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Bockrath R, Osman C, Trainor J, Wang HC, Phatak UP, Richards DG, Keeley M, Chung EK. Education Scholarship Assessment Reconsidered: Expansion of Glassick's Criteria to Incorporate Health Equity. Acad Med 2024; 99:487-492. [PMID: 38306582 DOI: 10.1097/acm.0000000000005654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
ABSTRACT Recent events have ignited widespread attention to structural racism and implicit bias throughout the U.S. health care system and medical institutions, resulting in a call for antiracism approaches to advance health equity. Medical education leaders are well positioned to advance health equity, not only through their training of fellows, residents, and medical students, but also in their approach to scholarship. Education scholarship drives innovation and critical evaluation of current practices; it impacts and intersects with multiple factors that have the potential to reduce health inequities. Thus, it is critical to prioritize the assessment of education scholarship through a health equity lens. Medical education scholarly dissemination has markedly expanded over the past 2 to 3 decades, yet medical educators have continued to embrace Boyer's and Glassick and colleagues' definitions of scholarship. The authors propose an approach to medical education scholarship assessment that expands each of Glassick's 6 existing criteria to address health inequities and adds health equity as a seventh criterion. With this, medical educators, researchers, reviewers, and others can consider how education scholarship affects diverse populations and settings, direct educational products and scholarship to address health inequities, and raise the importance of advancing health equity in medical education scholarship. By expanding and standardizing the assessment of scholarship to incorporate health equity, the medical education community can foster a cultural shift that brings health equity to the forefront of education scholarship.
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Chang PW, Goyal NK, Chung EK. Marijuana Use and Breastfeeding: A Survey of Newborn Nurseries. Pediatrics 2024; 153:e2023063682. [PMID: 38247374 DOI: 10.1542/peds.2023-063682] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Marijuana use has increased nationally and is the most common federally illicit substance used during pregnancy. This study aimed to describe hospital practices and nursery director knowledge and attitudes regarding marijuana use and breastfeeding and assess the association between breastfeeding restrictions and provider knowledge, geographic region, and state marijuana legalization status. We hypothesized that there would be associations between geography and/or state legalization and hospital practices regarding breastfeeding with perinatal marijuana use. METHODS A cross-sectional, 31-question survey was sent electronically to the 110 US hospital members of the Academic Pediatric Association's Better Outcomes through Research for Newborns (BORN) network. Survey responses were analyzed using descriptive statistics to report frequencies. For comparisons, χ2 and Fisher exact tests were used to determine statistical significance. RESULTS Sixty-nine (63%) BORN nursery directors across 38 states completed the survey. For mothers with a positive cannabinoid screen at delivery, 16% of hospitals universally or selectively restrict breastfeeding. Most (96%) nursery directors reported that marijuana use while breastfeeding is "somewhat" (70%) or "very harmful" (26%). The majority was aware of the potential negative impact of prenatal marijuana use on learning and behavior. There were no consistent statistical associations between breastfeeding restrictions and provider marijuana knowledge, geographic region, or state marijuana legalization status. CONCLUSIONS BORN newborn clinicians report highly variable and unpredictable breastfeeding support practices for mothers with perinatal marijuana use. Further studies are needed to establish evidence-based practices and to promote consistent, equitable care of newborns with perinatal marijuana exposure.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Neera K Goyal
- Department of Pediatrics, Sidney Kimmel College of Medicine and Nemours Children's Health, Philadelphia, Pennsylvania
| | - Esther K Chung
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington
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Abstract
OBJECTIVES Late preterm and term infants comprise 97.3% of annual births in the United States. Admission criteria and the availability of medical interventions in well newborn nurseries are key determinants of these infants remaining within a mother-infant dyad or requiring a NICU admission and resultant separation of the dyad. The objective of this study was to identify national patterns for well newborn nursery care practices. METHODS We surveyed a physician representative from each nursery in the Better Outcomes through Research for Newborns Network. We described the admission criteria and clinical management of common newborn morbidities and analyzed associations with nursery demographics. RESULTS Of 96 eligible nursery representatives, 69 (72%) completed surveys. Among respondents, 59 (86%) used a minimal birth weight criterion for admission to their well newborn nursery. The most commonly used criteria were 2000 g (n = 29, 49%) and 1800 g (n = 19, 32%), with a range between 1750 and 2500 g. All nurseries used a minimal gestational age criterion for admission; the most commonly used criterion was 35 weeks (n = 55, 80%). Eleven percent of sites required transfer to the NICU for phototherapy. Common interventions in the mother's room included dextrose gel (n = 56, 81%), intravenous antibiotics (n = 35, 51%), opiates for neonatal abstinence syndrome (n = 15, 22%), and an incubator for thermoregulation (n = 14, 20%). CONCLUSIONS Wide variation in admission criteria and medical interventions exists in well newborn nurseries. Further studies may help identify evidence-based optimal admission criteria to maximize care within the mother-infant dyad.
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Affiliation(s)
- Neha S. Joshi
- Department of Pediatrics, Stanford University, Stanford, California
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | | | - Esther K. Chung
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital, Seattle, Washington
| | - Jayme L. Congdon
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Henry C. Lee
- Department of Pediatrics, Stanford University, Stanford, California
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Fusfeld ZH, Goyal NK, Goldstein ND, Chung EK. Assessing and Validating a Model of Study Completion for a Prospective Cohort of Healthy Newborns. Hosp Pediatr 2022; 13:e2022006626. [PMID: 36475380 DOI: 10.1542/hpeds.2022-006626] [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: 06/17/2023]
Abstract
OBJECTIVES To identify potentially modifiable or actionable factors related to study completion among healthy mother-infant dyads participating in prospective research. PATIENTS/METHODS We conducted a secondary analysis of completion data from a prospective study on newborn jaundice in the first week of life at a tertiary-care hospital in Philadelphia, PA, from 2015 to 2019. Participation in the original study involved enrollment before newborn discharge and subsequent follow-up for a jaundice assessment between 2 and 6 days of life. For this study, our primary outcome was completion of all study procedures. Associations between predictor variables and the outcome were assessed using bivariate and multivariable analyses. We fit a predictive model of study completion using logistic regression and validated the model using 5-fold cross-validation. RESULTS Of 501 mother-infant dyads enrolled in the original study, 304 completed the study. Median maternal age was 28 years and 81.8% of mothers delivered via vaginal birth. Study completion was associated with colocation of the study visit with the initial well-child visit (adjusted odds ratio [aOR], 2.99, 95% confidence interval [CI], 2.01-4.46) and provision of an alternate phone number by the participant (aOR, 1.99; 95% CI, 1.34-2.96). The cross-validated model performed similarly to our final predictive model and had an average area under the receiver operating characteristic curve of 0.67 (range, 0.59-0.72), with a sensitivity of 68% and specificity of 60%. CONCLUSIONS Findings demonstrate the importance of communication and patient-centric approaches for recruitment and retention in newborn research. Future work should incorporate these approaches while continuing to evaluate study retention strategies.
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Affiliation(s)
- Zachary H Fusfeld
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Neera K Goyal
- Department of Pediatrics, Sidney Kimmel College of Medicine at Thomas Jefferson University and Nemours Children's Health, Philadelphia, Pennsylvania; and
| | - Neal D Goldstein
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Esther K Chung
- Department of Pediatrics, University of WashingtonSchool of Medicine and Seattle Children's Hospital, Seattle, Washington
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Chung EK, Painter I, Sitcov K, Souter VD. Exclusive Breastfeeding in the Northwest: Disparities Related to Race/Ethnicity and Substance Use. Acad Pediatr 2022; 22:918-926. [PMID: 34600112 DOI: 10.1016/j.acap.2021.09.016] [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: 04/12/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Mothers who are Black, Indigenous, and people of color (BIPOC) are disproportionately impacted by substance use in pregnancy and less likely to breastfeed. Our objectives were to assess relationships between substance use in pregnancy and exclusive breastfeeding at discharge (EBF) and race/ethnicity and EBF, and determine the extent to which substance use influences the relationship between race/ethnicity and EBF. METHODS This is a retrospective cohort study of term mother-infant dyads using 2016 to 2019 data from a Northwest quality improvement collaborative, Obstetrical Care Outcomes Assessment Program. Stepwise and stratified multivariable logistic regression analyses were conducted to determine associations between independent variables consisting of characteristics, including maternal race/ethnicity and substance use, and the dependent variable, EBF. RESULTS Our sample consisted of 84,742 dyads, 69.5% of whom had EBF. The adjusted odds of EBF for non-Hispanic Black and Hispanic mothers were half, and for American Indian/Alaska Native mothers two-thirds, that of White mothers (aOR [95% CI]: 0.52 [0.48, 0.57], 0.51 [0.48, 0.54], 0.64 [0.55, 0.76], respectively). Substance use did not mediate the association between race/ethnicity and EBF, but it modified the association. Among those reporting nicotine or marijuana use, Hispanic mothers were half as likely as White mothers were to exclusively breastfeed. Other factors associated with a lower likelihood of EBF included public or no insurance, rural setting, C-section, NICU admission, and LBW. CONCLUSIONS Disparities in EBF related to race/ethnicity and substance use were pronounced in this study, particularly among Hispanic mothers with nicotine or marijuana use.
