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Hartono SP, Chatrath S, Aktas ON, Kubala SA, Capozza K, Myles IA, Silverberg JI, Schwartz A. Interventions for anxiety and depression in patients with atopic dermatitis: a systematic review and meta-analysis. Sci Rep 2024; 14:8844. [PMID: 38632375 PMCID: PMC11024101 DOI: 10.1038/s41598-024-59162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease that is associated with anxiety and depression. Few studies have addressed interventions for symptoms of anxiety and depression in this population. To determine the efficacy of interventions for anxiety and depression in patients with AD. PubMed, MEDLINE, EMBASE, and PsycINFO were searched from inception to November 2023. English-language studies published in peer-reviewed journals evaluating the effect of interventions on anxiety and/or depression using validated assessment tools on patients with AD were included. Titles, abstracts, and articles were screened by at least two independent reviewers. Of 1410 references that resulted in the initial search, 17 studies were included. Fourteen of these studies are randomized controlled trials, while the other 3 studies are prospective controlled trials with pre and post-test designs. Data were extracted using a standardized extraction form, and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. To accommodate trials with multiple interventions (each compared to a control group), we conducted a mixed-effects meta-analysis with the trial as a random effect. Prespecified outcomes were changes in symptoms of anxiety and depression in patients with AD as evaluated using standardized assessment tools. Of the 17 studies included in this systematic review, 7 pharmacological intervention studies with 4723 participants examining 5 different medications were included in a meta-analysis. Of these studies, only 1 study evaluated medications prescribed to treat anxiety and/or depression; the rest evaluated medications prescribed to treat AD. Meta-analysis of all the pharmacological interventions resulted in significant improvement in anxiety, depression, and combined anxiety-depression scale scores (standardized mean difference [95% CI]: - 0.29 [- 0.49 to - 0.09], - 0.27 [- 0.45 to - 0.08], - 0.27 [- 0.45 to - 0.08]) respectively. The 10 non-pharmacological studies with 2058 participants showed general improvement in anxiety but not depression. A meta-analysis of the non-pharmacological interventions was not conducted due to variable approaches and limited data. Pharmacological interventions designed to improve AD were found to improve anxiety and depression in patients with moderate-severe disease. More comprehensive studies on non-pharmacological and pharmacological interventions that primarily target anxiety and depression are needed.
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Affiliation(s)
- Stella P Hartono
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, 10 Center Drive, Bethesda, MD, 20852, USA.
| | | | - Ozge N Aktas
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, 10 Center Drive, Bethesda, MD, 20852, USA
| | - Stephanie A Kubala
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, 10 Center Drive, Bethesda, MD, 20852, USA
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, CA, USA
| | - Ian A Myles
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jonathan I Silverberg
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Mink RB, Schwartz A, Mahan JD, Fussell JJ, George R, Schumacher DJ, McFadden V, Turner DA, Atlas MP. LEVEL OF SUPERVISION FOR THE EPAS COMMON TO GENERAL PEDIATRICS AND THE SUBSPECIALTIES DECREASES FROM RESIDENCY TO FELLOWSHIP. Acad Pediatr 2024:S1876-2859(24)00147-5. [PMID: 38631477 DOI: 10.1016/j.acap.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/06/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES To compare level of supervision (LOS) ratings of graduating pediatric residents with their assessments as fellows for the 5 Entrustable Professional Activities (EPAs) common to general pediatrics and the subspecialties and to determine if the difference between ratings from residency to fellowship is less for the QI and PRACTICE MANAGEMENT EPAs, since the skills needed to perform these may be less context-dependent. METHODS We compared ratings of graduating residents with their assessments as fellows using LOS data from 2 sequential EPA studies. RESULTS There were 65 ratings from 41 residents at the 1st fellow assessment. At graduation, most residents needed little to no supervision for all EPAs with 94% (61/65) of ratings level 4 or 5. In contrast, only 5/65 (8%) of the 1st fellow assessments were level 4 or 5. The ratings difference for the QI and PRACTICE MANAGEMENT EPAs was similar to the others. CONCLUSIONS LOS ratings for the EPAs common to generalists and subspecialists reset as residents become fellows. There was no evidence that the QI and PRACTICE MANAGEMENT EPAs are less context-dependent. This study provides additional validity evidence for using these LOS scales to assess trainees in pediatric residency and fellowship.
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Affiliation(s)
- Richard B Mink
- Department of Pediatrics, David Geffen School of Medicine at UCLA and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA.
| | - Alan Schwartz
- The Michael Reese Endowed Professor of Medical Education, University of Illinois College of Medicine at Chicago, Chicago, IL.
| | - John D Mahan
- Department of Pediatrics, Pediatric Nephrology Fellowship Program Director, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH.
| | - Jill J Fussell
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR.
| | - Roshan George
- Department of Pediatrics, Pediatric Nephrology Fellowship Program Director, Emory University and Children's Healthcare of Atlanta, Atlanta, GA.
| | - Daniel J Schumacher
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine.
| | - Vanessa McFadden
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - David A Turner
- Competency-Based Medical Education, American Board of Pediatrics, Chapel Hill, NC.
| | - Mark P Atlas
- Zucker School of Medicine at Hofstra-Northwell and Head, Neuro-Oncology, Cohen Children's Medical Center.
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Awad S, Turnnidge J, Cheung JJH, Taylor D, Dalgarno N, Schwartz A. Exploring perspectives of personal learning plans in a residency programme. Clin Teach 2024; 21:e13677. [PMID: 37969042 DOI: 10.1111/tct.13677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/21/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Personal learning plans (PLPs) have gained traction in postgraduate medical education as an avenue for enhancing resident learning. However, implementing PLPs in real-world education settings presents unique challenges. To realise the potential of PLPs, we must understand the factors that influence the quality of PLP implementation. The purpose of this study was to explore the use and implementation of PLPs during residency training from the residents' and academic advisors' perspectives within a competency-based residency programme. METHODS We conducted semi-structured interviews with residents (n = 18) and academic advisors (n = 9) in an Internal Medicine residency programme at a Canadian academic centre. Interviews were audio recorded, transcribed verbatim and analysed using open coding. FINDINGS Three higher order themes were developed to represent the participants' perceptions of implementing PLPs in a competency-based residency programme: (a) setting the stage for learning, (b) fostering meaningful engagement and (c) learning through reflection. Results indicated that implementing PLPs requires collaboration between residents and academic advisors and supports from the broader programme and institution. PLP implementation is an iterative process that can provide a salient avenue for reflection and the development of self-regulation skills. DISCUSSION AND CONCLUSION PLPs can be a useful tool to foster self-regulated learning skills in residency education. It is imperative to consider how social and environmental supports can be enacted to facilitate engagement with, and implementation of, PLPs.
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Affiliation(s)
- Sara Awad
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jennifer Turnnidge
- Office of Professional Development and Educational Scholarship, Queen's University, Kingston, Ontario, Canada
| | - Jeffrey J H Cheung
- Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois, USA
| | - David Taylor
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nancy Dalgarno
- Office of Professional Development and Educational Scholarship, Queen's University, Kingston, Ontario, Canada
| | - Alan Schwartz
- Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois, USA
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Adavadkar PA, Brooks L, Pappalardo AA, Schwartz A, Rasinski K, Martin MA. Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis. J Clin Sleep Med 2024; 20:595-601. [PMID: 38217477 PMCID: PMC10985290 DOI: 10.5664/jcsm.10936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 01/15/2024]
Abstract
STUDY OBJECTIVES To examine the risk of increased health care utilization (HU) linked to individual sleep disorders in children with chronic medical conditions. METHODS Medicaid claims data from a cohort of 16,325 children enrolled in the Coordinated Healthcare for Complex Kids (CHECK) project were used. Sleep disorders and chronic medical conditions were identified using International Classification of Diseases, Ninth, and 10th Revision, codes. Three HU groups were identified based on participants' prior hospitalizations and emergency department (ED) visits in the 12 months prior to enrollment: low (no hospitalization or ED visit), medium (1-2 hospitalizations or 1-3 ED visits), and high (≥ 3 hospitalizations or ≥ 4 ED visits). The odds of being in an increased HU group associated with specific sleep disorders after controlling for confounding factors were examined. RESULTS Children with chronic medical conditions and any sleep disorder had nearly twice the odds (odds ratio = 1.83; 95% confidence interval: 1.67-2.01) of being in an increased HU group compared with those without a sleep disorder. The odds of being in the increased HU group varied among sleep disorders. Only sleep-disordered breathing (odds ratio = 1.51; 95% confidence interval : 1.17-1.95), insomnia (odds ratio = 1.46; 95% confidence interval : 1.06-2.02), and circadian rhythm sleep disorder (odds ratio = 2.45; 95% confidence interval : 1.07-5.64) increased those odds. Younger age and being White were also linked to increased HU. CONCLUSIONS Sleep disorders are associated with increased risk of heightened HU (ED visits and/or hospitalizations) in children with chronic medical conditions. This risk varies by specific sleep disorders. These findings indicate the need for careful evaluation and management of sleep disorders in this high-risk cohort. CITATION Adavadkar PA, Brooks L, Pappalardo AA, Schwartz A, Rasinski K, Martin MA. Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis. J Clin Sleep Med. 2024;20(4):595-601.
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Affiliation(s)
| | - Lee Brooks
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey
| | | | - Alan Schwartz
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | - Kenneth Rasinski
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | - Molly A. Martin
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
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Colón-Semenza C, Zajac JA, Schwartz A, Darbandsari P, Ellis TD. Experiences from the implementation of physical therapy via telehealth for individuals with Parkinson disease during the COVID-19 pandemic. Disabil Rehabil 2024; 46:1593-1601. [PMID: 37088939 DOI: 10.1080/09638288.2023.2202418] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 04/08/2023] [Indexed: 04/25/2023]
Abstract
PURPOSE To (1) determine the characteristics and participation rate of adults with Parkinson disease (PD) in physical therapy (PT) delivered via telehealth, (2) identify the outcome measures and interventions implemented, (3) determine the safety of and (4) patient and therapist satisfaction with PT via telehealth in a clinic specializing in the care of people with PD during the coronavirus pandemic. MATERIALS & METHODS A retrospective analysis of PT services via telehealth was conducted. Participating patients completed a satisfaction survey. Physical therapists (PTs) who delivered this care were interviewed. Three coders conducted thematic analysis of interviews. Descriptive statistics described the participation rate, demographics, outcome measures, interventions, and safety. RESULTS There was a 71.4% participation rate. Participants (n = 55) were white (96%), non-Hispanic (100%), older adult (mean = 69.5 years (8.3)) males (65.5%). Non-participants (n = 22) had similar demographics. Therapists selected patient-reported measures more often than performance-based measures. Therapeutic exercise was the most common intervention. All patients (80% response rate) reported satisfaction with their experience. PTs reported the home enhanced specificity of training but impeded evaluation. Therapists endorsed a hybrid model for future practice. CONCLUSIONS Patients reported satisfaction with PT via telehealth during the pandemic. A hybrid model may support optimal delivery of PT.IMPLICATIONS FOR REHABILITATIONPhysical therapy via telehealth for patients with Parkinson disease was acceptable to patients and physical therapists in our study.Physical therapy via telehealth was safe for people with Parkinson disease in our study, although availability and benefits may not be reaching all populations equitably.Both physical therapists and patients endorse a hybrid model of care (a combination of in-person and remote assessment and treatment) to profit from the strengths of in-person and virtual formats while minimizing barriers to access.
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Affiliation(s)
- C Colón-Semenza
- Department of Kinesiology, University of Connecticut, Storrs, CT, USA
| | - J A Zajac
- Department of Physical Therapy, Boston University, Boston, MA, USA
| | - A Schwartz
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, USA
| | - P Darbandsari
- Department of Kinesiology, University of Connecticut, Storrs, CT, USA
| | - T D Ellis
- Department of Physical Therapy, Boston University, Boston, MA, USA
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Cifra N, Pitts S, Mink R, Schwartz A, Herman B, Turner DA, Yussman S. Analysis of fellowship program director opinions of entrustable professional activities in adolescent medicine fellowship. Int J Adolesc Med Health 2024; 0:ijamh-2023-0154. [PMID: 38522004 DOI: 10.1515/ijamh-2023-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/08/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES This study aimed to explore the minimum entrustable professional activity (EPA) supervision levels at which pediatric fellowship program directors (FPDs) would be willing to graduate fellows and the levels deemed necessary for safe and effective practice for each of the common pediatric subspecialty and the four adolescent medicine-specific EPAs. METHODS This cross-sectional study utilized survey data from pediatric FPDs in 2017. FPDs indicated the minimum level of supervision (LOS) for fellows at graduation and for safe and effective practice. RESULTS 82 percent (23/28) of adolescent medicine FPDs completed the survey. For each EPA, there were differences (p<0.05) between LOS expected for graduation and for safe and effective practice. There was also variability in the level at which FPDs would graduate fellows. CONCLUSIONS This study summarizes pediatric FPD opinions regarding the minimum levels of supervision required for fellows at the time of graduation as well as the levels deemed necessary for safe and effective practice. The difference between the minimum LOS at which FPDs would graduate a fellow and that deemed appropriate for safe and effective practice, along with variability in minimum LOS for graduation, highlight the need for clearer standards for fellowship graduation as well as more structured early career support for ongoing learning. These data highlight variability in FPD opinion regarding such expectations and both the need to better define desired training outcomes and potential need for post-graduation supervision in clinical practice.
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Affiliation(s)
- Nicole Cifra
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Sarah Pitts
- Department of Pediatrics, Boston Children's Hospital, Boston, USA
| | | | - Alan Schwartz
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | | | | | - Susan Yussman
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, USA
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Chiel L, Gans HA, Bales M, King S, Mason K, Schwartz A, Kesselheim J, Boyer D. A Pilot Survey on the Perceptions of Pediatric Subspecialty Fellows and Program Directors on Virtual Compared with In-Person Interview Experiences. J Pediatr 2024; 270:114019. [PMID: 38514003 DOI: 10.1016/j.jpeds.2024.114019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/25/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Abstract
Pediatric fellowship programs have conducted virtual interviews since the start of the COVID-19 pandemic in 2020. In this national survey of fellowship program directors and fellows interviewed in-person and virtually, fellowship program directors and fellows formed accurate impressions, regardless of format, but our data did not clearly support one interview format over another.
