Pediatric Integrative Medicine in Residency (PIMR): Description of a New Online Educational Curriculum

Use of integrative medicine (IM) is prevalent in children, yet availability of training opportunities is limited. The Pediatric Integrative Medicine in Residency (PIMR) program was designed to address this training gap. The PIMR program is a 100-hour online educational curriculum, modeled on the successful Integrative Medicine in Residency program in family medicine. Preliminary data on site characteristics, resident experience with and interest in IM, and residents' self-assessments of perceived knowledge and skills in IM are presented. The embedded multimodal evaluation is described. Less than one-third of residents had IM coursework in medical school or personal experience with IM. Yet most (66%) were interested in learning IM, and 71% were interested in applying IM after graduation. Less than half of the residents endorsed pre-existing IM knowledge/skills. Average score on IM medical knowledge exam was 51%. Sites endorsed 1-8 of 11 site characteristics, with most (80%) indicating they had an IM practitioner onsite and IM trained faculty. Preliminary results indicate that the PIMR online curriculum targets identified knowledge gaps. Residents had minimal prior IM exposure, yet expressed strong interest in IM education. PIMR training site surveys identified both strengths and areas needing further development to support successful PIMR program implementation.

Vitamin D in Children's Health

Knowledge of vitamin D in the health of children has grown greatly over the years, extending past the importance for calcium homeostasis and bone growth. There is growing recognition of the role vitamin D plays in health impacting the innate immune system to prevent infections and the adaptive immune system to modulate autoimmunity. Other studies are starting to reveal the neurohormonal effects of vitamin D on brain development and behavior, with a link to mental health disorders. Many of these effects start well before the birth of the child, so it is important that each pregnant woman be assessed for vitamin D deficiency and supplemented for the best possible health outcome of the child. It is recommended that targeting a 25(OH)D level of 40–70 ng/mL for each individual would provide optimal health benefits and reduce health care costs. Current recommended doses of vitamin D supplementation fall short of what is needed to obtain ideal serum levels. A vitamin D supplementation program to prevent disease, much like the current vaccination program, could potentially have a dramatic impact on overall health worldwide.

Methodological challenges to treatment trials for recurrent abdominal pain in children

BACKGROUND

Studies evaluating the efficacy of treatments for recurrent abdominal pain (RAP) in children have used a wide range of methods, causing difficulty in the comparison of results. An expert panel on functional gastrointestinal disorders recently made recommendations regarding the standardization of study methods for childhood RAP, but many of their recommendations remain untested or lack supportive evidence.

METHODS

During completion of a pilot study and randomized controlled trial for childhood RAP, baseline data were collected regarding the child and parent reports of abdominal pain frequency and intensity, type of abdominal pain, missed activities due to abdominal pain, psychological factors for the parent and child, parenting styles, and referral source (pediatric gastroenterologist vs general pediatrician).

RESULTS

Children and parent pain reports showed good agreement in children younger than 13 years (weighted kappa, 0.77; 95% confidence interval [CI], 0.71-0.84), but only marginal agreement in children 13 years or older (weighted kappa, 0.37; 95% CI, 0.30-0.45). We found no significant differences in pain characteristics or psychological factors between children referred by pediatric gastroenterologists in a tertiary care center and those referred by community-based primary care pediatricians. However, children with symptoms consistent with nonspecific functional abdominal pain were reported by their parents to have less frequent pain (P=.003) and fewer missed activities (P=.003) than children with symptoms of irritable bowel syndrome or functional dyspepsia.

CONCLUSIONS

Subjects referred by gastroenterologists and general pediatricians were similar, but the subtype of functional gastrointestinal disorder might be an important baseline characteristic of subjects in future RAP studies. We suggest that future interventional studies of childhood RAP measure 2 outcomes with pain reports obtained directly from children. Any child with fewer days of pain and missed activities due to pain after therapy would be considered improved, and those with no missed activities and 4 or fewer days of pain per month at follow-up would be considered healed.

A pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children

Few effective therapies are available for children with recurrent abdominal pain (RAP). Relaxation and guided imagery have been shown to impact the autonomic nervous system, which is altered in patients with functional gastrointestinal disorders. Ten children with RAP were enrolled in the study after evaluation by a pediatric gastroenterologist. They were trained in relaxation and guided imagery during 4 weekly 50-minute sessions. Pain diaries were completed at 0, 1, and 2 months. Children and parents also completed psychological questionnaires at enrollment. Although refractory to conventional treatment by their physician and pediatric gastroenterologist, the children experienced a 67% decrease in pain during the therapy (chi-square for trend, p < 0.001). No baseline psychological characteristics impacted the response to therapy. The use of relaxation along with guided imagery is an effective and safe treatment for childhood RAP.

Systematic review of treatments for recurrent abdominal pain

OBJECTIVE

To conduct a systematic review of evaluated treatments for recurrent abdominal pain (RAP) in children.

METHODS

Online bibliographic databases were searched for the terms "recurrent abdominal pain," "functional abdominal pain," "children," or "alternative therapies" in articles classified as randomized controlled trials. The abstracts or full text of 57 relevant articles were examined; 10 of these met inclusion criteria. Inclusion criteria required that the study involve children aged 5 to 18 years, subjects have a diagnosis of RAP, and that subjects were allocated randomly to treatment or control groups. The methodology and findings of these articles were evaluated critically, and data were extracted from each article regarding study methods, specific interventions, outcomes measured, and results.

RESULTS

Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules showed a decrease in measured pain outcomes for those who received the interventions when compared with others in control groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or showed no efficacy, in the case of lactose avoidance.

CONCLUSIONS

Evidence for efficacy of treatment of RAP in children was found for therapies that used famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules. The effects of dietary fiber were less conclusive, and the use of a lactose-free diet showed no improvement. There seemed to be greater improvement when therapy (famotidine, pizotifen, peppermint oil) was targeted to the specific functional gastrointestinal disorder (dyspepsia, abdominal migraine, irritable bowel syndrome). The behavioral interventions seemed to have a general positive effect on children with nonspecific RAP. Many of these therapies have not been used widely as standard treatment for children with RAP. Although the mechanism of action for each effective therapy is not fully understood, each is believed to be safe for use in RAP.

Site-directed mutations of human hemoglobin at residue 35beta: a residue at the intersection of the alpha1beta1, alpha1beta2, and alpha1alpha2 interfaces

Because Tyr35beta is located at the convergence of the alpha1beta1, alpha1beta2, and alpha1alpha2 interfaces in deoxyhemoglobin, it can be argued that mutations at this position may result in large changes in the functional properties of hemoglobin. However, only small mutation-induced changes in functional and structural properties are found for the recombinant hemoglobins betaY35F and betaY35A. Oxygen equilibrium-binding studies in solution, which measure the overall oxygen affinity (the p50) and the overall cooperativity (the Hill coefficient) of a hemoglobin solution, show that removing the phenolic hydroxyl group of Tyr35beta results in small decreases in oxygen affinity and cooperativity. In contrast, removing the entire phenolic ring results in a fourfold increase in oxygen affinity and no significant change in cooperativity. The kinetics of carbon monoxide (CO) combination in solution and the oxygen-binding properties of these variants in deoxy crystals, which measure the oxygen affinity and cooperativity of just the T quaternary structure, show that the ligand affinity of the T quaternary structure decreases in betaY35F and increases in betaY35A. The kinetics of CO rebinding following flash photolysis, which provides a measure of the dissociation of the liganded hemoglobin tetramer, indicates that the stability of the liganded hemoglobin tetramer is not altered in betaY35F or betaY35A. X-ray crystal structures of deoxy betaY35F and betaY35A are highly isomorphous with the structure of wild-type deoxyhemoglobin. The betaY35F mutation repositions the carboxyl group of Asp126alpha1 so that it may form a more favorable interaction with the guanidinium group of Arg141alpha2. The betaY35A mutation results in increased mobility of the Arg141alpha side chain, implying that the interactions between Asp126alpha1 and Arg141alpha2 are weakened. Therefore, the changes in the functional properties of these 35beta mutants appear to correlate with subtle structural differences at the C terminus of the alpha-subunit.