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Affiliation(s)
- Esther K Chung
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital (EK Chung).
| | - Ian Painter
- Department of Health Services, University of Washington (I Painter and VD Souter), Seattle, Wash; The Foundation for Health Care Quality (I Painter, K Sitcov, and VD Souter), Seattle, Wash
| | - Kristin Sitcov
- The Foundation for Health Care Quality (I Painter, K Sitcov, and VD Souter), Seattle, Wash
| | - Vivienne D Souter
- Department of Health Services, University of Washington (I Painter and VD Souter), Seattle, Wash; The Foundation for Health Care Quality (I Painter, K Sitcov, and VD Souter), Seattle, Wash
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Crowley HR, Goyal NK, Chung EK. Marijuana and Breastfeeding: A Pilot Survey of Mothers. Hosp Pediatr 2022; 12:e255-e260. [PMID: 35642492 DOI: 10.1542/hpeds.2021-006420] [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: 11/24/2022]
Abstract
OBJECTIVE To describe maternal knowledge, attitudes, and practices related to marijuana use and breastfeeding, and determine their association with knowledge about potential harmful effects of marijauna use while breastfeeding. METHODS Cross-sectional study design, using a 48-item survey, including previously validated questions, of postpartum mothers at a single urban, academic hospital from 2018 to 2019. Mothers ≥ 18 years with a newborn ≥ 35 weeks' gestation were eligible. Descriptive statistics were tabulated, and associations were tested by using χ2 analysis. RESULTS Of 46 participants, 57% reported marijuana use, and 13% use within the past 12 months. The large majority (87%) knew that use while breastfeeding may be harmful to the infant, whereas just 46% knew that marijuana or THC is found in breast milk. Only 35% received prenatal and 30% postnatal counseling on the risks of marijuana use while breastfeeding. Those aware compared to those unaware that marijuana use during pregnancy may cause learning and behavior problems were more likely to know that use while breastfeeding may be harmful to the infant (75% vs. 25%, P = .03). Those reporting prenatal HCP discussion about the risks of marijuana use while breastfeeding compared to those without such counseling were more likely to know that marijuana/ or HC is found in breast milk (69% vs. 33%, P = .02). CONCLUSIONS The majority of mothers were aware that marijuana use while breastfeeding may be harmful to the infant, but a minority received counseling about the risks of marijuana use while breastfeeding.
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Affiliation(s)
| | - Neera K Goyal
- Sidney Kimmel College of Medicine at Thomas Jefferson University and Nemours Children's Health, Philadelphia, Pennsylvania
| | - Esther K Chung
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; and.,Seattle Children's Hospital, Seattle, Washington
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Riley T, Nethery E, Chung EK, Souter V. Impact of the COVID-19 pandemic on perinatal care and outcomes in the United States: An interrupted time series analysis. Birth 2022; 49:298-309. [PMID: 34957595 DOI: 10.1111/birt.12606] [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: 10/08/2021] [Accepted: 12/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hospitals quickly adapted perinatal care to mitigate SARS-CoV-2 transmission at the onset of the COVID-19 pandemic. The objective of this study was to estimate the impact of pandemic-related hospital policy changes on perinatal care and outcomes in one region of the United States. METHODS This interrupted time series analysis used retrospective data from consecutive singleton births at 15 hospitals in the Pacific Northwest from 2017 to 2020. The primary outcomes were those hypothesized to be affected by pandemic-related hospital policies and included labor induction, epidural use, oxytocin augmentation, mode of delivery, and early discharge (<48 hours after cesarean and <24 hours after vaginal births). Secondary outcomes included preterm birth, severe maternal morbidity, low 5-minute Apgar score, neonatal intensive care unit (NICU) admission, and 30-day readmission. Segmented Poisson regression models estimated the outcome level shift changes after the pandemic onset, controlling for underlying trends, seasonality, and stratifying by parity. RESULTS No statistically significant changes were detected in intrapartum interventions or mode of delivery after onset of the pandemic. Early discharge increased for all births following cesarean and vaginal birth. Newborn readmission rates increased but only among nulliparas (aRR: 1.49, 95%CI: 1.17, 1.91). Among multiparas, decreases were observed in preterm birth (aRR: 0.90, 95%CI: 0.84, 0.96), low 5-minute Apgar score (aRR: 0.75, 95%CI: 0.68, 0.81), and term NICU admission rates (aRR: 0.85, 95%CI: 0.80, 0.91). CONCLUSIONS Increases in early discharge and newborn readmission rates among nulliparas suggest a need for more postpartum support during the pandemic. Decreases in preterm birth and term NICU admission among multiparas may have implications beyond the pandemic and deserve further study.
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Affiliation(s)
- Taylor Riley
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Elizabeth Nethery
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Esther K Chung
- Department of Pediatrics, University of Washington School of Medicine, and Seattle Children's Hospital, Seattle, Washington, USA
| | - Vivienne Souter
- Obstetrical Care Outcomes Assessment Program, Seattle, Washington, USA.,Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
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Chung EK, Solomon BS, Perrin EM, Starmer A, Turner TL, Chandran L. High-Quality Primary Care Implementation: The Time is Now. Acad Pediatr 2022; 22:176-178. [PMID: 34818589 DOI: 10.1016/j.acap.2021.11.011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Esther K Chung
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital (EK Chung), Seattle, Wash.
| | - Barry S Solomon
- Department of Pediatrics, Johns Hopkins University School of Medicine (BS Solomon and EM Perrin), Baltimore, Md
| | - Eliana M Perrin
- Department of Pediatrics, Johns Hopkins University School of Medicine (BS Solomon and EM Perrin), Baltimore, Md; Johns Hopkins University School of Nursing (EM Perrin), Baltimore, Md
| | - Amy Starmer
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School (A Starmer), Boston, Mass
| | - Teri Lee Turner
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital (TL Turner), Houston, Tex
| | - Latha Chandran
- Departments of Pediatrics and Medical Education, University of Miami Miller School of Medicine (L Chandran), Miami, Fla
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McClintock AH, Kim S, Chung EK. Bridging the Gap Between Educator and Learner: The Role of Psychological Safety in Medical Education. Pediatrics 2022; 149:183907. [PMID: 34972228 DOI: 10.1542/peds.2021-055028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Adelaide H McClintock
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Sara Kim
- Academic and Regional Affairs and the Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Esther K Chung
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
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Affiliation(s)
- Esther K Chung
- Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington; and
| | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
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Chung EK, Short VL, Hand DJ, Gubernick RS, Abatemarco DJ. Poor prenatal care does not predict well child care for children born to mothers with opioid use disorder. Journal of Substance Use 2020. [DOI: 10.1080/14659891.2020.1736665] [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: 10/24/2022]
Affiliation(s)
- Esther K. Chung
- Department of Pediatrics, The Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, The A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Vanessa L. Short
- Department of Obstetrics and Gynecology, The Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dennis J. Hand
- Department of Obstetrics and Gynecology, The Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ruth S. Gubernick
- Quality Improvement Advisor, RSG Consulting, Collingswood, New Jersey, USA
| | - Diane J. Abatemarco
- Department of Obstetrics and Gynecology, The Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Goyal NK, Rohde JF, Short V, Patrick SW, Abatemarco D, Chung EK. Well-Child Care Adherence After Intrauterine Opioid Exposure. Pediatrics 2020; 145:peds.2019-1275. [PMID: 31896548 PMCID: PMC6993495 DOI: 10.1542/peds.2019-1275] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Accepted: 11/13/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES For children with intrauterine opioid exposure (IOE), well-child care (WCC) provides an important opportunity to address medical, developmental, and psychosocial needs. We evaluated WCC adherence for this population. METHODS In this retrospective cohort study, we used PEDSnet data from a pediatric primary care network spanning 3 states from 2011 to 2016. IOE was ascertained by using physician diagnosis codes. WCC adherence in the first year was defined as a postnatal or 1-month visit and completed 2-, 4-, 6-, 9-, and 12-month visits. WCC adherence in the second year was defined as completed 15- and 18-month visits. Gaps in WCC, defined as ≥2 missed consecutive WCC visits, were also evaluated. We used multivariable regression to test the independent effect of IOE status. RESULTS Among 11 334 children, 236 (2.1%) had a diagnosis of IOE. Children with IOE had a median of 6 WCC visits (interquartile range 5-7), vs 8 (interquartile range 6-8) among children who were not exposed (P < .001). IOE was associated with decreased WCC adherence over the first and second years of life (adjusted relative risk 0.54 [P < .001] and 0.74 [P < .001]). WCC gaps were more likely in this population (adjusted relative risk 1.43; P < .001). There were no significant adjusted differences in nonroutine primary care visits, immunizations by age 2, or lead screening. CONCLUSIONS Children <2 years of age with IOE are less likely to adhere to recommended WCC, despite receiving on-time immunizations and lead screening. Further research should be focused on the role of WCC visits to support the complex needs of this population.
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Affiliation(s)
| | - Jessica F. Rohde
- Departments of Pediatrics and,Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Vanessa Short
- Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Stephen W. Patrick
- Division of Neonatology, Departments of Pediatrics and Health Policy and Vanderbilt Center for Child Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Diane Abatemarco
- Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Esther K. Chung
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children’s Hospital, Seattle, Washington
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Chung EK, Gubernick RS, LaNoue M, Abatemarco DJ. Child Abuse and Neglect Risk Assessment: Quality Improvement in a Primary Care Setting. Acad Pediatr 2019; 19:227-235. [PMID: 30273689 DOI: 10.1016/j.acap.2018.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 02/19/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Practicing Safety is an American Academy of Pediatrics toolkit to help practices address child abuse and neglect (CAN) risk by increasing screening and providing resources. The objectives in an urban practice serving low-income children were to 1) standardize CAN risk assessment and developmental screening, and 2) improve resource provision. METHODS A quality improvement initiative to standardize CAN risk assessment, using materials adapted from Practicing Safety, was conducted through the use of SmartTools in an electronic health record. The Edinburgh Postnatal Depression Scale and Parents Evaluation of Developmental Status were used to assess maternal depression and child development, respectively. Charts were reviewed in waves-pre-, immediate post-, and early post-implementation (waves 1 to 3); monthly for 6 months (waves 4 to 9); and quarterly for 12 months (waves 10 to 13)-to assess screening and resource provision for 6 domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training. RESULTS A total of 581 charts were reviewed (92, 95, and 94 for waves 1 to 3, respectively; 30 each for waves 4 to 13). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre-implementation to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and from 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation. CONCLUSIONS Incorporating an adapted version of Practicing Safety into an electronic health record is a practical and effective approach to improving CAN risk assessment and resource provision. This quality improvement initiative is an example of a practice-wide improvement that resulted in clinical practice change.