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Affiliation(s)
- Laura Chiel
- Instructor, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Hayley A Gans
- Stanford University Medical Center, Department of Pediatrics, Center for Academic Medicine, Palo Alto, CA
| | - Melissa Bales
- Pediatric Subspecialty Program Coordinator, Department of Pediatric, Riley Hospital for Children at Indiana University School of Medicine, Indianapolis, IN
| | - Sarah King
- Director of Fellowship Programs, Department of Graduate Medical Education, Children's Mercy Kansas City, Kansas City, MO
| | - Katherine Mason
- Assistant Dean Faculty Development, Warren Alpert Medical School at Brown University, Vice Chair of Education, Department of Pediatrics, Providence, RI
| | - Alan Schwartz
- The Michael Reese Endowed Professor of Medical Education, Department of Medical Education, University of Illinois at Chicago, Chicago, IL; Research Professor, Department of Pediatrics, University of Illinois at Chicago, Chicago, IL; Director, Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN), McLean, VA
| | - Jennifer Kesselheim
- Associate Professor and Designated Institutional Official, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Debra Boyer
- Designated Institutional Official and Chief Medical Education Officer, Nationwide Children's Hospital, Columbus, OH
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Capozza K, Tu M, Schwartz A, de Tena Smith ÁL. Atopic dermatitis in Spain: Patient and caregiver experiences with disease burden, care and treatments. Aten Primaria 2024; 56:102908. [PMID: 38479199 PMCID: PMC10944104 DOI: 10.1016/j.aprim.2024.102908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 03/19/2024] Open
Affiliation(s)
- Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, CA, USA.
| | - Michelle Tu
- Global Parents for Eczema Research, Santa Barbara, CA, USA
| | - Alan Schwartz
- Global Parents for Eczema Research, Santa Barbara, CA, USA; University of Illinois at Chicago, Chicago, IL, USA
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Cogen JD, Perkins A, Mockler B, Barton KS, Schwartz A, Boos M, Radhakrishnan A, Rai P, Tandon P, Philipsborn R, Grow HM. Pediatric Resident and Program Director Views on Climate Change and Health Curricula: A Multi-Institution Study. Acad Med 2024:00001888-990000000-00733. [PMID: 38232072 DOI: 10.1097/acm.0000000000005633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
PURPOSE The American Academy of Pediatrics emphasized in a 2007 policy statement the importance of educating trainees on the impacts of climate change on children's health, yet few studies have evaluated trainee knowledge and attitudes about climate change-related health effects in children. This multi-institution study assessed pediatric resident and program director 1) knowledge/attitudes on climate change and health, 2) perspectives on the importance of incorporating climate and health content into pediatric graduate medical education, and 3) preferred topics/activities to include in climate and health curricula. METHOD This mixed-methods study employed an anonymous cross-sectional survey of pediatric residents and residency program directors from Association of Pediatric Program Directors (APPD) Longitudinal Educational Assessment Research Network (LEARN)-affiliated programs. Multivariable regression models and factor analyses were used to examine associations among resident demographics and resident knowledge, attitudes, and interest in a climate change curriculum. A conventional content analysis was conducted for the open-ended responses. RESULTS Eighteen programs participated in the study with all program directors (100% response rate) and 663 residents (average response rate per program 53%, overall response rate 42%) completing respective surveys. Of program directors, only 3 (17%) felt very or moderately knowledgeable about the association between climate change and health impacts. The majority of residents (n = 423, 64%) agreed/strongly agreed that physicians should discuss global warming/climate change and its health effects with patients/families, while only 138 residents (21%) agreed/strongly agreed that they were comfortable talking with patients and families about these issues. Most residents (n = 498, 76%) and program directors (n = 15, 83%) agreed/strongly agreed that a climate change curriculum should be incorporated into their pediatrics training program. CONCLUSIONS Pediatric residents and program directors support curricula that prepares future pediatricians to address the impact of climate change on children's health; however, few programs currently offer specific training, despite identified needs.
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Affiliation(s)
- Jonathan D Cogen
- J.D. Cogen is associate professor, Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Alexandra Perkins
- A. Perkins is pediatric hospitalist and former pediatric resident, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Blair Mockler
- B. Mockler is pediatric pulmonary fellow, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Krysta S Barton
- K.S. Barton is biostatistician, Core for Biostatistics, Epidemiology and Analytics for Research (BEAR) Core, Seattle Children's Research Institute, Seattle, Washington
| | - Alan Schwartz
- A. Schwartz is professor, Departments of Medical Education and Pediatrics, University of Illinois College of Medicine, Chicago, Illinois; Association of Pediatric Program Directors
| | - Markus Boos
- M. Boos is associate professor, Division of Dermatology, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Anjana Radhakrishnan
- A. Radhakrishnan is program manager, Longitudinal Educational Assessment Research Network, Association of Pediatric Program Directors
| | - Pragya Rai
- P. Rai is pediatric pulmonologist, Sacred Heart Children's Hospital, Spokane, Washington
| | - Pooja Tandon
- P. Tandon is associate professor, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Rebecca Philipsborn
- R. Philipsborn is assistant professor, Department of Pediatrics, Emory University School of Medicine and Gangarosa Department of Environmental Health, Emory Rollins School of Public Health, Atlanta, Georgia
| | - H Mollie Grow
- H.M. Grow is professor, Department of Pediatrics, University of Washington, Seattle, Washington
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Chong AC, Schwartz A, Lang J, Ong PY, Myles IA, Silverberg JI, Capozza K. Patients' and Caregivers' Preferences for Mental Health Care and Support in Atopic Dermatitis. Dermatitis 2024; 35:S70-S76. [PMID: 37579072 DOI: 10.1089/derm.2023.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Background: Atopic dermatitis (AD) has large mental health impacts for patients and caregivers, yet their preferences regarding how to relieve these impacts are poorly understood. Objective: To understand patients' and caregivers' preferences for AD-related mental health care and support. Methods: We surveyed 279 adult AD patients and 154 caregivers of children with AD across 26 countries regarding their AD-related mental health burden, preferred strategies for improving AD-related mental health, and experiences with mental health care in AD. Results: Caregivers reported significantly worse overall mental health (P = 0.01) and anxiety (P = 0.03) than adult patients when controlling for AD severity. Among adult patients, 58% selected treating the AD, 51% managing itch, 44% wearing clothing to cover up skin, 43% avoiding social situations, and 41% spending time alone, as strategies they felt would improve their own AD-related mental health. Caregivers selected managing itch and treating the AD most frequently for both their own (76% and 75%, respectively) and their children's (75% and 61%) mental health. Adult patients were less satisfied with mental health care from mental health providers versus nonmental health providers (P < 0.001). Conclusions: Effective AD management is the preferred method for improving mental health among patients as well as caregivers, who may experience the greatest mental health impacts. Self-care strategies should be considered in a shared decision-making approach.
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Affiliation(s)
- Albert C Chong
- From the Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alan Schwartz
- Department of Medical Education and Department of Pediatrics, University of Illinois Chicago, Chicago, Illinois, USA
| | - Jessica Lang
- Global Parents for Eczema Research, Santa Barbara, California, USA
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Ian A Myles
- Epithelial Therapeutics Unit, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, USA
| | - Jonathan I Silverberg
- School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia, USA
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, California, USA
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Karnik R, Robinson B, Glickstein J, Schwartz A, Mink R, Neal AE, Frank LH, McMahon CJ, Kim ME, Turner DA, Srivastava S. Minimum Supervision Levels Required for Pediatric Cardiology Fellowship Graduation by Pediatric Cardiology Fellowship Program Directors. Pediatr Cardiol 2023:10.1007/s00246-023-03371-y. [PMID: 38117291 DOI: 10.1007/s00246-023-03371-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023]
Abstract
Entrustable professional activities (EPAs) are "observable essential tasks expected to be performed by a physician for safe patient care in practice." Six Pediatric Cardiology (PC) EPAs and their level of supervision (LOS) scales were developed by medical educators in PC using a modified Delphi process and reviewed by the Subspecialty Pediatrics Investigator Network (SPIN). However, their general use in assessment for PC fellows for graduation requirements has yet to be studied. The objective of this study was to determine the minimum LOS required for PC fellows to graduate and compare it with the minimum LOS expected for safe and effective practice for the six PC EPAs, from the perspective of the PC Fellowship Program Directors(FPD). All Fellowship Program Directors(FPD) of ACGME-accredited PC fellowships were surveyed through SPIN between April 2017 and August 2017. For each of the PC EPAs, the FPDs were asked to indicate the minimum LOS expected for graduation and whether they would allow a fellow to graduate if this level was not achieved and the minimum LOS expected for a practicing pediatric cardiologist to provide safe and effective patient care. The minimum LOS was defined as the LOS for which no more than 20% of FPDs would want a lower level. The survey response rate was 80% (47/59). The majority of the FPDs did not require a minimum LOS of five corresponding to unsupervised practice in any of the six PC EPAs at graduation. For EPAs related to imaging, arrhythmia management, and management of cardiac problems, the minimum LOS for graduation was 3, corresponding to being "trusted to perform a task with indirect supervision for most simple and a few complex cases." For the EPAs related to interventional cardiology, heart failure pulmonary hypertension, and cardiac intensive care, the minimum LOS for graduation was 2, corresponding to being "trusted to perform a task only with direct supervision and coaching." The minimum LOS considered necessary for safe and effective practice for all but one EPA was 3. For the EPA related to the management of cardiac problems, the minimum LOS for safe practice was 4, corresponding to being "trusted to execute tasks independently except for few complex and critical cases." Most PC FPDs reported they would not require fellows to achieve the highest entrustment level for any of the six PC EPAs for graduation. It is crucial that educational programs evolve to address these essential activities during training better and that stakeholders ensure that graduating PC fellows have adequate resources and infrastructure to continue professional development as early career pediatric cardiologists.
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Affiliation(s)
- Ruchika Karnik
- Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT, USA.
| | - Bradley Robinson
- Department of Pediatrics, Section of Pediatric Cardiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Julie Glickstein
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA
| | - Alan Schwartz
- Department of Medical Education and Department of Pediatrics, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Richard Mink
- David Geffen School of Medicine at UCLA and The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Ashley E Neal
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lowell H Frank
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Colin J McMahon
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - Michael E Kim
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - David A Turner
- Competency-Based Medical Education, American Board of Pediatrics, Chapel Hill, NC, USA
| | - Shubhika Srivastava
- Department of Pediatrics, Section of Pediatric Cardiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Chong AC, Schwartz A, Smith Begolka W, Tullos KZ, Capozza K. Specialist care and mental health is associated with long-term control of atopic dermatitis symptoms: A cross-sectional survey of patients and caregivers in the United States. JAAD Int 2023; 13:112-114. [PMID: 37779557 PMCID: PMC10541459 DOI: 10.1016/j.jdin.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Affiliation(s)
- Albert C. Chong
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alan Schwartz
- Department of Medical Education and Department of Pediatrics, University of Illinois Chicago, Chicago, Illinois
| | | | | | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, California
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Yemane L, Kas-Osoka O, Burns A, Blankenburg R, Prakash LK, Poitevien P, Schwartz A, Lucas CT, Marbin J. Upholding Our PROMISE: Underrepresented in Medicine Pediatric Residents' Perspectives on Interventions to Promote Belonging. Acad Med 2023; 98:1434-1442. [PMID: 37643583 DOI: 10.1097/acm.0000000000005443] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE Underrepresented in medicine (UIM) residents experience challenges during training that threaten their sense of belonging in medicine; therefore, residency programs should intentionally implement interventions to promote belonging. This study explored UIM pediatric residents' perspectives on current residency program measures designed to achieve this goal. METHOD The authors conducted a secondary qualitative analysis as part of a national cross-sectional study, PROmoting Med-ed Insight into Supportive Environments (PROMISE), which explored pediatric residents' experiences and perspectives during training in relation to their self-identities. A 23-item web-based survey was distributed through the Association of Pediatric Program Directors Longitudinal Educational Research Assessment Network from October 2020 to January 2021. Participants provided free-text responses to the question "What are current measures that promote a sense of belonging for the UIM community in your training program?" The authors used conventional content analysis to code and identify themes in responses from UIM participants. RESULTS Of the 1,748 residents invited to participate, 931 (53%) residents from 29 programs completed the survey, with 167 (18%) identifying as UIM. Of the 167 UIM residents, 74 (44%) residents from 22 programs responded to the free-text question. The authors coded more than 140 unique free-text responses and identified 7 major themes: (1) critical mass of UIM residents; (2) focused recruitment of UIM residents; (3) social support, including opportunities to build community among UIM residents; (4) mentorship; (5) caring and responsive leadership; (6) education on health disparities, diversity, equity, inclusion, and antiracism; and (7) opportunities to serve, including giving back to the local community and near-peer mentorship of UIM premedical and medical students. CONCLUSIONS This is the first national study to describe UIM pediatric residents' perspectives on interventions that promote a sense of belonging. Programs should consider implementing these interventions to foster inclusion and belonging among UIM trainees.
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Burns AM, Kester Prakash L, Yemane L, Blankenburg R, Kas-Osoka OA, Poitevien P, Marbin J, Schwartz A, Taylor Lucas C. Upholding Our PROMISE: Discrimination and Lack of Belonging Negatively Influence Pediatric Residents' Desire to Stay at Home Institution. Acad Med 2023; 98:S195-S196. [PMID: 37983441 DOI: 10.1097/acm.0000000000005379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
- Audrea M Burns
- Author affiliations: A.M. Burns, Baylor College of Medicine; L. Kester Prakash, University of California Davis School of Medicine; L. Yemane, R. Blankenburg, Stanford School of Medicine; P. Poitevien, Warren Alpert Medical School of Medicine at Brown University; O.A. Kas-Osoka, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas; J. Marbin, University of California Berkeley-University of California San Francisco Joint Medical Program; A. Schwartz, University of Illinois at Chicago; C. Taylor Lucas, University of California Irvine School of Medicine/CHOC
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Zuniga LM, Schuh A, Schwartz A, Seo-Mayer P, Cramton R, Sieplinga K, Kaushik R, Nassetta L, Homme JH, Babal J, Mahan JD, Batra M. Burnout During the COVID-19 Pandemic: A Report on Pediatric Residents. Acad Pediatr 2023; 23:1620-1627. [PMID: 37207966 PMCID: PMC10191699 DOI: 10.1016/j.acap.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND AND OBJECTIVE The Pediatric Resident Burnout and Resilience Consortium (PRB-RSC) has described the epidemiology of burnout in pediatric residents since 2016. We hypothesized burnout rates during the pandemic would increase. We explored resident burnout during the COVID-19 pandemic and its relationship to resident perception of workload, training, personal life, and local COVID burden. METHODS Since 2016, PRB-RSC has sent an annual, confidential survey to over 30 pediatric and medicine-pediatrics residencies. In 2020 and 2021, seven questions were added to explore the relationship of COVID-19 and perceptions of workload, training, and personal life. RESULTS In 2019, 46 programs participated, 22 in 2020, and 45 in 2021. Response rates in 2020 (n = 1055, 68%) and 2021(n = 1702, 55%) were similar to those of previous years (P = .09). Burnout rates in 2020 were significantly lower than in 2019 (54% vs 66%, P < .001) but returned to pre-COVID levels in 2021 (65%, P = .90). In combined 2020-2021 data, higher rates of burnout were associated with reported increased workload (Adjusted Odds Ratio (AOR) 1.38, 95% CI 1.19-1.6) and concerns regarding the effect of COVID on training (AOR 1.35, 95% CI 1.2-1.53). Program-level county COVID burden in combined 2020-2021 data was not associated with burnout in this model (AOR=1.03, 95% CI 0.70-1.52). CONCLUSIONS Burnout rates within reporting programs decreased significantly in 2020 and returned to prepandemic levels in 2021. Increased burnout was associated with perceived increases in workload and concerns regarding effect of the pandemic on training. Given these findings, programs should consider further investigation into workload and training uncertainty on burnout.
