in both pregnant women and children, and suggest further investigation of the potential impacts on cardiovascular health in these susceptible populations.

BACKGROUND AND OBJECTIVES: Poorly designed labels and dosing tools contribute to dosing errors. We examined the degree to which errors could be reduced with pictographic diagrams, milliliter-only units, and provision of tools more closely matched to prescribed volumes. METHODS: This study involved a randomized controlled experiment in 3 pediatric clinics. English- and Spanish-speaking parents (n = 491) of children 20% deviation), and large error (>2x dose). RESULTS: We found that 83.5% of parents made >/=1 dosing error (overdosing was present in 12.1% of errors) and 29.3% of parents made >/=1 large error (>2x dose). The greatest impact on errors resulted from the provision of tools more closely matched to prescribed dose volumes. For the 2-mL dose, the fewest errors were seen with the 5-mL syringe (5- vs 10-mL syringe: adjusted odds ratio [aOR] = 0.3 [95% confidence interval: 0.2-0.4]; cup versus 10-mL syringe: aOR = 7.5 [5.7-10.0]). For the 7.5-mL dose, the fewest errors were with the 10-mL syringe, which did not necessitate measurement of multiple instrument-fulls (5- vs 10-mL syringe: aOR = 4.0 [3.0-5.4]; cup versus 10-mL syringe: aOR = 2.1 [1.5-2.9]). Milliliter/teaspoon was associated with more errors than milliliter-only (aOR = 1.3 [1.05-1.6]). Parents who received text only (versus text and pictogram) instructions or milliliter/teaspoon (versus milliliter-only) labels and tools made more large errors (aOR = 1.9 [1.1-3.3], aOR = 2.5 [1.4-4.6], respectively). CONCLUSIONS: Provision of dosing tools more closely matched to prescribed dose volumes is an especially promising strategy for reducing pediatric dosing errors.