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Affiliation(s)
- Esther K Chung
- Department of Pediatrics (EK Chung),; Nemours/Alfred I. duPont Hospital for Children (EK Chung), Wilmington, Del.
| | | | | | - Diane J Abatemarco
- Department of Obstetrics and Gynecology (D Abatemarco), Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Penn
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Taylor JA, Stout JW, de Greef L, Goel M, Patel S, Chung EK, Koduri A, McMahon S, Dickerson J, Simpson EA, Larson EC. Use of a Smartphone App to Assess Neonatal Jaundice. Pediatrics 2017; 140:peds.2017-0312. [PMID: 28842403 PMCID: PMC5574723 DOI: 10.1542/peds.2017-0312] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [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: 06/28/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The assessment of jaundice in outpatient neonates is problematic. Visual assessment is inaccurate, and more exact methodologies are cumbersome and/or expensive. Our goal in this study was to assess the accuracy of a technology based on the analysis of digital images of newborns obtained using a smartphone application called BiliCam. METHODS Paired BiliCam images and total serum bilirubin (TSB) levels were obtained in a diverse sample of newborns (<7 days old) at 7 sites across the United States. By using specialized software, data on color values in the images ("features") were extracted. Machine learning and regression analysis techniques were used to identify features for inclusion in models to predict an estimated bilirubin level for each newborn. The correlation between estimated bilirubin levels and TSB levels was calculated. In addition, the sensitivity and specificity of the estimated bilirubin levels in identifying newborns with high TSB levels were calculated by using 2 recommended decision rules for jaundice screening. RESULTS Estimated bilirubin levels were calculated and compared with TSB levels in a diverse sample of 530 newborns (20.8% African American, 26.3% Hispanic, and 21.2% Asian American). The overall correlation was 0.91, and correlations among white, African American, Hispanic, and Asian American newborns were 0.92, 0.90, 0.91, and 0.88, respectively. The sensitivities of BiliCam in identifying newborns with high TSB levels were 84.6% and 100%, respectively, by using 2 decision rules; specificities were 75.1% and 76.4%, respectively. CONCLUSIONS BiliCam provided accurate estimates of TSB values, demonstrating that an inexpensive technology that uses commodity smartphones could be used to effectively screen newborns for jaundice.
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Affiliation(s)
- James A. Taylor
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - James W. Stout
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Lilian de Greef
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Mayank Goel
- Department of Pediatrics, University of Washington, Seattle, Washington;,Department of Computer Science and Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Shwetak Patel
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Esther K. Chung
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania;,Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Aruna Koduri
- Kaiser Permanente Northern California, San Leandro, California
| | | | | | | | - Eric C. Larson
- Department of Computer Science and Engineering, Southern Methodist University, Dallas, Texas
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Chung EK, Gable EK, Golden WC, Hudson JA, Hackman NM, Andrews JP, Jackson DS, Beavers JB, Mirchandani DR, Kellams A, Krevitsky ME, Monroe K, Madlon-Kay DJ, Stratbucker W, Campbell D, Collins J, Rauch D. Current Scope of Practice for Newborn Care in Non-Intensive Hospital Settings. Hosp Pediatr 2017; 7:471-482. [PMID: 28694290 DOI: 10.1542/hpeds.2016-0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Esther K Chung
- Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania and Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware;
| | - E Kaye Gable
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina and Cone Health, Greensboro, North Carolina
| | - W Christopher Golden
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer A Hudson
- Department of Pediatrics, Greenville Health System, Greenville, South Carolina
| | - Nicole M Hackman
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jennifer P Andrews
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - DeeAnne S Jackson
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jessica B Beavers
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Dipti R Mirchandani
- Department of Pediatrics, Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York and Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Ann Kellams
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Meredith E Krevitsky
- Department of Pediatrics, Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York and Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Kimberly Monroe
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Diane J Madlon-Kay
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - William Stratbucker
- Department of Pediatrics, Michigan State University and Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Deborah Campbell
- Department of Pediatrics, Albert Einstein College of Medicine, New York, New York and Children's Hospital at Montefiore, Bronx, New York
| | - Jolene Collins
- Department of Pediatrics, University of Southern California Keck School of Medicine and Children's Hospital Los Angeles, Los Angeles, California; and
| | - Daniel Rauch
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Elmhurst, New York
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Chung EK, Kahn S, Altshuler M, Lane JL, Plumb J. The JeffSTARS Advocacy and Community Partnership Elective: A Closer Look at Child Health Advocacy in Action. MedEdPORTAL 2016; 12:10526. [PMID: 30800729 PMCID: PMC6365684 DOI: 10.15766/mep_2374-8265.10526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 12/20/2016] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Advocacy and service-learning increasingly are being incorporated into medical education and residency training. The Jefferson Service Training in Advocacy for Residents and Students (JeffSTARS) curriculum is an educational program for Thomas Jefferson University and Nemours trainees. The JeffSTARS Advocacy and Community Partnership Elective is one of two core components of the larger curriculum. METHODS The elective is a monthlong rotation that provides trainees in their senior year of medical school or residency training the opportunity to learn about health advocacy in depth. Trainees develop a basic understanding of social determinants of health, learn about health policy, participate in legislative office visits, and work directly with community agencies on a mutually agreeable project. The elective provides advocacy training to self-selected trainees from area medical schools and residency programs to develop a cadre of physicians empowered to advocate for child health. RESULTS JeffSTARS has advanced the field of child health advocacy locally by forging new partnerships and building a network of experts, agencies, and academic institutions. After this experience, trainees realize that their health expertise is very valuable to health advocacy and policy development. JeffSTARS is recognized nationally as one of a growing number of advocacy training programs for students and residents, with trainees presenting selected projects at national meetings. DISCUSSION Teaching advocacy has raised awareness about social determinants of health, community resources, and the medical home. One of the many benefits of the elective has been to strengthen the skills and expertise of trainees and faculty members alike.
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Affiliation(s)
- Esther K. Chung
- Professor of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University
- Nemours and Director, JeffSTARS
| | - Stephanie Kahn
- First-year Medical Student, Sidney Kimmel Medical College at Thomas Jefferson University
- Past Educational Coordinator, JeffSTARS at Jefferson Pediatrics/Nemours duPont Philadelphia
| | - Marc Altshuler
- Associate Professor of Family and Community Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
- Associate Program Director of the Family and Community Medicine Residency, Sidney Kimmel Medical College at Thomas Jefferson University
| | - J. Lindsey Lane
- Professor of Pediatrics, University of Colorado School of Medicine
- Vice Chair of Medical Education, University of Colorado School of Medicine
| | - James Plumb
- Professor of Family and Community Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
- Director of the Center on Urban Health, Thomas Jefferson University
- Associate Course Director, JeffSTARS
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Chung EK, Siegel BS, Garg A, Conroy K, Gross RS, Long DA, Lewis G, Osman CJ, Jo Messito M, Wade R, Shonna Yin H, Cox J, Fierman AH. Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians. Curr Probl Pediatr Adolesc Health Care 2016; 46:135-53. [PMID: 27101890 PMCID: PMC6039226 DOI: 10.1016/j.cppeds.2016.02.004] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.
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Affiliation(s)
- Esther K Chung
- The Department of Pediatrics, The Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA; Nemours, Wilmington, DE.
| | - Benjamin S Siegel
- The Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, MA
| | - Arvin Garg
- The Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, MA
| | - Kathleen Conroy
- The Division of General Pediatrics, Boston Children׳s Hospital, Boston, MA
| | - Rachel S Gross
- The Department of Pediatrics, Albert Einstein College of Medicine, The Children׳s Hospital at Montefiore, Bronx, NY
| | - Dayna A Long
- The Department of Pediatrics, UCSF Benioff Children׳s Hospital Oakland, Oakland, CA
| | - Gena Lewis
- The Department of Pediatrics, UCSF Benioff Children׳s Hospital Oakland, Oakland, CA
| | - Cynthia J Osman
- The Department of Pediatrics, New York University, New York, NY
| | - Mary Jo Messito
- The Department of Pediatrics, New York University, New York, NY
| | - Roy Wade
- The Department of Pediatrics, The Children׳s Hospital of Philadelphia, Philadelphia, PA
| | - H Shonna Yin
- The Department of Pediatrics, New York University, New York, NY
| | - Joanne Cox
- The Division of General Pediatrics, Boston Children׳s Hospital, Boston, MA
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Taylor JA, Burgos AE, Flaherman V, Chung EK, Simpson EA, Goyal NK, Von Kohorn I, Dhepyasuwan N. Utility of Decision Rules for Transcutaneous Bilirubin Measurements. Pediatrics 2016; 137:peds.2015-3032. [PMID: 27244792 PMCID: PMC4845868 DOI: 10.1542/peds.2015-3032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 02/03/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Transcutaneous bilirubin (TcB) meters are widely used for screening newborns for jaundice, with a total serum bilirubin (TSB) measurement indicated when the TcB value is classified as "positive" by using a decision rule. The goal of our study was to assess the clinical utility of 3 recommended TcB screening decision rules. METHODS Paired TcB/TSB measurements were collected at 34 newborn nursery sites. At 27 sites (sample 1), newborns were routinely screened with a TcB measurement. For sample 2, sites that typically screen with TSB levels also obtained a TcB measurement for the study. Three decision rules to define a positive TcB measurement were evaluated: ≥75th percentile on the Bhutani nomogram, 70% of the phototherapy level, and within 3 mg/dL of the phototherapy threshold. The primary outcome was a TSB level at/above the phototherapy threshold. The rate of false-negative TcB screens and percentage of blood draws avoided were calculated for each decision rule. RESULTS For sample 1, data were analyzed on 911 paired TcB-TSB measurements from a total of 8316 TcB measurements. False-negative rates were <10% with all decision rules; none identified all 31 newborns with a TSB level at/above the phototherapy threshold. The percentage of blood draws avoided ranged from 79.4% to 90.7%. In sample 2, each rule correctly identified all 8 newborns with TSB levels at/above the phototherapy threshold. CONCLUSIONS Although all of the decision rules can be used effectively to screen newborns for jaundice, each will "miss" some infants with a TSB level at/above the phototherapy threshold.
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Affiliation(s)
- James A. Taylor
- Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Valerie Flaherman
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Esther K. Chung
- Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University and Nemours, Philadelphia, Pennsylvania
| | | | - Neera K. Goyal
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
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Fierman AH, Beck AF, Chung EK, Tschudy MM, Coker TR, Mistry KB, Siegel B, Chamberlain LJ, Conroy K, Federico SG, Flanagan PJ, Garg A, Gitterman BA, Grace AM, Gross RS, Hole MK, Klass P, Kraft C, Kuo A, Lewis G, Lobach KS, Long D, Ma CT, Messito M, Navsaria D, Northrip KR, Osman C, Sadof MD, Schickedanz AB, Cox J. Redesigning Health Care Practices to Address Childhood Poverty. Acad Pediatr 2016; 16:S136-46. [PMID: 27044692 DOI: 10.1016/j.acap.2016.01.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [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: 10/06/2015] [Revised: 12/30/2015] [Accepted: 01/05/2016] [Indexed: 01/16/2023]
Abstract
Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.