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Affiliation(s)
- Linessa M Zuniga
- Baylor College of Medicine and Texas Children's Hospital (LM Zuniga), Houston, Tex.
| | - Abigail Schuh
- Medical College of Wisconsin and Children's Wisconsin (A Schuh), Milwaukee, Wis.
| | - Alan Schwartz
- University of Illinois College of Medicine (A Schwartz), Chicago, Ill.
| | | | - Rachel Cramton
- University of Arizona College of Medicine (R Cramton), Tucson, Ariz.
| | - Kira Sieplinga
- Spectrum Health/Michigan State University College of Human Medicine and Helen DeVos Children's Hospital (K Sieplinga), Grand Rapids, Mich.
| | - Ruchi Kaushik
- Baylor College of Medicine and The Children's Hospital of San Antonio (R Kaushik), San Antonio, Tex.
| | - Lauren Nassetta
- UAB Medicine and Children's of Alabama (L Nassetta), Birmingham, Ala.
| | - Jason H Homme
- Mayo Clinic Children's Center (JH Homme), Rochester, Minn.
| | - Jessica Babal
- University of Wisconsin School of Medicine (J Babal), Madison, Wis.
| | - John D Mahan
- The Ohio State University College of Medicine and Nationwide Children's Hospital (JD Mahan), Columbus, Ohio.
| | - Maneesh Batra
- University of Washington and Seattle Childrens, Neonatology (M Batra).
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Perez S, Schwartz A, Hauer KE, Karani R, Hirshfield LE, McNamara M, Henry D, Lupton KL, Woods M, Teherani A. Developing Evidence for Equitable Assessment Characteristics Based on Clinical Learner Preferences Using Discrete Choice Experiments. Acad Med 2023; 98:S108-S115. [PMID: 37983403 DOI: 10.1097/acm.0000000000005360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
PURPOSE Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training. METHOD A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most. RESULTS Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner's patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students. CONCLUSIONS This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.
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Affiliation(s)
- Sandra Perez
- S. Perez is a resident, Department of Pathology, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Alan Schwartz
- A. Schwartz is the Michael Reese Endowed Professor of Medical Education, Department of Medical Education, and research professor, Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois, and director, Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN), McLean, Virginia; ORCID: http://orcid.org/0000-0003-3809-6637
| | - Karen E Hauer
- K.E. Hauer is professor, Department of Medicine, and associate dean for competency assessment and professional standards, University of California, San Francisco, School of Medicine, San Francisco, California; ORCID: https://orcid.org/0000-0002-8812-4045
| | - Reena Karani
- R. Karani is professor, Departments of Medicine, Medical Education, and Geriatrics and Palliative Medicine, and director, Institute for Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura E Hirshfield
- L.E. Hirshfield is the Dr. Georges Bordage Medical Education Faculty Scholar, associate professor, PhD program codirector, and associate director of graduate studies, Department of Medical Education, University of Illinois College of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-0894-2994
| | - Margaret McNamara
- M. McNamara is professor, Department of Pediatrics, and pediatric residency program director, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Duncan Henry
- D. Henry is associate professor, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Katherine L Lupton
- K.L. Lupton is professor, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Majka Woods
- M. Woods holds the Dibrell Family Professorship in the Art of Medicine, and is assistant professor, Department of Surgery, and vice dean for academic affairs, John Sealy School of Medicine at the University of Texas Medical Branch, Galveston, Texas
| | - Arianne Teherani
- A. Teherani is professor, Department of Medicine, education scientist, Center for Faculty Educators, director of program evaluation and education continuous quality improvement, and founding codirector, University of California Center for Climate Health and Equity, University of California, San Francisco, School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0003-2936-9832
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Metgud DC, Ajgaonkar R, Chivate S, Schwartz A, Fernandes M, Shah R. Impact of a Brief Healthcare-based Intervention to Support Early Childhood Development in India: A Pilot Randomized Controlled Trial. Indian Pediatr 2023; 60:811-815. [PMID: 37551871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
OBJECTIVES To study the impact of a brief early childhood develop-ment (ECD) intervention, Sit Down and Play (SDP), integrated within routine healthcare visits on parent and child outcomes. METHODS Between April, 2018 and March, 2019, caregivers and their infants aged 5-6 months attending a well-baby clinic were enrolled and randomized to intervention (n=26) or control (n=26) groups. Intervention families received SDP at recruitment and two subsequent immunization visits (8 months and 10 months). Control families received usual care. ECD outcomes were assessed through in-person assessments at the age of 12 months using the Stim Q subscales to assess parenting behaviors, and the Developmental Assessment Scale for Indian Infants (DASII) for neurodevelopment. RESULTS There was a significant improvement in parent-child stimulation activities and verbal interactions in the intervention group compared with the control group [6.1(1.4) vs 4.9 (1.3); P=0.002]. Infants in the intervention group had significantly higher DASII scores in multivariable analyses [108.0 (103.0-111.3) vs 102.0 (96.8-108.0); P=0.04]. CONCLUSION Our findings suggest a brief healthcare intervention supports opportunities for early learning among caregivers and neurodevelopmental outcomes in their infants.
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Affiliation(s)
- Deepa C Metgud
- Pediatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
| | - Ronita Ajgaonkar
- Department of Pediatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
| | - Shukra Chivate
- Pediatric Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
| | - Alan Schwartz
- Department of Medical Education, University of Illinois at Chicago, Chicago, IL , USA
| | - Michelle Fernandes
- Faculty of Medicine, Department of Pediatrics, University of Southampton, Southampton, UK
| | - Reshma Shah
- Department of Pediatrics, College of Medicine, The University of Illinois at Chicago, Chicago, IL, USA. Correspondence to: Dr Reshma Shah, 840 South Wood St, MC 856, Chicago, IL 60612, USA.
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Mink RB, Carraccio CL, Herman BE, Weiss P, Turner DA, Stafford DEJ, McGann KA, Kesselheim J, Hsu DC, High PC, Fussell JJ, Curran ML, Chess PR, Sauer C, Pitts S, Myers AL, Mahan JD, Dammann CEL, Aye T, Schwartz A. Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment. BMC Med Educ 2023; 23:720. [PMID: 37789289 PMCID: PMC10548580 DOI: 10.1186/s12909-023-04689-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/15/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment. OBJECTIVES We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME). METHODS In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale. RESULTS One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05). CONCLUSIONS We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.
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Affiliation(s)
- Richard B Mink
- Department of Pediatrics, David Geffen School of Medicine at UCLA and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA, 90502, USA.
| | | | - Bruce E Herman
- University of Utah School of Medicine, Salt Lake, UT, USA
| | - Pnina Weiss
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | | | - Diane E J Stafford
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kathleen A McGann
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jennifer Kesselheim
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | | | - Pamela C High
- Alpert Medical School of Brown University, Providence, RI, USA
- Developmental-Behavioral Pediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - Jill J Fussell
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Megan L Curran
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Cary Sauer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sarah Pitts
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Angela L Myers
- Center for Wellbeing, Children's Mercy Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - John D Mahan
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Tandy Aye
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Alan Schwartz
- University of Illinois College of Medicine at Chicago, Chicago, IL, USA
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Koo A, Irwin J, Sturgis M, Schwartz A, Hasnain M, Davis E, Stillerman A. Is Academic Medicine Prepared to Teach About the Intersection of Childhood Experiences and Health? An Exploratory Survey of Faculty. J Contin Educ Health Prof 2023; 43:225-233. [PMID: 36877822 DOI: 10.1097/ceh.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Childhood experiences affect health across the lifespan. Evidence-based strategies targeting early-life stress are emerging. Nevertheless, faculty physicians' preparation to incorporate this science into practice has not been well studied. This study explores medical faculty knowledge and beliefs, timing and route of knowledge acquisition, perceived relevance and application of study topics, and characteristics associated with concept mastery. METHODS The authors developed and administered an exploratory survey to faculty from six departments at two medical schools. The team analyzed responses using quantitative and qualitative methods. RESULTS Eighty-one (8.8%) eligible faculty completed the survey. Of respondents, 53 (65.4%) achieved high knowledge, 34 (42.0%) high beliefs, and 42 (59.1%) high concept exposure question scores, but only 6 (7.4%) through a formal route. Although 78 (96.8%) respondents indicated that survey concepts are relevant, only 18 (22.2%) reported fully incorporating them in their work, and 48 (59.2%) identified the need for additional coaching. Respondents reporting full incorporation were significantly more likely to attain high concept exposure scores (17 respondents, 94.4%, versus 25 respondents, 39.7%, P < .001). Quantitative and qualitative analysis highlighted limited respondent awareness of trauma prevalence among health care workers, lack of familiarity with interventions, and time and resource challenges addressing childhood adversity. DISCUSSION Although survey respondents had some familiarity with study concepts and perceived their relevance, most are not fully applying them. Results suggest that exposure to study concepts is associated with full incorporation. Therefore, intentional faculty development is essential to prepare faculty to include this science in practice.
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Affiliation(s)
- Angie Koo
- Dr. Koo : PGY-2 Resident Physician in the Department of Psychiatry, Olive View-University of California Los Angeles Medical Center, Sylmar, CA. Dr. Irwin : PGY-1 Resident Physician in the Department of Pediatrics, University of California San Francisco, San Francisco, CA. Dr. Sturgis : PGY-1 Resident in the Department of Urology, Rush Medical College, Chicago, IL. Dr. Schwartz : Michael Reese Endowed Professor and Interim Head in the Department of Medical Education, Research Professor and Director of the Pediatrics Research Core in the Department of Pediatrics, and JD Candidate in the Chicago School of Law, University of Illinois Chicago, Chicago, IL. Dr. Hasnain : Professor and Associate Head of Faculty Development & Research in the Department of Family and Community Medicine, Associate Dean for Faculty Development, Director of Patientcentered Medicine Scholars Program, and Co-Director, ENGAGE-IL University of Illinois Chicago, Chicago, IL. Dr. Davis : Associate Professor in the Department of Internal Medicine, Rush University Medical Center, Chicago, IL. Dr. Stillerman : Clinical Assistant Professor of Family and Community Medicine and Medical Director of the Office of Community Engagement/Mile Square School Health Centers, University of Illinois Chicago, and Co-Founder of The Center for Trauma, Health Equity, and Neurobiology (THEN), Chicago, IL
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Taff H, Gilkerson L, Osta A, Seo-Lee A, Schwartz A, Chunara Z, McGinn L, Pillai N, Barnes MM. Strengthening Parent - Physician Communication: A Mixed Methods Study on Attuned Communication Training for Pediatric Residents. Teach Learn Med 2023; 35:577-588. [PMID: 35946430 DOI: 10.1080/10401334.2022.2107528] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/11/2022] [Indexed: 06/15/2023]
Abstract
Problem: High-quality communication improves patient satisfaction and clinical outcomes, yet formal communication training in residency is often minimal. Many studies on empathic communication show mixed results and are often hindered and skewed by brief study lengths, insufficiently and ambiguously defined concepts, and limited methods for objective measurements. Intervention: The FAN Curriculum is a unique communication curriculum, based on the conceptual frameworks of patient-centered communication, reflective practice, mindfulness, and attunement using the Facilitating Attuned Interactions (FAN) model. The first part of the FAN Curriculum was delivered as a 3-hour interactive workshop involving didactics, group discussion, and role play with pediatric residents. Residents then completed weekly self-reflections, a follow-up one-hour training to reinforce concepts, and five monthly mentor sessions, all emphasizing reflective practice. Context: This longitudinal, mixed-methods study examined the effects of the FAN Curriculum on residents' empathy levels and ability to communicate with parents in the clinical setting. The study was conducted at two urban, academic, medium-sized pediatric residency programs in Chicago between October 2016 and November 2017. First- and second-year pediatric residents whose continuity clinic site was located at their home institution participated. Residents received training in the use of the FAN Communication Tool using a delayed-start crossover study design. Impact: At five time points, residents and parents completed instruments validated for measuring physician empathy and mindfulness. Post-study interviews were conducted for one institution's residents and mentors and were evaluated using open and focused coding. Participants (n = 23) demonstrated a high degree of use of the FAN Communication Tool six months post-training and a significant rise in self-reported comfort with four of five FAN core processes. One parent-completed survey (Consultation and Relational Empathy, CARE) showed a statistically significant rise of 3.26% in resident relational empathy and collaboration after training (p = 0.02). In qualitative analysis of interviews, residents and mentors found the FAN Communication Tool beneficial, making clinic visits more efficient and collaborative. Both groups noted improvement in the residents' relationship-building skills; residents were able to use enhanced communication skills to better approach challenging encounters and work through parent concerns. Lessons Learned: Family-centered communication training can improve physician-perceived empathy and mindfulness. Effective communication for pediatric residents incorporates an empathic approach, and introduction to this formal curriculum supported their growth in connecting and engaging with children and parents. The FAN Curriculum may provide a useful method for improving resident communication skills with a positive impact on pediatricians' collaboration with patients and families.
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Affiliation(s)
- Heather Taff
- Department of Pediatrics, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
- VNA Health Care, Aurora, Illinois, USA
| | | | - Amanda Osta
- Department of Pediatrics, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Alisa Seo-Lee
- Department of Pediatrics, Cook County Health, Chicago, Illinois, USA
| | - Alan Schwartz
- Department of Pediatrics, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
- Department of Medical Education, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Zobia Chunara
- Department of Medical Education, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Lander McGinn
- Department of Medical Education, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Nikita Pillai
- Department of Medical Education, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Michelle M Barnes
- Department of Pediatrics, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
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Liu A, Ben-Zion S, Schwartz A, Mahan JD, Reed S. Well-being factors associated with confidence in providing calm, compassionate care in pediatric residents. Patient Educ Couns 2023; 115:107906. [PMID: 37478547 DOI: 10.1016/j.pec.2023.107906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/06/2023] [Accepted: 07/16/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Engagement in calm, compassionate care (CCC) is important in fostering patient-centered care. We aimed to study factors which predict confidence in providing CCC in pediatric residents. METHODS We performed a retrospective, multi-center, cohort study utilizing data from the Pediatric Resident Burnout and Resilience Study (PRB-RSC) from 2016 to 2018. The Calm Compassionate Care Scale (CCCS) was used to assess confidence in delivering CCC. We examined cross-sectional associations between CCC, demographic measures, programmatic features, and psychological scales. RESULTS The following showed significant positive associations with confidence in providing CCC: Cognitive and Affective Mindfulness Scale, Neff's Self Compassion, Patient Reported Outcomes Measures-mental health, and Interpersonal Reactivity Index-empathetic concern. For the Maslach Burnout Index subscales, decreased personal accomplishment, increased emotional exhaustion, and increased depersonalization showed significant negative associations. CONCLUSIONS We found that several well-being measures and an increased sense of personal accomplishment are associated with increased confidence in providing CCC. These findings underscore the interrelatedness of these measures and highlight the importance of personal accomplishment as a positive factor in trainee development. PRACTICE IMPLICATIONS Program level interventions that decrease trainee burnout and enhance resiliency as well as support trainees' development of empathy and compassion may help trainees develop skills that promote patient-centered, compassionate care.