High-resolution crystal structures of human hemoglobin with mutations at tryptophan 37beta: structural basis for a high-affinity T-state,

The high-resolution X-ray structures of the deoxy forms of four recombinant hemoglobins in which Trp37(C3)beta is replaced with Tyr (betaW37Y), Ala (betaW37A), Glu (betaW37E), or Gly (betaW37G) have been refined and analyzed with superposition methods that partition mutation-induced perturbations into quaternary structure changes and tertiary structure changes. In addition, a new cross-validation statistic that is sensitive to local changes in structure (a "local Rfree" parameter) was used as an objective measure of the significance of the tertiary structure changes. No significant mutation-induced changes in tertiary structure are detected at the mutation site itself for any of the four mutants studied. Instead, disruption of the intersubunit contacts associated with Trp37(C3)beta results in (1) a change in quaternary structure at the alpha1beta2 interface, (2) alpha subunit tertiary structure changes that are centered at Asp94(G1)alpha-Pro95(G2)alpha, (3) beta subunit tertiary structure changes that are located between residues Asp99(G1)beta and Asn102(G4)beta, (4) increased mobility of the alpha subunit COOH-terminal dipeptide, and (5) shortening of the Fe-Nepsilon2His(F8) bond in the alpha and beta subunits of the betaW37G and betaW37E mutants. In each case, the magnitude of the change in a particular structural parameter increases in the order betaW37Y < betaW37A < betaW37E approximately betaW37G, which corresponds closely to the degree of functional disruption documented in the preceding papers.

Verbal fluency and naming performance in type I diabetes at different blood glucose concentrations

The effect of serum glucose alterations on selected verbal skills was examined in a group of diabetic men between 18 and 35 yr of age. An artificial insulin infusion system was used to set and maintain glucose concentrations during testing at each of three levels: hypoglycemia (55 mg/dl), euglycemia (110 mg/dl), and hyperglycemia (300 mg/dl). Subjects were used as their own controls, with performance at euglycemia serving as the comparison standard. A double-blind crossover design was employed as described in Holmes et al. (see ref. 14). Results showed significantly disrupted naming or labeling skills at hypoglycemia, with a trend toward poorer performance at hyperglycemia. During hypoglycemia, rate of responding was slowed from 6% to 18%, compared with euglycemic performance, but accuracy was not impaired. In contrast, word recognition skills were not affected by deviations in glucose. These performance effects were not correlated with duration of disease except for one of the five tests administered. This one exception, on the most difficult task, was less notable than the general finding of no relation between disease duration (from 6 mo to 17.5 yr) and test performance. Thus, in addition to considering long-term consequences of blood glucose alterations, clinicians and diabetic patients may wish to consider acute neuropsychological consequences of disrupted euglycemia.

A survey of cognitive functioning at difference glucose levels in diabetic persons

Cognitive functioning was assessed in diabetic patients during hypoglycemia (60 mg/dl), euglycemia/control (110 mg/dl), and hyperglycemia (300 mg/dl). Blood glucose levels were set and maintained to within 4% of targeted levels by an artificial insulin/glucose infusion system (Biostator). Attention and fine motor skills, assessed by visual reaction time, was slowed at altered glucose levels. Performance was less impaired during hyperglycemia than hypoglycemia when a longer interstimulus interval was used, although it was still slower than normal. The time required to solve simple addition problems was increased during hypoglycemia, although reading comprehension was not affected. The possibility that some automatic brain skills are disrupted at altered glucose concentrations is discussed, while associative or inferential skills may be less affected.

Validity of urine glucose measurements for estimating plasma glucose concentration

Both physicians and diabetic patients have traditionally relied on measurement of glycosuria as an indirect method of estimating plasma glucose concentration to guide adjustment of insulin and diet therapy. Our observations on the correlation between mean plasma glucose concentration with simultaneous urine glucose concentration or excretion rate re-emphasize the limitations of this approach. Although our observations show a significant correlation (P less than 0.0001) between plasma glucose concentration and urine glucose concentration or urine glucose excretion rate, the wide confidence limits [95% confidence limits (minimum) +/- 150 mg/dl] on plasma glucose concentration estimated from urine glucose measurements limit the clinical applicability of such estimates. Differences among subjects in the renal resorption of glucose contribute to the wide variance of estimates. However, significant variability in renal glucose resorption within individuals is documented, further reinforcing the limitations of urine glucose determinations for reliable estimates of plasma glucose concentrations. Diabetologists need to reconsider the applicability of urine glucose measurements in evaluation of adequacy of therapy and in adjustment of insulin dosage.