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Affiliation(s)
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Esther K Chung
- Department of Pediatrics, The Sidney Kimmel Medical College of Thomas Jefferson University and Nemours, Philadelphia, PA
| | - Megan M Tschudy
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Tumaini R Coker
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kamila B Mistry
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD; Office of Extramural Research, Education, and Priority Populations, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD
| | - Benjamin Siegel
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | | | - Kathleen Conroy
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Steven G Federico
- General Pediatrics, Department of Pediatrics, Denver Health, Denver, CO
| | - Patricia J Flanagan
- Department of Pediatrics, Warren Alpert Medical School of Brown University/Hasbro Children's Hospital, Providence, RI
| | - Arvin Garg
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | | | - Aimee M Grace
- Department of Pediatrics, George Washington University, Washington, DC
| | - Rachel S Gross
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, Bronx, New York
| | - Michael K Hole
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Perri Klass
- Department of Pediatrics, NYU School of Medicine, New York, NY
| | - Colleen Kraft
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Alice Kuo
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Medicine, David Geffen School of Medicine at UCLA
| | - Gena Lewis
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, San Francisco, CA
| | - Katherine S Lobach
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, Bronx, New York
| | - Dayna Long
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, San Francisco, CA; Center of Community Health and Engagement, UCSF Benioff Children's Hospital Oakland, San Francisco, CA
| | - Christine T Ma
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, San Francisco, CA
| | - Mary Messito
- Department of Pediatrics, NYU School of Medicine, New York, NY
| | - Dipesh Navsaria
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Cynthia Osman
- Department of Pediatrics, NYU School of Medicine, New York, NY
| | - Matthew D Sadof
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA; Baystate Children's Hospital, Springfield, MA
| | - Adam B Schickedanz
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joanne Cox
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
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20
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Taylor JA, Burgos AE, Flaherman V, Chung EK, Simpson EA, Goyal NK, Von Kohorn I, Dhepyasuwan N. Discrepancies between transcutaneous and serum bilirubin measurements. Pediatrics 2015; 135:224-31. [PMID: 25601981 PMCID: PMC4306797 DOI: 10.1542/peds.2014-1919] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [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] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To characterize discrepancies between transcutaneous bilirubin (TcB) measurements and total serum bilirubin (TSB) levels among newborns receiving care at multiple nursery sites across the United States. METHODS Medical records were reviewed to obtain data on all TcB measurements collected during two 2-week periods on neonates admitted to participating newborn nurseries. Data on TSB levels obtained within 2 hours of a TcB measurement were also abstracted. TcB--TSB differences and correlations between the values were determined. Data on demographic information for individual newborns and TcB screening practices for each nursery were also collected. Multivariate regression analysis was used to identify characteristics independently associated with the TcB--TSB difference. RESULTS Data on 8319 TcB measurements were collected at 27 nursery sites; 925 TSB levels were matched to a TcB value. The mean TcB--TSB difference was 0.84 ± 1.78 mg/dL, and the correlation between paired measurements was 0.78. In the multivariate analysis, TcB--TSB differences were 0.67 mg/dL higher in African-American newborns than in neonates of other races (P < .001). The TcB--TSB difference also varied significantly based on brand of TcB meter used and hour of age of the infant. For 2.2% of paired measurements, the TcB measurement underestimated the TSB level by ≥ 3 mg/dL. CONCLUSIONS During routine clinical care, TcB measurement provided a reasonable estimate of TSB levels in healthy newborns. Discrepancies between TcB and TSB levels were increased in African-American newborns and varied based on brand of meter used.
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Affiliation(s)
- James A. Taylor
- Department of Pediatrics, University of Washington, Seattle, Washington
| | | | | | - Esther K. Chung
- Department of Pediatrics, Jefferson Medical College and Nemours, Philadelphia, Pennsylvania
| | | | - Neera K. Goyal
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
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21
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Simpson E, Goyal NK, Dhepyasuwan N, Flaherman VJ, Chung EK, Von Kohorn I, Burgos A, Taylor J. Prioritizing a research agenda: a Delphi study of the better outcomes through research for newborns (BORN) network. Hosp Pediatr 2014; 4:195-202. [PMID: 24986986 DOI: 10.1542/hpeds.2014-0003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [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: 11/24/2022]
Abstract
BACKGROUND There is a paucity of evidence to guide clinical management for term and late preterm newborns. The Better Outcomes through Research for Newborns (BORN) network is a national collaborative of clinicians formed to increase the evidence-base for well newborn care. OBJECTIVE To develop a consensus-based, prioritized research agenda for well newborn care. DESIGN A two-round modified Delphi survey of BORN members was conducted. Round 1 was an open-ended survey soliciting 5 clinical questions identified as important and under-researched. Using qualitative methods, 20 most common themes were extracted and transformed into research questions. Round 2 survey respondents ranked the top 20 questions using a 5- point Likert scale and a quantitative analysis was conducted. RESULTS Round 1 survey generated 439 unique research questions that fell into 57 themes. In the Round 2 survey, the highest rated questions were: 1) At what weight-loss percentage is it medically necessary to formula supplement a breastfeeding infant? 2) What is the optimal management of infants with neonatal abstinence syndrome? 3) How and when should we initiate a workup for sepsis, and how should these newborns be managed? CONCLUSIONS Research priorities of clinicians include criteria for medically indicated formula supplementation of the breastfed newborn, management of neonatal abstinence syndrome and management of newborns at-risk for sepsis.
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Affiliation(s)
- Elizabeth Simpson
- University of Missouri-Kansas City School of Medicine, Children's Mercy Hospital Kansas City, Missouri
| | - Neera K Goyal
- Division of Neonatology and Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Esther K Chung
- Nemours and Jefferson Medical College, Philadelphia, Pennsylvania
| | | | - Anthony Burgos
- Well Newborn Care, Kaiser Permanente, Downey, California
| | - James Taylor
- Department of Pediatrics, University of Washington, Seattle, and Newborn Nursery, University of Washington Medical Center, Seattle, Washington
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22
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Crivelli-Kovach A, Chung EK. An evaluation of hospital breastfeeding policies in the Philadelphia metropolitan area 1994-2009: a comparison with the baby-friendly hospital initiative ten steps. Breastfeed Med 2011; 6:77-84. [PMID: 20958103 DOI: 10.1089/bfm.2010.0009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [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: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to describe current breastfeeding policies and practices among Philadelphia, PA metropolitan hospitals and changes in their policies and practices over time. METHODS In-person group interviews were conducted to obtain a composite picture of actual breastfeeding policies and practices. One questionnaire per hospital was completed based on responses from group consensus. Twenty-five hospitals providing maternity care were contacted. Information was obtained from personnel representing different areas of maternity services. Hospitals were classified according to the degree to which they were implementing the Ten Steps to Successful Breastfeeding. RESULTS Mean breastfeeding rates at suburban hospitals were significantly higher than urban hospitals (72% vs. 49%, p = 0.015). Most hospitals were classified as high or moderately high implementers on six of the Ten Steps, including staff training (67%), printed information distributed to breastfeeding mothers (94%), breastfeeding initiation (61%), oral breastfeeding instruction given to mothers (83%), infant feeding schedules (89%), and hospital postpartum support (83%). Most hospitals reported partial or low implementation on two maternity practices: infant formula supplementation (61%) and rooming-in (72%). CONCLUSIONS In the past 15 years, hospitals in the Philadelphia area have an increased awareness about breastfeeding and enhanced support of breastfeeding by healthcare professionals. In spite of an increase in overall breastfeeding rates, formula supplementation in hospitals and contact time between mothers and their newborns continue to be areas of concern.
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Affiliation(s)
- Andrea Crivelli-Kovach
- Department of Medical Science and Community Health, Arcadia University, Glenside, Pennsylvania 19038, USA.
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Denney JM, Nelson EL, Wadhwa PD, Waters TP, Mathew L, Chung EK, Goldenberg RL, Culhane JF. Longitudinal modulation of immune system cytokine profile during pregnancy. Cytokine 2010; 53:170-7. [PMID: 21123081 DOI: 10.1016/j.cyto.2010.11.005] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Revised: 10/16/2010] [Accepted: 11/08/2010] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To characterize immune modulation as expressed by cytokine assays at three time-points in human pregnancy. STUDY DESIGN This is a prospective, longitudinal study of a broad panel of cytokine expression during singleton pregnancies resulting in an uncomplicated, full-term, live births. Peripheral blood was obtained at 8-14, 18-22, and 28-32 weeks gestation. Six cytokines - IFN-γ, IL-4, TNF-α, IL-1β, IL-6, and IL-10 - were measured in supernatants obtained from whole blood stimulations with PHA or LPS and were compared to unstimulated controls. Samples were processed by Luminex-100 MAP®. We used Generalized Linear Models (GLM) to evaluate cytokine trajectories. RESULTS Complete data were obtained for 45 uncomplicated pregnancies. Overall, peripheral blood WBC's demonstrated dampened cytokine responses. However, over the course of pregnancy, we found enhanced counter-regulatory cytokine expression (e.g., shown by increased IL-10). CONCLUSION The overall decrease in pro-inflammatory cytokines and increase in counter-regulatory cytokines as uncomplicated pregnancy progresses supports the evolving concepts of immunoregulation for the maintenance of a viable pregnancy.
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Affiliation(s)
- Jeffrey M Denney
- Children's Hospital of Philadelphia, Department of Pediatrics, Division of Adolescent Medicine, PA, USA.