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Affiliation(s)
- Alex Liu
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sabrina Ben-Zion
- Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
| | - Alan Schwartz
- Department of Pediatrics, University of Illinois College of Medicine - Chicago, Chicago, IL, USA
| | - John D Mahan
- Department of Pediatrics Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
| | - Suzanne Reed
- Department of Pediatrics Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA.
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Zwemer E, Serwint JR, Sieplinga K, Wilson PM, Webber S, Lien ER, Babal JC, Donnelly KM, Nichols MH, Batra M, Schwartz A, Reese JW. Implementation and Maturity of Clinical Learning Environment Components Across Pediatric Residency Programs. Acad Pediatr 2023; 23:1301-1306. [PMID: 37094643 DOI: 10.1016/j.acap.2023.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/29/2023] [Accepted: 04/15/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE Pediatric residency programs prioritize clinical learning environment components depending on resource availability, institutional constraints and culture, and accreditation requirements. However, there is limited literature on the landscape of implementation and maturity of clinical learning environment components across programs nationally. METHODS We used Nordquist's clinical learning environment conceptual framework to craft a survey around the implementation and maturity of learning environment components. We performed a cross-sectional survey of all pediatric program directors enrolled in the Pediatric Resident Burnout-Resiliency Study Consortium. RESULTS Components with the highest implementation rates were resident retreats, in-person social events, and career development, while components least likely to be implemented were scribes, onsite childcare, and hidden curriculum topics. The most mature components were resident retreats, anonymous systems for reporting patient safety events, and faculty-resident mentoring programs, while the least mature components were use of scribes and formalized mentorship for trainees underrepresented in medicine. Learning environment components included in the Accreditation Council of Graduate Medical Education Program Requirements were significantly more likely to be implemented and mature than nonrequired components. CONCLUSIONS To our knowledge, this is the first study to use an iterative and expert process to provide extensive and granular data about learning environment components for pediatric residencies.
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Affiliation(s)
- Eric Zwemer
- Department of Pediatrics (E Zwemer), University of North Carolina School of Medicine, Chapel Hill.
| | - Janet R Serwint
- Department of Pediatrics (JR Serwint), Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Kira Sieplinga
- Department of Pediatrics and Human Development (K Sieplinga), Helen DeVos Children's Hospital/Michigan State University College of Human Medicine, Life Sciences Bldg, Grand Rapids.
| | - Paria M Wilson
- Division of Emergency Medicine (M Wilson), Cincinnati Children's Hospital Medical Center, OH; Department of Pediatrics (M Wilson), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, OH.
| | - Sarah Webber
- Department of Pediatrics (S Webber), University of Wisconsin School of Medicine and Public Health, Madison.
| | - Elizabeth Rodriguez Lien
- Department of Pediatrics (ER Lien), University of Texas Medical Branch School of Medicine, Galveston.
| | - Jessica C Babal
- Department of Pediatrics (C Babal), University of Wisconsin-Madison School of Medicine and Public Health.
| | - Kathleen M Donnelly
- Department of Pediatrics (KM Donnelly), Inova Children's Hospital/Inova Fairfax Medical Campus, Falls Church, VA.
| | | | - Maneesh Batra
- Department of Pediatrics (M Batra), Division of Neonatology, University of Washington School of Medicine, Seattle.
| | - Alan Schwartz
- Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (A Schwartz), Chicago, IL; Department of Pediatrics (A Schwartz), University of Illinois at Chicago.
| | - Jennifer W Reese
- Department of Pediatrics (W Reese), University of Colorado School of Medicine, Aurora.
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Elmes AT, Schwartz A, Tekian A, Jarrett JB. Evaluating the Quality of the Core Entrustable Professional Activities for New Pharmacy Graduates. Pharmacy (Basel) 2023; 11:126. [PMID: 37624081 PMCID: PMC10458068 DOI: 10.3390/pharmacy11040126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
This study aimed to evaluate the quality of the American Association of Colleges of Pharmacy Core Entrustable Professional Activities (Core EPAs) for New Pharmacy Graduates according to standards outlined in competency-based education literature utilizing the Queen's EPA Quality (EQual) rubric. A cohort of pharmacists with EPA expertise rated Core EPA quality with the EQual rubric and provided recommendations for revisions. A generalizability study determined the reliability of the EQual ratings with pharmacist users. Nine pharmacists responded (4.4%). Most EPAs (9/15) did not reach the overall cut-off score, indicating low quality. EPAs 1 through 5 and EPA 14 (fulfill a medication order) were deemed high quality. EPA 12 (use evidence-based information to advance patient care) scored the lowest at 3.47 (SEM 0.29). EPA 14 scored the highest at 4.60 (SEM 0.14). EPA 15 (create a written plan for continuous professional development) was the only EPA to fail to reach the cut-off across all EQual domains. EPAs in the Patient Care Provider Domain received significantly higher ratings than other EPAs. On average, three respondents recommended revision for each. Most comments aligned with the EPA's EQual rubric performance. The generalizability study analysis revealed excellent reliability (G = 0.80). Determining EPA quality utilizing objective measurement tools should drive EPA development and revisions to more accurately reflect the roles, responsibilities, and expectations of pharmacists on the healthcare team.
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Affiliation(s)
- Abigail T. Elmes
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA;
| | - Alan Schwartz
- Department of Medical Education, University of Illinois Chicago College of Medicine, Chicago, IL 60612, USA; (A.S.); (A.T.)
| | - Ara Tekian
- Department of Medical Education, University of Illinois Chicago College of Medicine, Chicago, IL 60612, USA; (A.S.); (A.T.)
| | - Jennie B. Jarrett
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA;
- American Medical Association, Chicago, IL 60611, USA
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Sawicki JG, Richards BF, Schwartz A, Balmer D. Measuring the Learning Orientation Fostered by Pediatric Residency Programs With the Graduate Medical Education Learning Environment Inventory Instrument. Acad Pediatr 2023; 23:1288-1294. [PMID: 36997151 DOI: 10.1016/j.acap.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Mastery learning orientation, conceptualized as a growth mindset, can be beneficial to learners in medical education and is supported by a program...s learning environment. Currently, there are no instruments which reliably assess the learning orientation of a graduate medical education program...s learning environment. OBJECTIVE To explore the reliability and validity of the Graduate Medical Education Learning Environment Inventory (GME-LEI). METHODS Leaders of the Education in Pediatrics Across the Continuum (EPAC) project revised Krupat...s Educational Climate Inventory to create the GME-LEI. We investigated the GME-LEI...s reliability and validity through confirmatory factor and parallel factor analyses and calculated Cronbach...s alpha for each subscale. We compared mean subscale scores between residents in traditional programs and the EPAC project. As EPAC is known to foster a mastery-focused learning orientation, we hypothesized differences detected between resident groups would strengthen the instrument...s validity. RESULTS One hundred and twenty-seven pediatric residents completed the GME-LEI. The final 3-factor model was an acceptable fit to the data, and Cronbach...s alpha for each subscale was acceptable (Centrality: 0.87; Stress: 0.73; Support: 0.77). Mean scores on each subscale varied by program type (EPAC vs traditional) with EPAC residents reporting statistically significant higher scores in the Centrality of Learning subscale (2.03, SD 0.30, vs 1.79, SD 0.42; P.ß=.ß.023; scale of 1...4). CONCLUSIONS The GME-LEI reliably measures 3 distinct aspects of the GME learning environment with respect to learning orientation. The GME-LEI may be used to help programs better monitor the learning environment and make changes to support mastery-oriented learning.
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Affiliation(s)
- Jonathan G Sawicki
- Department of Pediatrics (JG Sawicki and BF Richards), University of Utah School of Medicine, Salt Lake City; Division of Pediatric Hospital Medicine (JG Sawicki), Primary Children...s Hospital.
| | - Boyd F Richards
- Department of Pediatrics (JG Sawicki and BF Richards), University of Utah School of Medicine, Salt Lake City.
| | - Alan Schwartz
- Department of Pediatrics (A Schwartz), University of Illinois College of Medicine.
| | - Dorene Balmer
- Department of Pediatrics (D Balmer), University of Pennsylvania School of Medicine.
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Malik Z, Ahn J, Schwartz A, Blackie M. Narrative medicine workshops for emergency medicine residents: Effects on empathy and burnout. AEM Educ Train 2023; 7:e10895. [PMID: 37485471 PMCID: PMC10357272 DOI: 10.1002/aet2.10895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 07/25/2023]
Abstract
Background Emergency medicine (EM) residents face unique affective challenges and barriers to interpersonal connection in their clinical environment which may contribute to decreased empathy and increased burnout. Narrative medicine (NM) might address these barriers and has had beneficial impacts in various populations but has never been studied in EM residents. In this study, we sought to evaluate the effect of NM workshops on burnout and empathy and to assess resident perceptions of the workshops. Methods We performed a quasi-experimental study at two EM residencies from June to October 2020. Residents at the intervention site participated in two NM workshops led by EM faculty that were composed of a close reading of a literary text, reflective writing, and group discussion. Residents were asked to complete the abbreviated Interpersonal Reactivity Index (IRI) and a single-item burnout measure pre- and postintervention. We fitted linear regression models to IRI subscores; we treated burnout as an ordinal variable and fitted a conditional logistic regression model. Residents completed a postintervention survey that we analyzed using summary statistics. Results A total of 46.7% of control (28/60) and 100% of intervention (48/48) residents responded (n = 76). While all respondents demonstrated worsening burnout with time (p = 0.001), residents at the intervention site exhibited less severe increases (interaction p < 0.001). Empathy remained unchanged. A total of 50% of intervention residents (24/48) responded to the postintervention survey; most (n = 20, 83.3%) agreed that the workshops should be a standard part of EM didactics. Conclusions These findings establish the feasibility and desirability of NM in residency education and offers a model for EM-centered narrative workshops. Additionally, while our outcomes are limited, we found that exposure to an NM curriculum may be protective against worsening burnout.
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Affiliation(s)
- Zayir Malik
- Department of Emergency MedicineBoston University School of MedicineBostonMassachusettsUSA
| | - James Ahn
- Section of Emergency Medicine in the Department of MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Alan Schwartz
- Department of Medical EducationUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Michael Blackie
- Department of Medical EducationUniversity of Illinois at ChicagoChicagoIllinoisUSA
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Fleury Curado T, Pham L, Otvos T, Klopfer T, Freire C, Amorim MR, Nishimura Y, Sennes LU, Psoter KJ, Abdelwahab M, Huang A, Dedhia R, Liu S, Capasso R, Oliven A, Polotsky V, Eisele D, Schwartz A. Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. J Clin Sleep Med 2023; 19:947-955. [PMID: 36727502 PMCID: PMC10152343 DOI: 10.5664/jcsm.10474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES The major goal of the study was to determine whether changes in tongue morphology under selective hypoglossal nerve therapy for obstructive sleep apnea were associated with alterations in airway patency during sleep when specific portions of the hypoglossal nerve were stimulated. METHODS This case series was conducted at the Johns Hopkins Sleep Disorders Center at Johns Hopkins Bayview Medical Center. Twelve patients with apnea implanted with a multichannel targeted hypoglossal nerve-stimulating system underwent midsagittal ultrasound tongue imaging during wakefulness. Changes in tongue shape were characterized by measuring the vertical height and polar dimensions between tongue surface and genioglossi origin in the mandible. Changes in patency were characterized by comparing airflow responses between stimulated and adjacent unstimulated breaths during non-rapid eye movement sleep. RESULTS Two distinct morphologic responses were observed. Anterior tongue base and hyoid-bone movement (5.4 [0.4] to 4.1 [1.0] cm (median and [interquartile range]) with concomitant increases in tongue height (5.0 [0.9] to 5.6 [0.7] cm) were associated with decreases in airflow during stimulation. In contrast, comparable anterior hyoid movement (tongue protrusion from 5.8 [0.5] to 4.5 [0.9] cm) without significant increases in height (5.2 [1.6] to 4.6 [0.8] cm) were associated with marked increases in airflow during sleep. CONCLUSIONS Tongue protrusion with preservation of tongue shape predicted increases in patency, whereas anterior movement with concomitant increases in height were associated with decreased pharyngeal patency. These findings suggest that pharyngeal patency can be best stabilized by stimulating lingual muscles that maintain tongue shape while protruding the tongue, thereby preventing it from prolapsing posteriorly during sleep. CITATION Fleury Curado T, Pham L, Otvos T, et al. Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. J Clin Sleep Med. 2023;19(5):947-955.
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Affiliation(s)
- Thomaz Fleury Curado
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luu Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tamas Otvos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tracy Klopfer
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carla Freire
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Mateus R. Amorim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yoichi Nishimura
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Luiz Ubirajara Sennes
- Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kevin J. Psoter
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohamed Abdelwahab
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Allen Huang
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Raj Dedhia
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- B’nai Zion Hospital, Technion School of Medicine, Haifa, Israel
| | - Stanley Liu
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Robson Capasso
- Sleep Surgery Division, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Arie Oliven
- Department of Otorhinolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Vsevolod Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David Eisele
- Department of Otorhinolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alan Schwartz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Jarrett JB, Elmes AT, Schwartz A. Which Entrustment-Supervision Scale is Right for Pharmacy Education? Am J Pharm Educ 2023; 87:100021. [PMID: 37288689 DOI: 10.1016/j.ajpe.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/16/2022] [Accepted: 12/23/2022] [Indexed: 06/09/2023]
Abstract
Entrustable professional activities (EPAs) are an outgrowth of the competency-based educational model to support workplace-based learner assessments and evaluation. A learner's performance of EPAs is assessed by the degree of provided entrustment and required supervision rather than by a score, percentage, or letter grade typically assigned in traditional academic coursework. Entrustment-supervision (ES) scales are used to document learner progression and steer learner development over time. The purpose of this article is to critique various ES tools in health professions education for utilization within an EPA framework for learner assessment in workplace-based settings and to determine which will best suit pharmacy education. Exploring the advantages and disadvantages across all types of ES scales is a critical step in determining the most useful ES tool for use within a specific pharmacy institution and across the Academy. An ES scale with the traditional 5 levels, a prospective assessment frame, and increased stratification at lower levels should be recommended by the Academy and utilized in workplace-based settings for formative and summative assessment to provide more valid assessment of learners, support the ideal of life-long learning, and give more meaning for pharmacy faculty and learners within assessment.
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Affiliation(s)
- Jennie B Jarrett
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA.
| | - Abigail T Elmes
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Alan Schwartz
- Department of Medical Education, University of Illinois Chicago College of Medicine, Chicago, IL, USA
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Schwartz A, King B, Mink R, Turner T, Abramson E, Blankenburg R, Degnon L. The APPD Longitudinal Educational Assessment Research Network's First Decade. Pediatrics 2023; 151:191115. [PMID: 37122062 DOI: 10.1542/peds.2022-059113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2023] [Indexed: 05/02/2023] Open
Abstract
ABSTRACT In 2009, the Association of Pediatric Program Directors (APPD) Longitudinal Educational Assessment Research Network (LEARN), a national educational research network, was formed. We report on evaluation of the network after 10 years of operation by reviewing program context, input, processes, and products to measure its progress in performing educational research that advances training of future pediatricians. Historical changes in medical education shaped the initial development of the network. APPD LEARN now includes 74% (148 of 201) of US Pediatric residency programs and has recently incorporated a network of Pediatric subspecialty fellowship programs. At the time of this evaluation, APPD LEARN had approved 19 member-initiated studies and 14 interorganizational studies, resulting in 23 peer-reviewed publications, numerous presentations, and 7 archived sharable data sets. Most publications focused on how and when interventions work rather than whether they work, had high scores for reporting rigor, and included organizational and objective performance outcomes. Member program representatives had positive perceptions of APPD LEARN's success, with most highly valuing participation in research that impacts training, access to expertise, and the ability to make authorship contributions for presentations and publication. Areas for development and improvement identified in the evaluation include adopting a formal research prioritization process, infrastructure changes to support educational research that includes patient data, and expanding educational outreach within and outside the network. APPD LEARN and similar networks contribute to high-rigor research in pediatric education that can lead to improvements in training and thereby the health care of children.
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Affiliation(s)
- Alan Schwartz
- Departments of Medical Education and Pediatrics,University of Illinois at Chicago, Chicago, Illinois
- Association of Pediatric Program Directors, McLean, Virginia
| | - Beth King
- Association of Pediatric Program Directors, McLean, Virginia
| | - Richard Mink
- Association of Pediatric Program Directors, McLean, Virginia
- Harbor-UCLA Medical Center, Torrance, California
| | - Teri Turner
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Erika Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | | | - Laura Degnon
- Association of Pediatric Program Directors, McLean, Virginia
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Tu M, Amaro L, Kidder B, Kelley K, Capozza K, Schwartz A. 318 Facilitating mentorship for caregivers of children with atopic dermatitis: the supporting eczema caregivers initiative. Br J Dermatol 2023. [DOI: 10.1093/bjd/ljac140.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Abstract
Caregivers of children with atopic dermatitis (AD) report high levels of stress, feelings of failure and isolation, and a need for social support. These socioemotional effects accumulate over time, often resulting in dramatic changes in career, finances and social activities for caregivers and families when childhood AD is poorly controlled. Psychosocial support and supportive relationships are critical to handling stressful life events. The present study assesses a psychosocial support programme for parents of children with AD. This mentorship program’s primary objective was to promote improvements in stress, resilient coping and loneliness among AD caregivers. Participants were randomized to an email-only group (n = 40) or a one-to-one mentorship pairing (n = 17). We collected measures of stress, coping resilience, loneliness, AD severity and program satisfaction at baseline, 6 weeks and 12 weeks. Eczema severity significantly decreased overall from baseline to 6 weeks (P < 0.001) and remained decreased at 12 weeks (P < 0.001 vs. baseline). There was no significant difference between groups or change in stress, resilience or loneliness over time. Qualitative data demonstrated high program satisfaction. While there was no change in loneliness, resilience or stress, we found a reduction in self-reported eczema symptoms. Continued reduction in these symptoms could affect the overall quality of life, which in turn could yield improved measures of loneliness, resilience and stress.
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Affiliation(s)
- Michelle Tu
- Global Parents for Eczema Research , Santa Barbara, CA , USA
| | | | | | - Keri Kelley
- Global Parents for Eczema Research , Santa Barbara, CA , USA
| | - Korey Capozza
- Global Parents for Eczema Research , Santa Barbara, CA , USA
| | - Alan Schwartz
- University of Illinois College of Medicine , Chicago, IL , USA
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Capozza K, Funk M, Hering M, Lang J, Merhand S, Manion R, Orevillo K, Picozza M, Proctor A, Schwennesen T, Begolka WS, Tullos K, Talent C, Tu M, Vastrup AS, Schwartz A. Patients' and Caregivers' Experiences With Atopic Dermatitis-Related Burden, Medical Care, and Treatments in 8 Countries. J Allergy Clin Immunol Pract 2023; 11:264-273.e1. [PMID: 36332836 DOI: 10.1016/j.jaip.2022.10.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/25/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies have documented the high patient and caregiver burden associated with atopic dermatitis (AD). Less is known about the factors-especially those related to treatment options and the delivery of medical care-that may relate to burden and unmet needs among patients and their caregivers. OBJECTIVE Our primary aim was to characterize and compare health-related quality of life, long-term control of symptoms, satisfaction with treatments, the financial burden, and the prevalence of patient-centered care among adult and pediatric patients with AD in 8 developed nations. METHODS We developed a 53-item anonymous online survey for adult patients and caregivers of children with AD (N = 3171; self-reported disease severity: 8.2% clear, 33.2% mild, 41.1% moderate, 17.6% severe). The survey included questions across 7 domains selected by a steering committee of 11 patient organizations that advocate for patients with AD in the 8 countries. We used validated instruments when available including the 5-level EuroQol five-dimensional questionnaire and the Atopic Dermatitis Control Tool. The survey was offered in 5 languages and promoted through social media and other communication channels of the patient organizations. RESULTS The health-related quality-of-life scores for adult patients with AD (driven by 2 domains: pain/discomfort and anxiety/depression) were worse than those reported for asthma and type 2 diabetes in previous studies (0.72; 95% CI, 0.65-0.78). Patients and caregivers reported substantial financial impacts even in countries with government-funded health care systems, though the greatest impact was in the United States. In all countries, adults reported better control of symptoms than children, but neither group nor any nationality reported adequate control on average (rescaled mean, 57.5; 95% CI, 56.1-58.9), and control correlated negatively with disease severity. Similarly, satisfaction with treatments, which was moderate across countries on average, was much lower for respondents with more severe disease symptoms (F(3,3165) = 5.5; P < .001). Patients who saw a specialist (a dermatologist or an allergist) instead of a general practitioner for AD care indicated better long-term control of symptoms (by 4 points on average on the 100-point scale; 95% CI, 2.6-5.4; P < .001). Finally, self-management training and shared decision making were uncommonly reported by patients in all countries except by respondents from the United States, but both were associated with better long-term control of symptoms and higher satisfaction. CONCLUSIONS The burden of AD, evaluated as health-related quality-of-life detriments, financial impacts, and uncontrolled symptoms, is significant and highest for patients with more severe atopic dermatitis who report greater challenges in achieving symptom resolution with existing treatments and approaches to care. The better outcomes associated with respondents who saw specialists suggest that patients, especially those with more severe AD, might benefit from medical care that is guided by providers with more in-depth knowledge of this complex condition. Finally, wider use of patient-centered care practices (specifically, self-management training and shared decision making) could improve outcomes and boost satisfaction with treatments for AD, though more research on this topic is warranted.
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Affiliation(s)
- Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, Calif.
| | | | | | - Jessica Lang
- Global Parents for Eczema Research, Santa Barbara, Calif
| | | | | | - Kara Orevillo
- Global Parents for Eczema Research, Santa Barbara, Calif
| | - Mario Picozza
- Associazione Nazionale Dermatite Atopica and Santa Lucia Foundation IRCCS, Rome, Italy
| | | | | | | | - Kathryn Tullos
- International Topical Steroid Awareness Network, Dallas, Tex
| | - Cheryl Talent
- Eczema Association of Australasia, Brisbane, Australia
| | - Michelle Tu
- Global Parents for Eczema Research, Santa Barbara, Calif
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Kemper KJ, Schwartz A. Update on Mistreatment and Burnout in Pediatric Residents. Acad Pediatr 2022:S1876-2859(22)00630-1. [PMID: 36581102 DOI: 10.1016/j.acap.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/02/2022] [Accepted: 12/22/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Kathi J Kemper
- Department of Pediatrics, College of Medicine (KJ Kemper), The Ohio State University, Columbus.
| | - Alan Schwartz
- Departments of Medical Education and Pediatrics (A Schwartz), University of Illinois College of Medicine, Chicago
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Fleury Curado T, Pham L, Freire C, Amorim M, Abdelwahab M, Huang A, Taheri N, Hong Y, Dedhia R, Liu S, Capasso R, Polotsky V, Eisele D, Schwartz A. Changes in Tongue Morphology Predict Responses in Pharyngeal Patency to Selective Hypoglossal Nerve Stimulation. Sleep Med 2022. [DOI: 10.1016/j.sleep.2022.05.647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Curado TF, Pho H, Freire C, Amorim M, Sennes LU, Taheri N, Hong Y, Abdelwahab M, Huang A, Fishbein K, Liu S, Capasso R, Schwartz A, Fuller D, Polotsky V. Designer Receptors Exclusively Activated by Designer Drugs Treatment of Sleep-disordered Breathing. Sleep Med 2022. [DOI: 10.1016/j.sleep.2022.05.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Weiner SJ, Schwartz A, Weaver F, Galanter W, Olender S, Kochendorfer K, Binns-Calvey A, Saini R, Iqbal S, Diaz M, Michelfelder A, Varkey A. Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2238231. [PMID: 36279133 PMCID: PMC9593230 DOI: 10.1001/jamanetworkopen.2022.38231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE Contextualizing care is a process of incorporating information about the life circumstances and behavior of individual patients, termed contextual factors, into their plan of care. In 4 steps, clinicians recognize clues (termed contextual red flags), clinicians ask about them (probe for context), patients disclose contextual factors, and clinicians adapt care accordingly. The process is associated with a desired outcome resolution of the presenting contextual red flag. OBJECTIVE To determine whether contextualized clinical decision support (CDS) tools in the electronic health record (EHR) improve clinician contextual probing, attention to contextual factors in care planning, and the presentation of contextual red flags. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was performed at the primary care clinics of 2 academic medical centers with different EHR systems. Participants were adults 18 years or older consenting to audio record their visits and their physicians between September 6, 2018, and March 4, 2021. Patients were randomized to an intervention or a control group. Analyses were performed on an intention-to-treat basis. INTERVENTIONS Patients completed a previsit questionnaire that elicited contextual red flags and factors and appeared in the clinician's note template in a contextual care box. The EHR also culled red flags from the medical record, included them in the contextual care box, used passive and interruptive alerts, and proposed relevant orders. MAIN OUTCOMES AND MEASURES Proportion of contextual red flags noted at the index visit that resolved 6 months later (primary outcome), proportion of red flags probed (secondary outcome), and proportion of contextual factors addressed in the care plan by clinicians (secondary outcome), adjusted for study site and for multiple red flags and factors within a visit. RESULTS Four hundred fifty-two patients (291 women [65.1%]; mean [SD] age, 55.6 [15.1] years) completed encounters with 39 clinicians (23 women [59.0%]). Contextual red flags were not more likely to resolve in the intervention vs control group (adjusted odds ratio [aOR], 0.96 [95% CI, 0.57-1.63]). However, the intervention increased both contextual probing (aOR, 2.12 [95% CI, 1.14-3.93]) and contextualization of the care plan (aOR, 2.67 [95% CI, 1.32-5.41]), controlling for whether a factor was identified by probing or otherwise. Across study groups, contextualized care plans were more likely than noncontextualized plans to result in improvement in the presenting red flag (aOR, 2.13 [95% CI, 1.38-3.28]). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that contextualized CDS did not improve patients' outcomes but did increase contextualization of their care, suggesting that use of this technology could ultimately help improve outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03244033.
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Affiliation(s)
- Saul J. Weiner
- Department of Medicine, College of Medicine, University of Illinois Chicago
- Medical Services, Jesse Brown Department of Veterans Affairs (VA) Medical Center, Chicago, Illinois
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
| | - Alan Schwartz
- Department of Medical Education, College of Medicine, University of Illinois Chicago
| | - Frances Weaver
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois
| | - William Galanter
- Department of Medicine, College of Medicine, University of Illinois Chicago
| | - Sarah Olender
- University of Illinois Cancer Center, College of Medicine, University of Illinois Chicago
| | - Karl Kochendorfer
- Department of Family and Community Medicine, College of Medicine, University of Illinois Chicago
| | - Amy Binns-Calvey
- Department of Medicine, College of Medicine, University of Illinois Chicago
- Medical Services, Jesse Brown Department of Veterans Affairs (VA) Medical Center, Chicago, Illinois
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
| | - Ravisha Saini
- Department of Medicine, College of Medicine, University of Illinois Chicago
- Medical Services, Jesse Brown Department of Veterans Affairs (VA) Medical Center, Chicago, Illinois
| | - Sana Iqbal
- Clinical Research Office, Health Sciences Campus, Loyola University Chicago, Maywood, Illinois
| | - Monique Diaz
- Dignity Health, Pacific Central Coast Health Centers, Arroyo Grande, California
| | - Aaron Michelfelder
- Department of Family Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
- Loyola University Health System, Chicago, Illinois
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Kukulski P, Schwartz A, Hirshfield LE, Ahn J, Carter K. Racial Bias on the Emergency Medicine Standardized Letter of Evaluation. J Grad Med Educ 2022; 14:542-548. [PMID: 36274765 PMCID: PMC9580305 DOI: 10.4300/jgme-d-21-01144.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/03/2022] [Accepted: 07/07/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Studies on components of residency applications have shown evidence of racial bias. The Standardized Letter of Evaluation (SLOE) is an assessment measure for emergency medicine (EM) residency applications and, as more specialties opt to use SLOEs in place of narrative letters of recommendation, understanding bias on standardized assessments is essential. OBJECTIVE To determine whether there is a difference in rankings on the EM SLOE between underrepresented in medicine (UIM) and non-UIM applicants, White and non-White applicants, and to examine whether differences persist after controlling for other characteristics. METHODS The sample was drawn from medical students who applied to EM residency at the study institution in 2019. We compared rankings between UIM and non-UIM students and between students of each individual race/ethnicity and White students, after controlling for United States Medical Licensing Examination Step scores, Alpha Omega Alpha status, type of school (US MD, US DO, internation medical graduate), Medical Student Performance Evaluation class percentile, affiliated program vs visiting clerkship SLOE, gender and the interaction of race/ethnicity and gender, and adjusted for students submitting multiple SLOEs, using ordinal regression. RESULTS There were 1555 applicants to the study institution in 2019; 1418 (91.2%) had a SLOE and self-identified race/ethnicity. After controlling for applicant characteristics, non-UIM students were significantly more likely to be ranked higher than UIM students on "Rank Against Peers," (OR 1.46, 95% CI 1.03-2.07) and Grade (OR 1.46, 95% CI 1.05-2.04). CONCLUSIONS Analysis of EM SLOEs submitted to our institution demonstrates racial bias on this standardized assessment tool, which persists after controlling for other performance predictors.