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Chung EK, Nurmohamed L, Mathew L, Elo IT, Coyne JC, Culhane JF. Risky health behaviors among mothers-to-be: the impact of adverse childhood experiences. Acad Pediatr 2010; 10:245-51. [PMID: 20599179 PMCID: PMC2897837 DOI: 10.1016/j.acap.2010.04.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [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: 06/12/2009] [Revised: 04/08/2010] [Accepted: 04/15/2010] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Adverse childhood experiences (ACEs) are risk factors for health problems later in life. This study aims to assess the influence of ACEs on risky health behaviors among mothers-to-be and determine whether a dose response occurs between ACEs and risky behaviors. METHODS A prospective survey of women attending health centers was conducted at the first prenatal care visit, and at 3 and 11 months postpartum. Surveys obtained information on maternal sociodemographic and health characteristics, and 7 ACEs prior to age 16. Risky behaviors included smoking, alcohol use, marijuana use, and other illicit drug use during pregnancy. RESULTS Our sample (N = 1476) consisted of low-income (mean annual personal income, $8272), young (mean age, 24 years), African American (71%), single (75%) women. Twenty-three percent of women reported smoking even after finding out they were pregnant, 7% reported alcohol use, and 7% reported illicit drug use during pregnancy. Nearly three fourths (72%) had one or more ACEs. There was a higher prevalence of each risky behavior among those exposed to each ACE than among those unexposed. The exception was alcohol use during pregnancy, where there was not an increased risk among those exposed when compared with those unexposed to witnessing a shooting or having a guardian in trouble with the law or in jail. The adjusted odds ratio for each risky behavior was >2.5 for those with >3 ACEs when compared with those without. CONCLUSIONS ACEs were associated with risky health behaviors reported by mothers-to-be. Greater efforts should target the prevention of ACEs to lower the risk for adverse health behaviors that have serious consequences for adults and their children.
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Affiliation(s)
- Esther K Chung
- Jefferson Pediatrics/Nemours Pediatrics-Philadelphia, 833 Chestnut Street, Suite 300, Philadelphia, Pennsylvania 19107, USA.
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Abstract
OBJECTIVES To assess associations among maternal childhood experiences and subsequent parenting attitudes and use of infant spanking (IS), and determine if attitudes mediate the association between physical abuse exposure and IS. METHODS We performed a prospective study of women who received prenatal care at community health centers in Philadelphia, Pennsylvania. Sociodemographic characteristics, adverse childhood experiences (ACEs), attitudes toward corporal punishment (CP), and IS use were assessed via face-to-face interviews, conducted at the first prenatal care visit, 3 months postpartum, and 11 months postpartum. Bivariate and multiple logistic regression analyses were conducted. RESULTS The sample consisted of 1265 mostly black, low-income women. Nineteen percent of the participants valued CP as a means of discipline, and 14% reported IS use. Mothers exposed to childhood physical abuse and verbal hostility were more likely to report IS use than those not exposed (16% vs 10%, P = .002; 17% vs 12%, P = .02, respectively). In the adjusted analyses, maternal exposure to physical abuse, other ACEs, and valuing CP were independently associated with IS use. Attitudes that value CP did not mediate these associations. CONCLUSIONS Mothers who had childhood experiences of violence were more likely to use IS than mothers without such experiences. Intergenerational transmission of CP was evident. Mothers who had experienced physical abuse as a child, when compared to those who had not, were 1.5 times more likely to use IS. Child discipline attitudes and maternal childhood experiences should be discussed early in parenting in order to prevent IS use, particularly among at-risk mothers.
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Affiliation(s)
- Esther K. Chung
- Department of Pediatrics, Jefferson Medical College, Philadelphia, Pennsylvania,Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Leny Mathew
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Amy C. Rothkopf
- Department of Pediatrics, Jefferson Medical College, Philadelphia, Pennsylvania,Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Irma T. Elo
- Department of Sociology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James C. Coyne
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer F. Culhane
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania
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Abstract
BACKGROUND Postpartum physical health problems are common and have been understudied. The purpose of this investigation was to explore the associations among reported physical symptoms, functional limitations, and emotional well-being of postpartum women. METHODS The study included data from interviews conducted at 9 to 12 months postpartum from 1,323 women who had received prenatal care at nine community health centers located in Philadelphia, Pennsylvania, United States, between February 2000 and November 2002. Emotional well-being was assessed with the Center for Epidemiological Studies Depression Scale and perceived emotional health. Functional limitations measures were related to child care, daily activities (housework and shopping), and employment. A summary measure of postpartum morbidity burden was constructed from a checklist of potential health problems typically associated with the postpartum period, such as backaches, abdominal pain, and dyspareunia. RESULTS More than two-thirds (69%) of the women reported experiencing at least one physical health problem since childbirth. Forty-five percent reported at least one problem of moderate or major (as opposed to minor) severity and 20 percent reported at least one problem of major severity. The presence, severity, and cumulative morbidity burden associated with postpartum health problems were consistently correlated with reports of one or more functional limitations and measures of emotional well-being including depressive symptomatology. CONCLUSIONS Although physical problems typically associated with the postpartum period are often regarded as transient or comparatively minor, they are strongly related both to women's functional impairment and to poor emotional health. Careful assessment of the physical, functional, and emotional health status of women in the year after childbirth may improve the quality of postpartum care.
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Affiliation(s)
- David A Webb
- Department of Obstetrics and Gynecology, Drexel University School of Medicine, Philadelphia, PA 19102, USA
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Chung EK, Mathew L, Elo IT, Coyne JC, Culhane JF. Depressive symptoms in disadvantaged women receiving prenatal care: the influence of adverse and positive childhood experiences. ACTA ACUST UNITED AC 2008; 8:109-16. [PMID: 18355740 DOI: 10.1016/j.ambp.2007.12.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 11/21/2007] [Accepted: 12/07/2007] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the association between adverse childhood experiences (ACEs), positive influences in childhood (PICs), and depressive symptoms among low-income pregnant women. METHODS Face-to-face survey of women receiving prenatal care at Philadelphia community health centers. We conducted surveys at the first prenatal care visit and at a mean age +/- standard deviation of 11 +/- 1 months postpartum, and obtained information on sociodemographic characteristics and childhood experiences before age 16. Group differences were tested with respect to a cutpoint of 23 on the Center for Epidemiologic Studies-Depression scale (CES-D), with the chi(2) test used for categorical variables and the Student's t test used for continuous variables. Logistic regression analyses were conducted to adjust for potential confounding variables. RESULTS The sample consisted of 1476 mostly young, African American, low-income women. The majority (70% and 90%, respectively) of women reported at least one ACE and one PIC. For each ACE, affected women were more likely to have depressive symptoms than their counterparts. There was a dose-response effect in that a higher number of ACEs was associated with a higher likelihood of having depressive symptoms. PICs, on the other hand, were associated with a lower likelihood of having depressive symptoms. CONCLUSIONS Among low-income women, ACEs were associated with a higher likelihood of having depressive symptoms in a dose-response fashion, and PICs were associated with a lower risk. Efforts to prevent ACEs and to promote PICs might help reduce the risk of depressive symptoms and their associated problems in adulthood.
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Affiliation(s)
- Esther K Chung
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.
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Tyrala E, Chung EK. Cobedding twins and higher-order multiples. Pediatrics 2008; 121:1073; author reply 1073-4. [PMID: 18450918 DOI: 10.1542/peds.2008-0142] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eileen Tyrala
- Cribs for Kids,
Pittsburgh, PA 15212,
SIDS of PA,
Pittsburgh, PA 15212
| | - Esther K. Chung
- Department of Pediatrics,
Jefferson Medical College,
Philadelphia, PA 19107,
Department of Pediatrics,
Alfred I. duPont Hospital for Children,
Wilmington, DE 19803
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Chung EK, Mathew L, McCollum KF, Elo IT, Culhane JF. Continuous source of care among young underserved children: associated characteristics and use of recommended parenting practices. ACTA ACUST UNITED AC 2008; 8:36-42. [PMID: 18191780 DOI: 10.1016/j.ambp.2007.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 08/11/2007] [Accepted: 08/18/2007] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this study was to 1) assess sociodemographic and health characteristics associated with having a continuous source of care (CSOC) among young children and 2) determine the relationship between having a CSOC and use of parenting practices. METHODS We conducted a prospective, community-based survey of women receiving prenatal care at Philadelphia community health centers. We conducted surveys at the first prenatal visit and at a mean age +/- standard deviation of 3 +/-1, 11 +/- 1, and 24 +/- 2 months postpartum, obtaining information on sociodemographic and health characteristics, child's health care provider, and 6 parenting practices. Group differences were tested between those with and without a CSOC by using the chi-square test for categorical variables and the Student's t test for continuous variables. Logistic regression analysis was conducted to adjust for potential confounding variables. RESULTS Our sample consisted of 894 mostly young, African American, single women and their children. In the adjusted analysis, mothers of children with a CSOC, when compared with those without a CSOC, were more likely to have a high school education or less, be born in the United States, have a postpartum checkup, have stable child health insurance, and initiate care for their child at a site other than a community-based health center. Use of parenting practices was similar for children with and without a CSOC. CONCLUSIONS Maternal nativity, postpartum care, child health insurance, and initial site of infant care were associated with CSOC, but infant health characteristics were not. Use of parenting practices did not differ for those with and without a CSOC.
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Affiliation(s)
- Esther K Chung
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.
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Chung EK, Miller RL, Wilson MT, McGeady SJ, Culhane JF. Antenatal risk factors, cytokines and the development of atopic disease in early childhood. Arch Dis Child Fetal Neonatal Ed 2007; 92:F68-73. [PMID: 17185433 PMCID: PMC2675311 DOI: 10.1136/adc.2006.106492] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [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] [Indexed: 11/04/2022]
Abstract
Atopic diseases are complex entities influenced by an array of risk factors, including genetic predisposition, environmental allergens, antenatal exposures, infections and psychosocial factors. One proposed mechanism by which these risk factors contribute to the development of atopic disease is through changes in the production of T helper cell type 1 (Th1) and T helper cell type 2 (Th2) cytokines. The objectives of this review are to discuss antenatal exposures that are associated with paediatric atopic diseases, to discuss the influence of the intrauterine environment on neonatal immune responses, to provide an overview of the Th1 and Th2 pathways and how they relate to atopic disease, and to summarise our current understanding of the association between cytokine responses in cord blood and the development of atopic disease in early childhood.
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Affiliation(s)
- E K Chung
- The Division of General Pediatrics, Department of Pediatrics, Jefferson Medical College, Philadelphia, Pennsylvania, USA.