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Affiliation(s)
- Paul Kukulski
- Paul Kukulski, MD, MPHE, is Assistant Professor and Assistant Program Director, Section of Emergency Medicine, Department of Medicine, University of Chicago
| | - Alan Schwartz
- Alan Schwartz, PhD, is Professor and Interim Head, The Michael Reese Endowed Professor of Medical Education, Department of Medical Education, University of Illinois at Chicago
| | - Laura E. Hirshfield
- Laura E. Hirshfield, PhD, is The Dr. Georges Bordage Medical Education Faculty Scholar and Associate Professor of Medical Education and Sociology, Department of Medical Education, University of Illinois at Chicago
| | - James Ahn
- James Ahn, MD, MHPE, is Associate Professor and Program Director, Section of Emergency Medicine Department of Medicine, University of Chicago
| | - Keme Carter
- Keme Carter, MD, is Associate Professor, Associate Dean for Admissions, and Clerkship Director, Section of Emergency Medicine, Department of Medicine, University of Chicago
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Hsu DC, Baghdassarian A, Caglar D, Rose JA, Herman BE, Schwartz A, Mink R, Langhan ML. Pediatric Emergency Medicine Fellowship Program Directors' Viewpoint: Minimum Levels of Entrustment for Graduating Fellows and Practicing Physicians to Perform the Subspecialty's Professional Activities. Pediatr Emerg Care 2022:00006565-990000000-00110. [PMID: 35947053 DOI: 10.1097/pec.0000000000002817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Entrustable Professional Activities (EPAs) are essential tasks physicians perform within their professions. Entrustment levels that pediatric emergency medicine (PEM) fellowship program directors (FPDs) expect graduating fellows to achieve for PEM-specific and common pediatric subspecialty EPAs remain unreported. This study aims to determine minimum entrustment levels FPDs require fellows to achieve to graduate from fellowship and to compare FPD expectations for fellows versus practicing PEM physicians. METHODS Secondary analysis of PEM-specific data from a national multispecialty cross-sectional survey of pediatric subspecialty FPDs. For 6 PEM-specific and 7 common pediatric subspecialty EPAs, PEM FPDs indicated (1) minimum entrustment levels fellows should achieve by training completion, (2) whether they would allow a fellow to graduate below these minimum levels, and (3) minimum levels for safe and effective practice by PEM physicians. Minimum levels were defined as the level that more than 80% of FPDs would not drop below. RESULTS Sixty of 77 PEM FPDs (78%) completed the survey. Most respondents did not require fellows to achieve the highest level (level 5-no supervision) by graduation for any PEM-specific EPAs. The median level FPDs expected for practicing PEM physicians was 5 (trusted to perform without supervision) for EPAs 1 and 4 and level 4 (indirect supervision for complex cases) for the remaining PEM-specific EPAs. Minimum levels expected by FPDs for common subspecialty pediatric EPAs were lower for both groups. CONCLUSIONS Most PEM FPDs indicated that they would graduate fellows before their achievement of the highest entrustment level for all EPAs. Most also indicated that they do not expect practicing PEM physicians to perform all EPAs without supervision. These findings indicate need for stakeholders to evaluate current structure and outcomes of PEM fellowship programs and for institutions and organizations to ensure adequate support in time and resources for ongoing learning for practicing PEM physicians.
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Affiliation(s)
- Deborah C Hsu
- From the Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Aline Baghdassarian
- Inova L.J. Murphy Children's Hospital, Inova Fairfax Medical Campus, UVA School of Medicine, Falls Church, VA
| | - Derya Caglar
- Division of Emergency Medicine, University of Washington, Seattle Children's Hospital, Seattle, WA
| | - Jerri A Rose
- Division of Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Richard Mink
- Division of Pediatric Critical Care Medicine, Harbor-UCLA Medical Center, The Lundquist Institute for Biomedical Innovation and David Geffen School of Medicine, Los Angeles, CA
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Pitts S, Schwartz A, Carraccio CL, Herman BE, Mahan JD, Sauer CG, Dammann CEL, Aye T, Myers AL, Weiss PG, Turner DA, Hsu DC, Stafford DEJ, Chess PR, Fussell JJ, McGann KA, High P, Curran ML, Mink RB. Fellow Entrustment for the Common Pediatric Subspecialty Entrustable Professional Activities Across Subspecialties. Acad Pediatr 2022; 22:881-886. [PMID: 34936942 DOI: 10.1016/j.acap.2021.12.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the relationship between level of supervision (LOS) ratings for the Common Pediatric Subspecialty Entrustable Professional Activities (EPAs) with their associated subcompetency milestones across subspecialties and by fellowship training year. METHODS Clinical Competency Committees (CCCs) in 14 pediatric subspecialties submitted LOS ratings for 6 Common Subspecialty EPAs and subcompetency milestone levels mapped to these EPAs. We examined associations between these subcompetency milestone levels and LOS ratings across subspecialty training year by fitting per-EPA linear mixed effects models, regressing LOS rating on milestone level and on training year. RESULTS CCCs from 211 pediatric fellowship programs provided data for 369 first, 336 second, and 331 third year fellows. Mean subcompetency milestone levels increased similarly among subspecialties for most EPAs compared with the reference, Adolescent Medicine. Mean subcompetency milestones mapped to each EPA and mean EPA LOS ratings generally increased by training year across all subspecialties. CONCLUSIONS Subcompetency milestones levels mapped to each Common Subspecialty EPA and the EPA LOS ratings increase similarly across subspecialties and by training year, providing validity evidence for using EPA LOS to assess pediatric subspecialty trainee performance. This study supports the development of tools to facilitated the CCC evaluation process across all pediatric subspecialties.
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Affiliation(s)
- Sarah Pitts
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital (S Pitts), Boston, Mass.
| | - Alan Schwartz
- Departments of Medical Education and Pediatrics, University of Illinois at Chicago College of Medicine (A Schwartz), Chicago, Ill
| | - Carol L Carraccio
- Competency-Based Medical Education, American Board of Pediatrics (CL Carraccio and DA Turner), Chapel Hill, NC
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine (BE Herman), Salt Lake City, Utah
| | - John D Mahan
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital (JD Mahan), Columbus, Ohio
| | - Cary G Sauer
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (CG Sauer), Atlanta, Ga
| | | | - Tandy Aye
- Department of Pediatrics, Stanford University School of Medicine (T Aye), Los Gatos, Calif
| | - Angela L Myers
- Children's Mercy Kansas City, UMKC School of Medicine (AL Myers), Kansas City, Mo
| | - Pnina G Weiss
- Department of Pediatrics, Yale School of Medicine (PG Weiss), New Haven, Conn
| | - David A Turner
- Competency-Based Medical Education, American Board of Pediatrics (DA Turner), Chapel Hill, NC
| | - Deborah C Hsu
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital (DC Hsu), Houston, Tex
| | - Diane E J Stafford
- Department of Pediatrics, Stanford University School of Medicine, Stanford University School of Medicine, Center of Academic Medicine (DEJ Stafford), Stanford, Calif; Division of Pediatric Endocrinology (DEJ Stafford), Palo Alto, Calif
| | - Patricia R Chess
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry (PR Chess), Rochester, NY
| | - Jill J Fussell
- Department of Pediatrics, University of Arkansas for Medical Sciences (JJ Fussell), Little Rock, Ark
| | - Kathleen A McGann
- Department of Pediatrics, Duke University Medical Center (KA McGann), Durham, NC
| | - Pamela High
- Department of Pediatrics, W. Alpert Medical School of Brown University (P High), Providence, RI
| | - Megan L Curran
- Department of Pediatrics, University of Colorado (ML Curran), Aurora, Colo
| | - Richard B Mink
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles (UCLA) (RB Mink); Lundquist Institute for Biomedical Innovation at Harbor UCLA Medical Center (RB Mink), Torrance, Calif
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Fitzgerald M, Bhatt A, Thompson LA, Schwartz A, Thomas AO, Schinasi DA, Otero J, Carpenter P, Thomas JS, Black NP. Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training. Acad Pediatr 2022; 22:713-717. [PMID: 34732381 DOI: 10.1016/j.acap.2021.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE To describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees. METHODS We conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training. RESULTS Forty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited "time" (55%, n = 136/243) most frequently as a barrier. CONCLUSIONS Our needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.
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Affiliation(s)
- Melissa Fitzgerald
- University of Florida, Department of Pediatrics (M Fitzgerald, LA Thompson, J Otero, NP Black), Gainesville, Fla.
| | - Avni Bhatt
- University of California, Davis, School of Medicine (A Bhatt), Sacramento, Calif
| | - Lindsay A Thompson
- University of Florida, Department of Pediatrics (M Fitzgerald, LA Thompson, J Otero, NP Black), Gainesville, Fla
| | - Alan Schwartz
- University of Illinois Chicago, Department of Pediatrics (A Schwartz), Chicago, Ill
| | - Aaron O Thomas
- University of Florida, Information Technology (AO Thomas), Gainesville, Fla
| | - Dana A Schinasi
- Northwestern University Feinberg School of Medicine (DA Schinasi), Chicago, Ill
| | - Jaclyn Otero
- University of Florida, Department of Pediatrics (M Fitzgerald, LA Thompson, J Otero, NP Black), Gainesville, Fla
| | - Pamela Carpenter
- University of Utah/Primary Children's Hospital (P Carpenter), Salt Lake City, Utah
| | - Julie S Thomas
- University of Florida, UF Health Cancer Center, Clinical Research Office (JS Thomas), Gainesville, Fla
| | - Nicole Paradise Black
- University of Florida, Department of Pediatrics (M Fitzgerald, LA Thompson, J Otero, NP Black), Gainesville, Fla
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Shah R, Camarena A, Park C, Martin A, Clark M, Atkins M, Schwartz A. Healthcare-Based Interventions to Improve Parenting Outcomes in LMICs: A Systematic Review and Meta-Analysis. Matern Child Health J 2022; 26:1217-1230. [PMID: 35579803 DOI: 10.1007/s10995-022-03445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although a number of early childhood development (ECD) interventions in healthcare settings in low- and middle-income countries (LMICs) have been developed to improve parent-directed outcomes and support ECD, their impact have yet to be established. This review assesses the effectiveness of healthcare-based ECD interventions in LMICs on the following key evidence-informed parenting outcomes affecting ECD: (1) responsive caregiving (2) cognitive stimulation and (3) parental mental health. Impacts on parental knowledge regarding ECD and parenting stress were also assessed. METHODS PubMed, PsycINFO, Scopus, CINAHL and Embase were searched. We included randomized controlled trials reporting effects of healthcare-based ECD interventions in LMICs on parent-directed outcomes in the first five years of life. Data extraction included study characteristics, design, sample size, participant characteristics, settings, intervention descriptions, and outcomes. Meta-analyses were conducted using random effects models. RESULTS 8 articles were included. Summary standardized mean differences demonstrated significant benefits of healthcare-based interventions in LMICs for improving: (1) cognitive stimulation (n = 4; SMD = 0.32; 95% CI: 0.08 to 0.56) and (2) ECD knowledge (n = 4; SMD = 0.44; 95% CI: 0.27 to 0.60). No significant effects were seen on maternal depression and parenting stress; only one study assessed parent-child interactions in the context of responsiveness. Limitations included small number of studies for moderation analysis, high heterogeneity, variability in measures used for outcomes and timing of assessments. CONCLUSIONS FOR PRACTICE Our results demonstrate statistically significant effects of healthcare-based interventions in LMICs on improving key evidence-based parenting outcomes and offers one promising strategy to support children reach their full developmental potential.
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Affiliation(s)
- Reshma Shah
- Department of Pediatrics, University of Illinois at Chicago, 856 South Wood Street, 60612, Chicago, IL, United States.
| | - Andrea Camarena
- School of Medicine, Meharry Medical College, Nashville, TN, United States
| | - Christen Park
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, United States
| | - Aleah Martin
- Department of Pediatrics, University of Illinois at Chicago, 856 South Wood Street, 60612, Chicago, IL, United States
| | - Maureen Clark
- Library of the Health Sciences, University of Illinois at Chicago, Chicago, IL, United States
- Department of Medical Education, University of Illinois at Chicago, Chicago, IL, United States
| | - Marc Atkins
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, United States
| | - Alan Schwartz
- Department of Pediatrics, University of Illinois at Chicago, 856 South Wood Street, 60612, Chicago, IL, United States
- Department of Medical Education, University of Illinois at Chicago, Chicago, IL, United States
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Law EH, Pickard AS, Walton SM, Xie F, Lee TA, Schwartz A. Time-Specific Differences in Stated Preferences for Health in the United States. Med Care 2022; 60:462-469. [PMID: 35315380 DOI: 10.1097/mlr.0000000000001714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Changes over time in health state values from a societal perspective may be an important reason to consider updating societal value sets for preference-based measures of health. OBJECTIVE The aim was to examine whether stated health preferences are different between 2002 and 2017, controlling for demographic changes in the United States. METHODS Data from 2002 and 2017 US EQ-5D-3L valuation studies were combined. The primary analysis compared valuations of better-than-dead (BTD) states only, as both studies used the same time trade-off (TTO) method for these states. For worse-than-dead (WTD) states, the 2017 study used the lead-time TTO and the 2002 study used the conventional TTO, which necessitated transformation. Regression models were fitted to BTD values to estimate time-specific differences, adjusting for respondent characteristics. Secondary analyses examined models that fitted WTD values (using linear and nonlinear transformations of the 2002 data) and all values. RESULTS The adjusted BTD-only model showed mean values were higher for 2017 compared with 2002 (βY2017=0.05, P<0.001). WTD-only models showed negative changes over time but that were dependent on the transformation method (linear βY2017=-0.72; nonlinear βY2017=-0.35; both P<0.001). Using all values, 2017 mean valuations were lower using a linear transformation (βY2017=-0.11; P<0.001) but did not differ with the nonlinear transformation. CONCLUSIONS Individuals in 2017 are generally less willing to trade quantity for quality of life compared with 2002. This study provides evidence of time-specific differences in a society's preferences, suggesting that the era in which values were elicited may be an important reason to consider updating societal value sets.
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Affiliation(s)
- Ernest H Law
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL
| | - Alan Simon Pickard
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL
| | - Surrey M Walton
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL
| | - Feng Xie
- Department of Health Research Methods, McMaster University, St. Joseph's Hospital, Hamilton, ON, Canada
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL
| | - Alan Schwartz
- Department of Medical Education, University of Illinois at Chicago, Chicago, IL
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Adavadkar PA, Pappalardo AA, Glassgow AE, Zhang C, Schwartz A, Brooks LJ, Martin MA. Rates of diagnoses of sleep disorders in children with chronic medical conditions. J Clin Sleep Med 2022; 18:2001-2007. [PMID: 35621126 PMCID: PMC9340607 DOI: 10.5664/jcsm.10064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES This investigation examines sleep disorder (SD) diagnoses in a large population of children and adolescents with chronic medical conditions (CMCs). Little is known about SD diagnoses in this population. The large population used in this study allowed examination of SD rates by CMC type and demographics. METHODS Data were from the Coordinated Health Care for Complex Kids (CHECK) project designed for Medicaid-funded children and adolescents with at least one CMC from a large metropolitan area. The study population (N=16,609) was limited to children and adolescents, 0 to 18 years of age. SD and CMC diagnoses were obtained from Medicaid claims data. RESULTS Fourteen percent of the population (mean age of 9.1 years [SD= 5.2]; 35.8% African American (AA); 56.4% male; 77 with more than one CMC) received a sleep disorder diagnosis. The most frequent diagnosis was SDB (11.2%), followed by nocturnal enuresis (1.2%), and insomnia (1%). SDs were diagnosed more frequently in those with multiple CMCs than in those with one CMC (19.7% vs. 5.8%; p <0.001). Insomnia rates in Hispanic/Latinx (1.2%) and AA (0.8%) children and adolescents were significantly lower (both p<0.001) than in Caucasians (3.5%). Odds of receiving a sleep diagnosis varied among CMCs. CONCLUSIONS Our analysis of Medicaid claims data of a large urban cohort offers detailed information about the rates of sleep diagnoses and suggests under-diagnosis of SDs in this vulnerable, high-risk, primarily ethnic minority population. Under-recognition of sleep disorders have short- and long-term health and economic consequences. Study results may help clinicians implement appropriate SD screening and management for children and adolescents with CMCs.
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Affiliation(s)
- Pranshu A Adavadkar
- Department of Pediatrics, University of Illinois Children's Hospital, University of Illinois at Chicago, Chicago, Illinois.,Department of Medicine, University of Illinois Children's Hospital, University of Illinois at Chicago, Chicago, Illinois
| | - Andrea A Pappalardo
- Department of Pediatrics, University of Illinois Children's Hospital, University of Illinois at Chicago, Chicago, Illinois.,Department of Medicine, University of Illinois Children's Hospital, University of Illinois at Chicago, Chicago, Illinois
| | - Anne Elizabeth Glassgow
- Department of Pediatrics, University of Illinois Children's Hospital, University of Illinois at Chicago, Chicago, Illinois
| | - Christina Zhang
- Department of Pediatrics, University of Southern California, Los Angeles, California
| | - Alan Schwartz
- Department of Pediatrics, University of Illinois Children's Hospital, University of Illinois at Chicago, Chicago, Illinois.,Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois
| | - Lee J Brooks
- Department of Pediatrics, Rowan SOM, Stratford, NJ
| | - Molly A Martin
- Department of Pediatrics, University of Illinois Children's Hospital, University of Illinois at Chicago, Chicago, Illinois
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Schwartz A, Germany R, Meyer T, McKane S. 0708 Stage-dependent Differences in Central Sleep Apnea (CSA) Predominate in remedē System Pivotal Trial Participants. Sleep 2022. [DOI: 10.1093/sleep/zsac079.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Differences in neuroventilatory control can impact the type and severity of sleep disordered breathing between non-REM and REM sleep. We examined the distribution of central apneic episodes in polysomnograms from subjects with predominantly central sleep apnea, who received phrenic nerve stimulation.
Methods
Baseline in-lab polysomnograms from patients enrolled in the remedē System Pivotal Trial were scored by a central core laboratory (n=151). Participants with predominantly CSA were enrolled if the apnea-hypopnea index (AHI)≥20/hr, the central apnea index (CAI) exceeded the obstructive apnea index (OAI), and the OAI did not exceed 20% of the total AHI. This post-hoc analysis compared sleep apnea indices in REM and non-REM sleep in those with ≥5 minutes REM sleep (n=131). Within-patient median non-REM - REM differences were calculated and compared.
Results
REM sleep time was 40 [Q1=28, Q3=64] minutes, and non-REM sleep time was 301 [Q1=269,Q3=344] minutes. AHI in REM sleep was 22/hr [Q1=9,Q3=44] and was 46/hr (Q1=33,Q3=60) in non-REM sleep, yielding a within-patient difference between non-REM and REM sleep of 22/hr ([Q1=6, Q3=34], p<.001). CAI in REM was only 4/hr (Q1=0, Q3=11), but in non-REM was 25/hr [Q1=16,Q3=43] with all patients having a CAI≥5/hr during non-REM. In REM, 70% had a CAI>0/hr and 46% had a CAI ≥5/hr. The CAI difference between non-REM and REM sleep was 18/hr [Q1=10, Q3=30; p<.001]. The OAI and mixed apnea index (MAI) differed by <1/hr (p=0.235 and <.001, respectively). Of note, the hypopnea index [HI] did not differ between REM and non-REM sleep (12/hr [Q1=2,Q3=22] vs. 11/hr [Q1=4, Q3=20], respectively, p=0.273), yet hypopneas constituted a greater proportion of total AHI during REM compared to non-REM sleep.
Conclusion
Among subjects with predominantly CSA, the prevalence and severity of CSA was greater in non-REM than REM sleep, yet low-level CSA persisted in REM sleep. Stage-related differences in CAI but not OAI, MAI or HI can be attributed to alterations in ventilatory rather than upper airway control in this CSA cohort. These differences in the type and severity of sleep disordered breathing episodes comprise a key diagnostic signature, for which specific CSA therapeutic strategies are indicated.
Support (If Any)
ZOLL Respicardia, Inc. and NIH R01 HL144859
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Affiliation(s)
- Alan Schwartz
- University of Pennsylvania and Vanderbilt University Schools of Medicine
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Schwartz A, Jacobowitz O, Mickelson S, Miller M, Oliven A, Certal V, Hopp M, Winslow D, Huntley T, Nachlas N, Gillespie MB, Weeks B, Lovett E, Shen J, Maurer J. 0765 Enhanced Response to Targeted Hypoglossal Nerve Stimulation in Patients with Normal Sleep Efficiency: A THN3 Post-Hoc Analysis. Sleep 2022. [DOI: 10.1093/sleep/zsac079.761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
THN3 was the first reported parallel-arm, randomized controlled trial of hypoglossal nerve stimulation (HGNS), wherein targeted HGNS (THN) was shown to be safe and efficacious at ameliorating sleep disordered breathing in selected patients with moderate to severe OSA and BMI≤35kg/m2 without screening with drug-induced sleep endoscopy. A secondary THN3 objective was to identify baseline characteristics which enhance therapeutic response.
Methods
Predictors of long-term (Month 12/15) apnea-hypopnea index (AHI) response (reduction ≥50% to ≤20/hr) were identified in stages. Baseline characteristics, including polysomnography parameters, were screened one at a time using univariate logistic regression. Variables significant at α=0.25 were further selected using stepwise multivariate logistic regression. Candidate predictors were then optimized by manual, incremental threshold adjustment to maximize AHI response rate (RR). Optimized predictors were ranked according to the AHI RR and size of the corresponding subpopulation, with a goal of capturing at least 40% of the overall THN3 cohort.
Results
Baseline sleep efficiency (SE) in the normal range (>85%) achieved the highest AHI RR while retaining 42% (58/138) of the THN3 cohort. Similar to the overall study population, subgroup subjects were predominantly middle-aged (age 54±7 years), male (83%), Caucasian (86%) and overweight/obese (BMI 30±3 kg/m2). Short-term (Month 4) AHI RRs in the Treatment and Control groups were 59.5% and 20.0%, respectively, with long-term AHI RR at 50.9%. Median AHI was reduced from 35.1 to 16.0, as compared to 29.3 to 9.0 in the STAR trial of distal HGNS. ODI RRs (reduction ≥25%) for Treatment and Control were respectively 73.0% and 30.0% at Month 4 and 64.9% at Month12/15. Enhanced response carried through to larger point estimates for improvement in secondary variables, including the Epworth Sleepiness Scale and the Functional Outcomes of Sleep Questionnaire, exceeding minimum clinically important differences thresholds of 2-3 and 1.7-2.0, respectively.
Conclusion
Normal SE at Baseline was associated with enhanced AHI and ODI RR as well as patient-reported outcome measures for patients receiving THN therapy, providing results similar to those obtained with distal HGNS. Future studies, including the ongoing OSPREY trial, will be needed to prospectively validate these findings.
Support (If Any)
LivaNova
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Affiliation(s)
- Alan Schwartz
- Perelman School of Medicine, University of Pennsylvania
| | | | - Samuel Mickelson
- Advanced Ear, Nose & Throat Associates, The Atlanta Snoring and Sleep Disorders Institute
| | | | - Arie Oliven
- Department of Medicine, Bnai-Zion Medical Centre
| | - Victor Certal
- Department of Otorhinolaryngology/Sleep Medicine Centre , Hospital CUF Porto
| | - Martin Hopp
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center
| | | | | | | | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center
| | | | | | | | - Joachim Maurer
- Department of ORL-HNS, Division of Sleep Medicine, University Medical Centre Mannheim
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Seay E, Dedhia R, Thuler E, Jafari N, Keenan B, Troske K, Schwartz A. 0744 A Comparison of Visual and Physiologic Assessments of Upper Airway Collapse during Drug-Induced Sleep Endoscopy (DISE). Sleep 2022. [DOI: 10.1093/sleep/zsac079.740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The VOTE score, critical closing pressure (Pcrit), and therapeutic CPAP levels are assessments that quantify upper airway collapse by either subjective visual scoring or objective pressure-flow analysis. We hypothesized that there would be an association between collapse severity and physiologic metrics (VOTE versus Pcrit and PAP levels, respectively) acquired during drug-induced sleep endoscopy (DISE).
Methods
This prospective cohort study evaluated 100 consecutive patients with obstructive sleep apnea (OSA) who underwent DISE with application of nasal positive airway pressure between June 3rd, 2020 and June 11th, 2021. Patients were assigned a VOTE score of 0, 1, or 2 indicating no collapse, partial collapse, or complete collapse at the velum, oropharynx, tongue base, and epiglottis, respectively. We assessed two metrics of pharyngeal collapsibility with progressive increases in nasal pressure: (1) the pressure at which inspiratory airflow commences (critical pressure, Pcrit), and (2) the pressure at which inspiratory flow limitation is abolished (pharyngeal opening pressure, PhOP). Our analysis examined the association between the composite VOTE score [0-8 units] and collapsibility metrics.
Results
Ninety-one patients met inclusion criteria for VOTE scoring; of these, 87 were included for PhOP analysis and 79 for Pcrit analysis. The cohort was 76% male, mean (SD) age was 54.7 (14.1) years, body-mass index was 29.7 (4.9), and AHI was 30.3 (20.9). Composite VOTE score was positively associated with Pcrit (β = 0.88 ± 0.38 cm H2O per unit, standardized estimate = 0.26, p=0.023). We found no significant association between the composite VOTE score and PhOP (β = 0.57 ± 0.40 cm H2O per unit, standardized estimate = 0.15, p=0.162).
Conclusion
Our findings suggest that visual and physiological assessments of upper airway collapsibility provide both overlapping and complementary information in characterizing upper airway mechanics. Measures of pharyngeal collapsibility during DISE can be used to model the ultimate impact of therapeutic maneuvers on OSA. Future studies investigating the utility of each assessment both in isolation and in combination for predicting OSA therapy outcomes are indicated.
Support (If Any)
National Institutes of Health: 1R01HL144859
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Affiliation(s)
- Everett Seay
- University of Pennsylvania, Perelman School of Medicine
| | - Raj Dedhia
- University of Pennsylvania, Perelman School of Medicine
| | - Eric Thuler
- University of Pennsylvania, Perelman School of Medicine
| | - Niusha Jafari
- University of Pennsylvania, Perelman School of Medicine
| | | | - Kendra Troske
- University of Pennsylvania, Perelman School of Medicine
| | - Alan Schwartz
- University of Pennsylvania, Perelman School of Medicine
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Jacobowitz O, Schwartz A, Lovett E, Ranuzzi G, Malhotra A. 0761 Adaptability of the Treating Obstructive Sleep Apnea Using Targeted Hypoglossal Nerve Stimulation (OSPREY) Trial. Sleep 2022. [DOI: 10.1093/sleep/zsac079.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
With few exceptions, clinical trials of hypoglossal nerve stimulation (HGNS) for obstructive sleep apnea (OSA) are single-arm, open-label studies sometimes followed by short-term, unblinded, randomized withdrawal. By contrast, the THN3 study was a parallel-arm, randomized, controlled trial (RCT) of targeted HGNS (THN) in moderate to severe OSA, and provided higher-level evidence of HGNS safety and efficacy.Despite generating strong evidence, conventional RCTs are risky due to their inherent inflexible designs. We therefore launched a confirmatory THN RCT (OSPREY) with an adaptive, Bayesian “Goldilocks” design that optimize its sample size dynamically, yet achieve high-confidence results.
Methods
Four scenarios were simulated within the OSPREY design framework (randomized 2:1 Treatment:Control) for the primary endpoint of apnea-hypopnea index (AHI) response rate (RR): nominal with results equal to those of THN3 (Treatment AHI RR 52%/Control AHI RR 20%), improved Treatment RR (63%/20%), worsened Treatment RR (41%/20%) and null [Treatment RR=Control RR] (20%/20%). Each scenario was simulated 10 times with 10,000 simulations of each interim analysis. Subject outcomes were determined by randomly drawing from a binomial distribution with the relevant AHI RR.Interim analyses in OSPREY begin at 50 randomized subjects and repeat every 20 additional subjects to the maximum sample size of 150, with opportunities for early success and futility at each milestone to generate high-confidence results from an optimal sample size. OSPREY assesses secondary endpoints including quality of life inventories (Epworth Sleepiness Scale; Functional Outcomes of Sleep Questionnaire; EQ-5D, SF-6D and PROMIS sleep questionnaires) and oximetry metrics (Oxygen Desaturation Index, %sleep time below 90% oxygen saturation). Previous results suggest secondary endpoints will be adequately powered at the final sample size determined by AHI RR.
Results
Simulations produced the following outcomes formatted as [scenario: randomized sample size, overall success rate, probability of early success, mean success probability]: null: 150, 0%, 0%, 2.47%; nominal: 130-150, 100%, 80%, 95.3%; improved: 90-130, 100%, 100%, 98.9%; worsened: 150, 100%, 0%, 68.6%.