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Lee HJ, Rubio MR, Elo IT, McCollum KF, Chung EK, Culhane JF. Factors associated with intention to breastfeed among low-income, inner-city pregnant women. Matern Child Health J 2006; 9:253-61. [PMID: 16283532 DOI: 10.1007/s10995-005-0008-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine the relationship between sociodemographic factors, maternal characteristics, and intention to breastfeed among low-income, inner-city pregnant women. METHODS English and Spanish speaking low-income women recruited from local Philadelphia health centers were surveyed at the time of their first prenatal care visit. At the time of the visit, respondents were asked whether or not they planned to breastfeed their infant. The responses of 2,690 women were included in these analyses. Multivariate logistic regression was used to assess the independent associations of race/ethnicity, nativity status, education, and other factors on the odds of intending to breastfeed. RESULTS About half (53%) of the respondents reported that they intended to breastfeed their infant. In adjusted logistic regression models, immigrant black (adjusted OR [aOR] 5.82; 95% confidence interval [CI] 3.86, 8.77), other Hispanic (who were predominantly foreign-born) (aOR 6.05; 95% CI 3.92, 9.33), and island-born Puerto Rican (aOR 3.48; 95% CI 2.04, 5.95) women were significantly more likely to report that they intended to breastfeed than non-Hispanic whites. Somewhat surprisingly, non-Hispanic, US-born African Americans in this low-income sample were more likely to report that they intended to breastfeed than non-Hispanic white respondents (aOR 1.59; 95% CI 1.20, 2.11). Lower education, not living with the baby's father, multiparous pregnancy, and smoking were negatively and independently associated with intention to breastfeed. Maternal age, household income, public housing, and depressive symptoms were not significant predictors of breastfeeding intention in adjusted multivariate models. CONCLUSIONS Significant differences were documented in breastfeeding intention in our sample of low-income, inner-city women. Most notable was the higher likelihood of anticipated breastfeeding among our immigrant sub-groups when compared with non-Hispanic white women. An unexpected finding was the higher likelihood of anticipated breastfeeding among native-born, non-Hispanic African American women than among non-Hispanic white respondents. Because intentions are important predictors of future behavior, more focus needs to be directed towards breastfeeding promotion during the prenatal period and towards a better understanding of why some mothers intend to breastfeed while others do not.
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Affiliation(s)
- Helen J Lee
- Public Policy Institute of California, San Francisco, California 94111, USA.
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Chung EK, McCollum KF, Elo IT, Culhane JF. Does prenatal care at community-based health centers result in infant primary care at these sites? ACTA ACUST UNITED AC 2006; 6:25-31. [PMID: 16443180 DOI: 10.1016/j.ambp.2005.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [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: 11/06/2004] [Revised: 07/22/2005] [Accepted: 08/03/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To describe where women receiving prenatal care (PNC) at community-based health centers (CBHCs) go for infant primary care, and to assess reasons for and factors associated with leaving CBHCs and using other practices for infant care. METHODS A prospective survey of women receiving PNC at CBHCs from February 2000 to February 2002 was conducted. In-person, prepartum, and postpartum surveys included questions about sociodemographic and health characteristics, and health services use. RESULTS Among 1,107 primarily low-income, African American mothers, 60% of women left CBHCs and used other practices for their infants due to dissatisfaction, inconvenience, referral to and perceived expertise at other sites, and insurance changes. Leaving CBHCs was associated with being white, Latina, US born, educated beyond high school, single, owning a car, using non-CBHC practices for prepregnancy care, and having child health insurance. Among those who left, 48% used hospital-based clinics (HBCs) and 52% used private practices (PPs). Mothers using HBCs, when compared to those using PPs, were more likely to be African American (AOR = 6.83; 95% CI: 3.82, 12.22) or Latina (AOR = 5.60; 95% CI: 2.79, 11.24), dissatisfied with their PNC (AOR = 2.02; 95% CI: 1.05, 3.89) and to leave CBHCs because of insurance changes (AOR = 2.27; 95% CI: 1.18, 4.39) and perceived pediatric expertise at other sites (AOR = 4.81; 95% CI: 2.53, 9.11). CONCLUSIONS The majority of women in our study left CBHCs and used other sites for pediatric care. Higher education, having child health insurance, and car ownership were associated with leaving CBHCs. Among women who left, race/ethnicity and perceived pediatric expertise were major factors associated with using HBCs rather than PPs.
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Affiliation(s)
- Esther K Chung
- Division of General Pediatrics, Thomas Jefferson Medical College, Philadelphia, PA, USA.
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Abstract
OBJECTIVE To describe the range of risk reduction behaviors among women who continue to smoke after learning of their pregnancy, including reduced tobacco use, eventual cessation, and sustained abstinence as well as the patient-reported smoking cessation-promoting behaviors of prenatal care providers. METHODS This research is part of a larger prospective, community-based study conducted to assess the association between maternal stress and birth outcomes and infant health and development. Over a 2-year period, from February 2000 to November 2001, women receiving prenatal care at a consortium of public health centers in Philadelphia, Pennsylvania, were consecutively recruited (n = 1,451) completing interviews at their initial prenatal visit and again 3 to 4 months following their delivery. Smoking rates during pregnancy were determined from responses given during the first postpartum interview, at 3 to 4 months postpartum. RESULTS Of the 1,451 women interviewed at 3 to 4 months postpartum, 24.9 percent indicated smoking during their pregnancy. Of these antenatal smokers, 89.0 percent reported reducing their cigarette consumption during pregnancy. However, only 25.4 percent attained abstinence during their pregnancy. Among women who achieved abstinence during their pregnancy, 21.7 percent were still not smoking at the time of the postpartum interview. Antenatal smokers reported that prenatal care providers asked about their smoking (90.6%) and advised about quitting (76.5%). However, only 27.9 percent were given referrals to smoking cessation programs. CONCLUSION While cessation was achieved by only a quarter of antenatal smokers, almost 90 percent reduced their cigarette consumption. Prenatal care providers identified and provided cessation advice to the majority of women who were smoking but they did not follow through with material assistance in the form of referrals to smoking cessation programs.
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Affiliation(s)
- Brian C Castrucci
- Division of Maternal, Child and Family Health, Philadelphia Department of Public Health, Philadelphia, Pennsylvania 19107, USA.
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Sim K, Su A, Leong JY, Yip K, Chong MY, Fujii S, Yang S, Ungvari GS, Si T, Chung EK, Tsang HY, Shinfuku N, Kua EH, Tan CH. High dose antipsychotic use in schizophrenia: findings of the REAP (research on east Asia psychotropic prescriptions) study. Pharmacopsychiatry 2004; 37:175-9. [PMID: 15467975 DOI: 10.1055/s-2004-827174] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND High-dose antipsychotic regimes (defined as the prescription of more than 1000 chlorpromazine-equivalents milligrams of antipsychotic per day) in the management of patients with schizophrenia are not uncommon, but most reports are from western countries. Recent functional neuroimaging studies have found that the previous notion concerning the use of antipsychotic medication, especially in high doses, was unsupported and untenable. METHODS This international study examined the use of high dose antipsychotic medication and its clinical correlates in schizophrenia patients within six East Asian countries/territories. RESULTS Within the study group (n = 2399), 430 patients (17.9%) were prescribed high dose antipsychotics. Antipsychotic use varied significantly between countries, with Japan, Korea, and Singapore using higher doses than the other countries. High dose antipsychotic use was associated with younger age in Japan (p < 0.001), longer duration of admission (p < 0.001), duration of illness (p < 0.001, particularly in Korea and Taiwan), positive psychotic symptoms (p < 0.001, particularly in Japan and Korea), and aggression (p < 0.05, particularly in Japan), and also with a higher likelihood of extrapyramidal and autonomic adverse effects (p < 0.05, particularly in China). Country, younger age, the presence of delusions and disorganized speech, polypharmacy, and receiving depot medication but not atypical antipsychotic drugs were important predictors of high antipsychotic use. CONCLUSIONS This survey revealed that high antipsychotic dosing is not an uncommon practice in East Asia. It behooves the prescribing clinicians to constantly reevaluate the rationale for such a practice.
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Affiliation(s)
- K Sim
- Woodbridge Hospital/Institute of Mental Health--10 Buangkok View, Singapore.
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Abstract
OBJECTIVES To determine the relationships between maternal depressive symptoms and the use of infant health services, parenting practices, and injury-prevention measures. METHODS A prospective, community-based survey of women attending Philadelphia public health centers between February 2000 and November 2001 was conducted. Women were surveyed at 3 time points before and after parturition. Depressive symptoms were determined with the Center for Epidemiologic Studies Depression Scale at each time point. We studied 6 outcomes, clustered into 3 categories: 1) infant health service use (adequate well-child care and ever being hospitalized); 2) parenting practices (breastfeeding for > or =1 month and use of corporal punishment); and 3) injury-prevention measures (having a smoke alarm and using the back sleep position). RESULTS The sample consisted of 774 largely single (74%), uninsured (63%), African American (65%) women, with a mean age of 24 +/- 6 years and a mean annual income of 8063 dollars. Forty-eight percent of women had depressive symptoms at 1 or 2 time points (ever symptoms) and 12% had depressive symptoms at all points (persistent symptoms). Compared with women who never had depressive symptoms (without symptoms), women with persistent symptoms were nearly 3 times as likely to have their child ever hospitalized (adjusted odds ratio: 2.89; 95% confidence interval: 1.61-5.07) and twice as likely to use corporal punishment (adjusted odds ratio: 1.90; 95% confidence interval: 1.08-3.34). Mothers with persistent depressive symptoms were nearly three-quarters less likely to have smoke alarms in their homes (adjusted odds ratio: 0.28; 95% confidence interval: 0.11-0.70) and one-half as likely to use the back sleep position (adjusted odds ratio: 0.56; 95% confidence interval: 0.35-0.91), compared with women without symptoms. There was no association between maternal depressive symptoms and infant receipt of well-child care or the likelihood of breastfeeding for > or =1 month. CONCLUSIONS Maternal depressive symptoms persisting from the prepartum to postpartum periods were associated with increased risks of infant hospitalization and use of corporal punishment and with lower likelihood of having a smoke alarm and using the back sleep position. Additional efforts are needed to identify and evaluate mothers with depressive symptoms to improve the health and safety of young infants.
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Affiliation(s)
- Esther K Chung
- Division of General Pediatrics, A.I. duPont Hospital for Children and Thomas Jefferson Medical College, Philadelphia, Pennsylvania, USA
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Abstract
OBJECTIVE To determine the maternal and infant characteristics associated with the back sleep position for infants to guide efforts to increase its use and reduce the risk of Sudden Infant Death Syndrome. METHODS Cross-sectional survey of 3349 mothers delivering in California, February-May 1999. RESULTS Fifty-two percent of infants were placed in the back sleep position. Factors associated with a lower likelihood of using the back position included all levels of maternal education less than college (eg, for education eighth grade or less--adjusted odds ratio [OR] 0.59; 95% confidence interval [CI], 0.40-0.86); income at or below federal poverty level (OR, 0.65; 95% CI, 0.47-0.90); multiparity (OR, 0.80; 95% CI, 0.67-0.95); race/ethnicity African American (OR, 0.49; 95% CI, 0.37-0.65) and Asian/Pacific Islander (OR, 0.65; 95% CI, 0.48-0.89); speaking a non-English language (OR, 0.69; 95% CI, 0.55, 0.86); and infant age over 7 months (OR, 0.70, 95% CI, 0.52-0.96). Women in Los Angeles (OR, 0.57; 95% CI, 0.42-0.77) and urban areas other than San Diego (OR, 0.70; 95% CI, 0.53-0.92) were less likely to use the back position than those in San Francisco. CONCLUSIONS Greater efforts are needed to promote the back sleep position among families with mothers who lack education beyond some college; live in poverty; and who are African American, Asian/Pacific Islander, multiparous, or non-English speaking.
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Affiliation(s)
- Esther K Chung
- Division of General Pediatrics, University of California at San Francisco, San Francisco, Calif, USA.
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Martinez OP, Longman-Jacobsen N, Davies R, Chung EK, Yang Y, Gaudieri S, Dawkins RL, Yu CY. Genetics of human complement component C4 and evolution the central MHC. Front Biosci 2001; 6:D904-13. [PMID: 11487475 DOI: 10.2741/martinez] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The two classes of human complement component C4 proteins C4A and C4B manifest differential chemical reactivities and binding affinities towards target surfaces and complement receptor CR1. There are multiple, polymorphic allotypes of C4A and C4B proteins. A complex multiplication pattern of C4A and C4B genes with variations in gene size, gene dosage and flanking genes exists in the population. This is probably driven by the selection pressure to respond to a great variety of parasites efficiently and effectively, which the bony fish achieved through the multiplication and diversification of the related complement C3 proteins. Complement C4, C3 and C5 belong to the alpha2 macroglobulin protein family but acquired specific features that include an anaphylatoxin domain, a netrin (NTR) domain, and stretches of basic residues for proteolytic processings to form multiple chain structures. Complement C3 and C4 are important in the innate immune response as they opsonize parasites for phagocytosis. The emergence of complement C3 predates proteins involved in the adaptive immune response as C3 is present in deuterostome invertebrates such as echinoderms. The human C4 genes are located in the central MHC at chromosome 6p21.3. C3 and C5 are located at chromosome 19 and 9, respectively, with representatives of the other groups of genes paralogous to the MHC at 19p13.1-p13.3, 1q21-25, and 9q33-34. The central MHC also contains genes for complement components C2 and Bf. These genes appear to have similar evolutionary histories to C3/C4/C5 and are used here to illustrate stepwise processes resulting in co-location of diverse domains, chromosomal duplication, local segmental duplication and divergence of sequence and function. This model of evolution is useful in the investigation of innate and acquired immunity and in seeking explanations for diseases associated with MHC ancestral haplotypes.
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Affiliation(s)
- O P Martinez
- Centre for Molecular Immunology and Instrumentation, University of Western Australia, PO Box 5100, Canning Vale WA 6155, Australia.
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Chung EK, Webb D, Clampet-Lundquist S, Campbell C. A comparison of elevated blood lead levels among children living in foster care, their siblings, and the general population. Pediatrics 2001; 107:E81. [PMID: 11331731 DOI: 10.1542/peds.107.5.e81] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [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] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the prevalence of elevated blood lead levels (EBLLs) among children before and after foster care placement, and to compare the prevalence of EBLLs among children in foster care with that of their siblings and the general population. METHODS We conducted a retrospective cohort study using administrative databases from the Philadelphia Department of Human Services and the Birth Certificate Registry and the Childhood Lead Poisoning Prevention Program at the Philadelphia Department of Public Health. Logistic regression analyses were performed to control for confounding variables, including age, race, gender, and the year, seasonal timing, and source (capillary vs venous) of test. RESULTS From June 1992 to May 1997, there were 1824 children in foster care with available blood lead results in the Childhood Lead Poisoning Prevention Program database. Of these, 519 (28%) had initial lead screening before foster care placement and 654 (36%) after placement. There were 821 siblings and 73 608 children in the general population with available blood lead results. Before entering foster care, children were nearly twice as likely to have EBLLs as their siblings (adjusted odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.4, 2.0), those in placement (adjusted OR = 1.9; 95% CI = 1.6, 2.2), and the general population (adjusted OR = 1.7; 95% CI = 1.5, 2.0). At the highest point prevalence, 50% of children before placement had lead levels >/=20 microg/dL, and nearly 90% had levels >/=10 microg/dL. For all age categories, siblings of children in foster care placement had a higher prevalence of EBLLs than did the general population. After placement, children in foster care were nearly half as likely as the other groups to have EBLLs. CONCLUSIONS Our findings suggest that children are at high risk for lead poisoning before entering foster care and that placement in foster care may have a beneficial effect on lead exposure. Children before foster care placement are nearly twice as likely to have EBLLs compared with children in foster care placement, the general population, and their siblings. Furthermore, siblings of children in foster care are at high risk for lead poisoning. Children receiving social services in their own homes and children suffering from abuse and neglect should be actively screened for lead poisoning. Greater efforts at preventing lead poisoning among these children must be made.
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Affiliation(s)
- E K Chung
- Division of General Pediatrics, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Blanchong CA, Chung EK, Rupert KL, Yang Y, Yang Z, Zhou B, Moulds JM, Yu CY. Genetic, structural and functional diversities of human complement components C4A and C4B and their mouse homologues, Slp and C4. Int Immunopharmacol 2001; 1:365-92. [PMID: 11367523 DOI: 10.1016/s1567-5769(01)00019-4] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.9] [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] [Indexed: 11/22/2022]
Abstract
The complement protein C4 is a non-enzymatic component of the C3 and C5 convertases and thus essential for the propagation of the classical complement pathway. The covalent binding of C4 to immunoglobulins and immune complexes (IC) also enhances the solubilization of immune aggregates, and the clearance of IC through complement receptor one (CR1) on erythrocytes. Human C4 is the most polymorphic protein of the complement system. In this review, we summarize the current concepts on the 1-2-3 loci model of C4A and C4B genes in the population, factors affecting the expression levels of C4 transcripts and proteins, and the structural, functional and serological diversities of the C4A and C4B proteins. The diversities and polymorphisms of the mouse homologues Slp and C4 proteins are described and contrasted with their human homologues. The human C4 genes are located in the MHC class III region on chromosome 6. Each human C4 gene consists of 41 exons coding for a 5.4-kb transcript. The long gene is 20.6 kb and the short gene is 14.2 kb. In the Caucasian population 55% of the MHC haplotypes have the 2-locus, C4A-C4B configurations and 45% have an unequal number of C4A and C4B genes. Moreover, three-quarters of C4 genes harbor the 6.4 kb endogenous retrovirus HERV-K(C4) in the intron 9 of the long genes. Duplication of a C4 gene always concurs with its adjacent genes RP, CYP21 and TNX, which together form a genetic unit termed an RCCX module. Monomodular, bimodular and trimodular RCCX structures with 1, 2 and 3 complement C4 genes have frequencies of 17%, 69% and 14%, respectively. Partial deficiencies of C4A and C4B, primarily due to the presence of monomodular haplotypes and homo-expression of C4A proteins from bimodular structures, have a combined frequency of 31.6%. Multiple structural isoforms of each C4A and C4B allotype exist in the circulation because of the imperfect and incomplete proteolytic processing of the precursor protein to form the beta-alpha-gamma structures. Immunofixation experiments of C4A and C4B demonstrate > 41 allotypes in the two classes of proteins. A compilation of polymorphic sites from limited C4 sequences revealed the presence of 24 polymophic residues, mostly clustered C-terminal to the thioester bond within the C4d region of the alpha-chain. The covalent binding affinities of the thioester carbonyl group of C4A and C4B appear to be modulated by four isotypic residues at positions 1101, 1102, 1105 and 1106. Site directed mutagenesis experiments revealed that D1106 is responsible for the effective binding of C4A to form amide bonds with immune aggregates or protein antigens, and H1106 of C4B catalyzes the transacylation of the thioester carbonyl group to form ester bonds with carbohydrate antigens. The expression of C4 is inducible or enhanced by gamma-interferon. The liver is the main organ that synthesizes and secretes C4A and C4B to the circulation but there are many extra-hepatic sites producing moderate quantities of C4 for local defense. The plasma protein levels of C4A and C4B are mainly determined by the corresponding gene dosage. However, C4B proteins encoded by monomodular short genes may have relatively higher concentrations than those from long C4A genes. The 5' regulatory sequence of a C4 gene contains a Spl site, three E-boxes but no TATA box. The sequences beyond--1524 nt may be completely different as the C4 genes at RCCX module I have RPI-specific sequences, while those at Modules II, III and IV have TNXA-specific sequences. The remarkable genetic diversity of human C4A and C4B probably promotes the exchange of genetic information to create and maintain the quantitative and qualitative variations of C4A and C4B proteins in the population, as driven by the selection pressure against a great variety of microbes. An undesirable accompanying byproduct of this phenomenon is the inherent deleterious recombinations among the RCCX constituents leading to autoimmune and genetic disorders.
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Affiliation(s)
- C A Blanchong
- Children's Research Institute, 700 Children's Drive, Columbus, OH 43205-2696, USA
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40
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Abstract
BACKGROUND Children with asthma may be at increased risk for low immunization rates given that they have recurrent illnesses that often result in acute care visits to their pediatrician, visits to the emergency room, admissions to the hospital, and visits to subspecialists, where immunizations are not routinely administered. OBJECTIVES To assess immunization rates for routine and influenza vaccines in children with asthma and assess factors that may contribute to delay. METHODS We conducted a cross-sectional survey of 117 children aged 6 to 48 months with onset of asthma within the first 15 months of life. Subjects were recruited from an allergy and immunology clinic at an urban, tertiary care center. Those judged to have immunization delay did not have the required 4 DTP, 3 OPV, and 1 MMR vaccine by age 24 months (4:3:1 series). Receipt of influenza vaccine was determined for eligible children with moderate to severe asthma. RESULTS Seventy-four (80%) children had up-to-date immunizations at age 24 months. Those with delay had fewer visits to a subspecialist than those who were up-to-date (1 versus 2 visits P = .010). Twenty-two (25%) of 87 eligible subjects received influenza vaccine. Recipients were more likely to have been hospitalized than nonrecipients (77% versus 49%, P = .022). CONCLUSIONS Though the majority of young children with asthma were up-to-date for routine immunizations, only 25% of children with moderate to severe asthma received influenza vaccine. Greater efforts must be made by pediatricians and asthma subspecialists to ensure that children with moderate to severe asthma are immunized against influenza virus.