Conclusion
OSPREY is uniquely able to adapt to various Treatment/Control response scenarios and should provide high-confidence confirmation of the safety and efficacy of THN therapy in moderate to severe OSA.
Support (If Any)
LivaNova
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Affiliation(s)
| | - Alan Schwartz
- University of Pennsylvania Perelman School of Medicine
| | | | | | - Atul Malhotra
- Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego
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Schwartz A, Jacobowitz O, Mickelson S, Miller M, Oliven A, Certal V, Hopp M, Winslow D, Huntley T, Nachlas N, Gillespie MB, Weeks B, Lovett E, Shen J, Maurer J. 0766 Group Trajectories Demonstrate Robust Effects of Targeted Hypoglossal Nerve Stimulation in the THN3 Randomized, Controlled Trial. Sleep 2022. [DOI: 10.1093/sleep/zsac079.762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
THN3 was the first reported parallel-arm, randomized controlled trial (RCT) of hypoglossal nerve stimulation (HGNS), wherein targeted HGNS (THN) was shown to be safe and efficacious at ameliorating sleep disordered breathing in patients with moderate to severe OSA and BMI≤35kg/m2 without screening with drug-induced sleep endoscopy. Unique among reported HGNS trials, separate cohorts of patients receiving early and late THN were followed longitudinally.
Methods
Measurements of apnea-hypopnea index (AHI) were available Pre-enrollment, Baseline (2 nights), Month 4 and Month 12/15. Except for Pre-enrollment, AHI values were calculated by an independent core laboratory from polysomnographic recordings. All subjects with complete data were included for analysis. AHI trajectories were constructed for early and late THN activation (Treatment[T], N=83, Month 1 and Control[C], N=45, Month 4, respectively) by computing median values. Confidence intervals were calculated by bootstrapping each median (N=30,000). Patient-reported outcome measures (PROMs) were treated similarly.
Results
AHI (Median (95% CI)) trajectories demonstrated a consistent pattern of pre-implant alignment (Pre-enrollment T:39.1 (36.0-45.0), C:38.0 (32.0-41.0); Baseline 1 T:36.1 (33.0-39.9), C:31.3 (27.2-38.6); Baseline 2 T:37.0 (34.3-41.0), C:35.2 (32.3-38.2)), divergence at the conclusion of the randomization period (Month 4 T:15.6 (11.9-25.3), C:30.6 (23.7-38.6)) and reconvergence following 11 months of treatment (Month 12/15 T:20.7 (16.0-26.4), C:18.1 (16.3-23.3)). Non-standardized Pre-enrollment AHI was slightly higher than Baseline values. Trajectories were similar for oxygen desaturation index (Baseline 1 T:35.3 (31.9-38.0),C:34.3 (27.5-40.3); Baseline 2 T:37.1 (33.4-39.3),C:36.8 (33.9-38.3); Month 4 T:19.5 (16.2-28.5), C:33.8 (25.4-41.1); Month 12/15 T:19.5 (16.0-25.6), C:19.7 (16.3-26.0)), the Epworth Sleepiness Scale (Baseline T:11.0 (10.0-13.0),C:11.5 (8.5-14.0); Month 4 T:6.0 (5.0-7.0), C:11.5 (8.0-12.5); Month 12/15 T:6.0 (4.0-7.0), C:5.5 (4.5-6.0)), the Functional Outcomes of Sleep Questionnaire (Baseline T:15.3 (14.0-16.5),C:14.7 (13.3-16.6); Month 4 T:18.3 (17.7-18.8), C:16.7 (14.9-17.7); Month 12/15 T:18.8 (18.3-19.3), C:18.5 (17.5-19.5)) and the Snore Outcomes Survey (Baseline T:26.6 (21.9-31.3),C:21.9 (18.8-31.3); Month 4 T:60.9 (56.3-67.9), C:29.7 (23.4-42.9); Month 12/15 T:62.5 (59.4-68.8), C:68.8 (62.5-71.9)).
Conclusion
Group trajectories of sleep-disordered breathing and PROMs further demonstrate the robust effects of THN in patients with moderate to severe OSA and the value of parallel-arm RCTs. Similar results may be expected in the ongoing OSPREY confirmatory trial of THN.
Support (If Any)
LivaNova
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Affiliation(s)
- Alan Schwartz
- Perelman School of Medicine, University of Pennsylvania
| | | | - Samuel Mickelson
- Advanced Ear, Nose & Throat Associates, The Atlanta Snoring and Sleep Disorders Institute
| | | | - Arie Oliven
- Department of Medicine, Bnai-Zion Medical Centre
| | - Victor Certal
- Department of Otorhinolaryngology/Sleep Medicine Centre , Hospital CUF Porto
| | - Martin Hopp
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center
| | | | | | | | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center
| | | | | | | | - Joachim Maurer
- Department of ORL-HNS, Division of Sleep Medicine, University Medical Centre Mannheim
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Elowsky J, Bajaj S, Bashford-Largo J, Zhang R, Mathur A, Schwartz A, Dobbertin M, Blair KS, Leibenluft E, Pardini D, Blair RJR. Differential associations of conduct disorder, callous-unemotional traits and irritability with outcome expectations and values regarding the consequences of aggression. Child Adolesc Psychiatry Ment Health 2022; 16:38. [PMID: 35606814 PMCID: PMC9128221 DOI: 10.1186/s13034-022-00466-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 04/04/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Previous work has examined the association of aggression levels and callous-unemotional traits with outcome expectations and values regarding the consequences of aggression. Less work has examined the outcome expectations and values regarding the consequences of aggression of adolescents with Conduct Disorder (CD). Also, no studies have examined links between irritability (a second socio-affective trait associated with CD) and these social cognitive processes despite the core function of anger in retaliatory aggression and establishing dominance. METHOD The current study, investigating these issues, involved 193 adolescents (typically developing [TD; N = 106], 87 cases with CD [N = 87]). Participants completed an adaptation of the Outcomes Expectations and Values Questionnaire and were assessed for CU traits and irritability via the Inventory of Callous-Unemotional traits and the Affective Reactivity Index. RESULTS While CD was associated with atypical outcome expectations this was not seen within statistical models including CU traits and irritability. CU traits were associated with decreased expectation that aggression would result in feelings of remorse and victim suffering, as well as decreased concern that aggressive acts would result in punishment and victim suffering. Irritability was associated with increased expectations and concern that aggression would result in dominance and forced respect. CONCLUSIONS The results suggest that CU traits and irritability, often present in youth with CD, are associated with different forms of maladaptive outcome expectations and values regarding the consequences of aggression. This suggests that the atypical social cognitive processes underlying aggressive behavior among youth exhibiting CU traits may differ from those exhibiting problems regulating anger.
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Affiliation(s)
- J. Elowsky
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - S. Bajaj
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - J. Bashford-Largo
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.24434.350000 0004 1937 0060Center for Brain, Biology, and Behavior, University of Nebraska-Lincoln, Lincoln, NE USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - R. Zhang
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - A. Mathur
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - A. Schwartz
- grid.266862.e0000 0004 1936 81633Department of Psychology, University of North Dakota, Grand Forks, ND USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - M. Dobbertin
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - K. S. Blair
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - E. Leibenluft
- grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA
| | - D. Pardini
- grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA
| | - R. J. R. Blair
- grid.414583.f0000 0000 8953 4586Center for Neurobehavioral Research, Boys Town National Research Hospital, 14015 Flanagan Blvd. Suite #102, Boys Town, NE 68010 USA ,grid.94365.3d0000 0001 2297 5165Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD USA ,grid.215654.10000 0001 2151 2636School of Criminology & Criminal Justice, Arizona State University, Phoenix, AZ USA ,grid.466916.a0000 0004 0631 4836Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
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Sowho M, Schneider H, Jun J, MacCarrick G, Schwartz A, Pham L, Sgambati F, Lima J, Smith P, Polotsky V, Neptune E. D-dimer in Marfan syndrome: effect of obstructive sleep apnea induced blood pressure surges. Am J Physiol Heart Circ Physiol 2022; 322:H742-H748. [PMID: 35275761 PMCID: PMC8977140 DOI: 10.1152/ajpheart.00004.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 11/22/2022]
Abstract
Aortic dissection and rupture are the major causes of premature death in persons with Marfan syndrome (MFS), a rare genetic disorder featuring cardiovascular, skeletal, and ocular impairments. We and others have found that obstructive sleep apnea (OSA) confers significant vascular stress in this population and may accelerate aortic disease progression. We hypothesized that D-dimer, a diagnostic biomarker for several types of vascular injury that is also elevated in persons with MFS with aortic enlargement, may be sensitive to cardiovascular stresses caused by OSA. To test this concept, we recruited 16 persons with MFS without aortic dissection and randomized them to two nights of polysomnography, without (baseline) and with OSA treatment: continuous positive airway pressure (CPAP). In addition to scoring OSA by the apnea-hypopnea index (AHI), beat-by-beat systolic BP (SBP) and pulse-pressure (PP) fluctuations were quantified. Morning blood samples were also assayed for D-dimer levels. In this cohort (male:female, 10:6; age, 36 ± 13 yr; aortic diameter, 4 ± 1 cm), CPAP eliminated OSA (AHI: 20 ± 17 vs. 3 ± 2 events/h, P = 0.001) and decreased fluctuations in SBP (13 ± 4 vs. 9 ± 3 mmHg, P = 0.011) and PP (7 ± 2 vs. 5 ± 2 mmHg, P = 0.013). CPAP also reduced D-dimer levels from 1,108 ± 656 to 882 ± 532 ng/mL (P = 0.023). Linear regression revealed a positive association between the maximum PP during OSA and D-dimer in both the unadjusted (r = 0.523, P = 0.038) and a model adjusted for contemporaneous aortic root diameter (r = 0.733, P = 0.028). Our study revealed that overnight CPAP reduces D-dimer levels commensurate with the elimination of OSA and concomitant hemodynamic fluctuations. Morning D-dimer measurements together with OSA screening might serve as predictors of vascular injury in MFS.NEW & NOTEWORTHY What is New? Surges in blood pressure caused by obstructive sleep apnea during sleep increase vascular stress and D-dimer levels in Marfan syndrome. Elevations in D-dimer can be lowered with CPAP. What is Noteworthy? D-dimer levels might serve as a marker for determining the significance of obstructive sleep apnea in persons with Marfan syndrome. D-dimer or obstructive sleep apnea screening is a potential method to identify persons with Marfan syndrome at risk for adverse cardiovascular events.
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Affiliation(s)
- Mudiaga Sowho
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Hartmut Schneider
- American Sleep Clinic, Center for Sleep Medicine, Frankfurt, Germany
| | - Jonathan Jun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gretchen MacCarrick
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alan Schwartz
- Department of Otolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Luu Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Francis Sgambati
- Center for Interdisciplinary Sleep Research and Education, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joao Lima
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Philip Smith
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Vsevolod Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Enid Neptune
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Sowho M, Jun J, Sgambati F, Chaney M, Schneider H, Smith P, Schwartz A, Dietz H, MacCarrick G, Neptune E. Assessment of pleural pressure during sleep in Marfan syndrome. J Clin Sleep Med 2022; 18:1583-1592. [PMID: 35152942 DOI: 10.5664/jcsm.9920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Patients with Marfan syndrome (MFS) have a high risk for aortic aneurysms. They are also susceptible to sleep-disordered breathing that may expose them to highly negative intrathoracic pressures known to increase aortic transmural pressure which may accelerate aortic dilatation. Our objective was to quantify overnight intrathoracic pressure changes during sleep in snoring patients with MFS, and the therapeutic effect of continuous positive airway pressure (CPAP). METHODS We used a questionnaire to identify self-reported snoring patients with MFS. In these patients, we monitored intrathoracic pressure using esophageal pressure (Pes) during overnight baseline and CPAP sleep studies. We defined a peak inspiratory Pes (Pespeak-insp) < - 5 cmH2O as greater than normal, and examined the distribution of Pespeak-insp during baseline and CPAP studies. RESULTS In our sample of 23 MFS snorers, we found that 70% of sleep breaths exhibited Pespeak-insp < -5 cmH2O, with apneas/hypopneas accounting for only 12%, suggesting prevalent stable flow-limited breathing and snoring. In a subset (n=12) with Pes monitoring during CPAP night, CPAP lowered the mean proportion of breaths with Pespeak-insp < -5 cmH2O from 83.7±14.9% to 3.6±3.0% (p<0.001). In addition, contemporaneous aortic root diameter was associated with the mean Pespeak-insp during IFL and apneas/hypopneas (β= -0.05, r=0.675, p=0.033). CONCLUSIONS The sleep state in MFS revealed prolonged exposure to exaggerated negative inspiratory Pes, which was reversible with CPAP. Since negative intrathoracic pressure can contribute to thoracic aortic stress and aortic dilatation, snoring may be a reversible risk factor for progression of aortic pathology in MFS.
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Affiliation(s)
- Mudiaga Sowho
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan Jun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Francis Sgambati
- Center for Interdisciplinary Sleep Research and Education, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mariah Chaney
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Hartmut Schneider
- American Sleep Clinic, Center for Sleep Medicine, Frankfurt, Germany
| | - Philip Smith
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Alan Schwartz
- American Sleep Clinic, Center for Sleep Medicine, Frankfurt, Germany
| | - Harry Dietz
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Gretchen MacCarrick
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Enid Neptune
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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Capozza K, Schwartz A, Lang JE, Chalmers J, Camilo J, Abuabara K, Kelley K, Harrison J, Vastrup A, Stancavich L, Tai A, Kimball AB, Finlay AY. The Impact of Childhood Atopic Dermatitis on Life Decisions for Caregivers and Families. J Eur Acad Dermatol Venereol 2022; 36:e451-e454. [DOI: 10.1111/jdv.17943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- K. Capozza
- Global Parents for Eczema Research Santa Barbara USA
| | - A. Schwartz
- Departments of Medical Education and Pediatrics University of Illinois Chicago USA
| | - JE Lang
- Global Parents for Eczema Research Santa Barbara USA
| | - J Chalmers
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - J Camilo
- ADERMAP ‐ Associação Dermatite Atópica Portugal Lisboa Portugal
| | - K Abuabara
- Department of Dermatology University of California San Francisco USA
| | - K. Kelley
- Global Parents for Eczema Research Santa Barbara USA
| | - J. Harrison
- Global Parents for Eczema Research Santa Barbara USA
| | - A. Vastrup
- Atopisk Eksem Forening Copenhagen Denmark
| | - L. Stancavich
- Global Parents for Eczema Research Santa Barbara USA
| | - A. Tai
- Global Parents for Eczema Research Santa Barbara USA
| | | | - AY Finlay
- Division of Infection and Immunity School of Medicine Cardiff University Cardiff UK
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