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Affiliation(s)
- E K Chung
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Pennsylvania 19104-4399, USA
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Abstract
OBJECTIVE To determine the immunogenicity of hepatitis B vaccine in preterm infants when the first dose of vaccine is delayed until hospital discharge. METHODS One hundred two preterm infants (23 to 36 weeks gestational age) born to hepatitis B surface antigen-negative mothers were enrolled. Immunization was initiated just before hospital discharge with subsequent doses 1 and 6 months later. Serum specimens were obtained before the administration of each vaccine dose and 3 months after the last dose and were tested for antibody to hepatitis B surface antigen (antiHBs). RESULTS Eighty-seven infants (85%) completed the study. Ninety percent (n = 78) of infants who completed the study seroconverted (antiHBs > or = 10 mIU/mL); 10% (n = 9) remained seronegative at study completion. The geometric mean antibody titer to hepatitis B surface antigen for infants who seroconverted was 200 mIU/mL. Nonresponders (NR) differed from responders (R) in birth weight (NR = 2090 g, R = 1560 g) gestational age (NR = 33 weeks, R = 31 weeks), and weight gain before vaccine initiation (NR = 244 g, R = 633 g). There were no differences in weight or age at vaccine initiation, Apgar scores, interval between vaccine doses, or bacterial infections, steroid use, or transfusions before vaccine initiation. CONCLUSIONS Ninety percent of preterm infants responded to hepatitis B vaccine when the first dose of vaccine was delayed until hospital discharge. Nonresponders were more likely to be preterm infants of higher birth weight and higher gestational age, and to have gained less weight before vaccine initiation.
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Affiliation(s)
- S C Kim
- Children's Hospital of Philadelphia, Pennsylvania, USA
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Cho KH, Son YS, Lee DY, Chung EK, Hur KC, Hong SI, Fuchs E. Calcipotriol (MC 903), a synthetic derivative of vitamin D3 stimulates differentiation of squamous carcinoma cell line in the raft culture. Anticancer Res 1996; 16:337-47. [PMID: 8615633] [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: 01/31/2023]
Abstract
We investigated whether calcipotriol, a synthetic derivative of vitamin D3 has the ability to correct defects in the control of proliferation and differentiation of human squamous carcinoma cells using the raft culture of SCC 13 cell line. Calcipotriol treatment at concentrations of 10(-8)-10(-6) M considerably enhanced terminal differentiation of SCC 13 cells, as shown by the appearance of enucleated-eosinophilic cells as well as granular cells in their upper cell layers. Immunohistochemical staining showed marked increases in the differentiation of marker proteins such as keratin 1, involucrin, or filaggrin expressing cells in their upper layers. The elevated expression at protein level was confirmed by immunoblotting analysis. Furthermore, calcipotriol also stimulated basal cell marker proteins such as keratin 14 and EGF receptor. However, the numbers of basal marker expressing cells within the architecture of SCC 13 raft culture were markedly reduced upon calcipotriol treatment, and their localization was mainly restricted in the innermost cell layer. In addition, calcipotriol stimulated EGF receptor biosynthesis for the first 16 hours post treatment and subsequently inhibited [3H]-thymidine incorporation of SCC 13 cells at 24 hours. In this study, we have clearly demonstrated that the long term application of calcipotriol considerably improves the complex defects in the regulation of proliferation and differentiation of SCC 13 cells, as supported by morphological and biochemical observations. This provides an evidence that calcipotriol can be applied clinically as a potent differentiation inducer in the treatment of human squamous cell carcinoma.
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Affiliation(s)
- K H Cho
- Department of Dermatology, Seoul National University College of Medicine, Korea
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Tighe DA, Hutchinson HG, Park CH, Chung EK, Fischman DL, Raichlen JS. False-positive reversible perfusion defect during dobutamine-thallium imaging in left bundle branch block. J Nucl Med 1994; 35:1989-91. [PMID: 7989982] [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: 01/28/2023] Open
Abstract
In the presence of pre-existing left bundle branch block (LBBB) exercise stress thallium scans have been associated with false-positive septal and apical perfusion abnormalities. Recent reports have documented a lower incidence of false-positive septal perfusion defects when pharmacologic agents such as dipyridamole or adenosine are utilized in patients with LBBB. Dobutamine, a synthetic catecholamine, is being used with increasing frequency in combination with perfusion agents for the diagnosis of coronary artery disease in patients unable to achieve an adequate exercise workload. Because the positive inotropic and chronotropic actions of doubtamine are similar to the physiologic effects of treadmill exercise, it is conceivable that false-positive perfusion abnormalities will be observed in patients with pre-existing LBBB undergoing dobutamine perfusion imaging. We describe a patient with underlying LBBB who underwent dobutamine thallium imaging which revealed septal and periapical defects. Subsequent coronary angiography showed these abnormalities to be false-positive. It is concluded that septal and periapical perfusion abnormalities during dobutamine thallium imaging may be false-positive and should be interpreted cautiously.
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Affiliation(s)
- D A Tighe
- Division of Cardiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia
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Affiliation(s)
- D A Tighe
- Division of Cardiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107
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45
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Abstract
The incidence and hemodynamic changes associated with ST-segment depression during adenosine stress testing are poorly defined. To examine this, 550 consecutive patients who underwent adenosine perfusion testing were evaluated for the development of ST-segment depression. At least 1 mm of horizontal or downsloping depression developed in 82 patients (15.9%) and was observed with similar frequency in patients with normal scans and those with only fixed defects. ST depression developed in 58 of 242 patients with reversible defects (sensitivity = 24%) and in only 24 of 275 patients without reversible defects (specificity = 91%). Its presence was highly predictive of reversible perfusion defects (predictive accuracy = 71%). Similar findings were observed in patients with and without ECG evidence of left ventricular hypertrophy. Patients with ST depression had perfusion defects in more vessel distributions, had more severe defects, and had a greater increase in heart rate during adenosine infusion. Thus ST-segment depression occurs infrequently during adenosine infusion but is specific for and predictive of myocardial ischemia, as evidenced by reversible perfusion scan defects. Patients with ST depression have more severe disease and develop faster heart rates during infusion, which could result in decreased coronary perfusion during diastole allowing for the development of myocardial ischemia.
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Affiliation(s)
- E S Marshall
- Division of Cardiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
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Kim KI, Li D, Jiang Z, Cui X, Lin L, Kang JJ, Park KK, Chung EK, Kim CK. Schizophrenic delusions among Koreans, Korean-Chinese and Chinese: a transcultural study. Int J Soc Psychiatry 1993; 39:190-9. [PMID: 8225815 DOI: 10.1177/002076409303900305] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [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] [Indexed: 01/29/2023]
Abstract
In this transcultural study of schizophrenic delusions among Koreans, Korean-Chinese and Chinese, many delusions were shown to be different among the three groups in their frequency and content and the differences could be explained by sociocultural and political factors. Delusional themes sensitive to influence by sociocultural or political situations and changes seem to be 'family', 'love affairs', 'religious matters', 'economic matters', 'specific physical damage' and 'political themes.' Delusions about 'family', 'love affair', 'being raped', 'religious matters' and 'economic and business matters' were most frequent in Koreans. Delusions of 'blood-relatedness', 'longevity' and 'political themes' were most frequent in Korean-Chinese. Delusions of 'bloodsucking and brain or viscera extracted' and 'poison or being pricked by poisoned needle' were most prominent in Chinese.
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Affiliation(s)
- K I Kim
- Department of Neuropsychiatry, School of Medicine, Hanyang University, Seoul, Korea
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Savage MP, Squires LS, Hopkins JT, Raichlen JS, Park CH, Chung EK. Usefulness of ST-segment depression as a sign of coronary artery disease when confined to the postexercise recovery period. Am J Cardiol 1987; 60:1405-6. [PMID: 3687794 DOI: 10.1016/0002-9149(87)90632-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- M P Savage
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Berger BC, Abramowitz R, Park CH, Desai AG, Madsen MT, Chung EK, Brest AN. Abnormal thallium-201 scans in patients with chest pain and angiographically normal coronary arteries. Am J Cardiol 1983; 52:365-70. [PMID: 6869289 DOI: 10.1016/0002-9149(83)90140-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We reviewed the exercise thallium-201 (TI-201) scans and clinical data of 41 patients with chest pain and normal coronary arteries to identify clinical factors associated with "false-positive" studies. Exercise TI-201 studies were performed before angiography and often precipitated referral. Sex, beta-blocker therapy, anginal pattern, and results of exercise electrocardiography were evaluated and compared with TI-201 imaging. A negative TI-201 study was the most common finding (p less than 0.005). Of the 41 patients, 11 (27%) had abnormal exercise TI-201 scans. No clinical factor was significantly associated with a false-positive TI-201 scans. Of the 11 patients with abnormal scans, 9 had greater than or equal to 1 cardiac abnormality: right bundle branch block in 2, mitral valve prolapse in 3, paroxysmal atrial fibrillation in 2, abnormal left ventricular diastolic pressure in 3, and left bundle branch block in 1. Thus, (1) when results of exercise TI-201 imaging are used to refer patients for angiography, "false-positive" TI-201 studies are common; (2) sex, beta blockade, anginal pattern, and results of exercise electrocardiogram are not useful predictors of a false-positive TI-201 study; and (3) patients with chest pain, normal coronary arteries, and abnormal TI-201 scans frequently have other cardiac abnormalities.
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Kim HS, Chung EK. Torsade de pointes: polymorphous ventricular tachycardia. Heart Lung 1983; 12:269-73. [PMID: 6551376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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50
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Chung EK. Sick sinus syndrome: current views. Part II. Mod Concepts Cardiovasc Dis 1980; 49:67-70. [PMID: 7219408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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