phox2ba: The Potential Genetic Link behind the Overlap in the Symptomatology between CHARGE and Central Congenital Hypoventilation Syndromes

CHARGE syndrome typically results from mutations in the gene encoding chromodomain helicase DNA-binding protein 7 (CHD7). CHD7 is involved in regulating neural crest development, which gives rise to tissues of the skull/face and the autonomic nervous system (ANS). Individuals with CHARGE syndrome are frequently born with anomalies requiring multiple surgeries and often experience adverse events post-anesthesia, including oxygen desaturations, decreased respiratory rates, and heart rate abnormalities. Central congenital hypoventilation syndrome (CCHS) affects ANS components that regulate breathing. Its hallmark feature is hypoventilation during sleep, clinically resembling observations in anesthetized CHARGE patients. Loss of PHOX2B (paired-like homeobox 2b) underlies CCHS. Employing a chd7-null zebrafish model, we investigated physiologic responses to anesthesia and compared these to loss of phox2b. Heart rates were lower in chd7 mutants compared to the wild-type. Exposure to tricaine, a zebrafish anesthetic/muscle relaxant, revealed that chd7 mutants took longer to become anesthetized, with higher respiratory rates during recovery. chd7 mutant larvae demonstrated unique phox2ba expression patterns. The knockdown of phox2ba reduced larval heart rates similar to chd7 mutants. chd7 mutant fish are a valuable preclinical model to investigate anesthesia in CHARGE syndrome and reveal a novel functional link between CHARGE syndrome and CCHS.

Dating app usage and motivations for dating app usage are associated with increased disordered eating

The centrality of physical appearance in dating app environments may constitute an appearance-related pressure that increases the likelihood of body dissatisfaction (BD) and disordered eating (DE), thus exacerbating the relationship between DE-predictive traits and DE itself. Although dating app use has been linked to BD and DE, prior research has also neglected the role of individuals' dating app use motivations and relevant traits in eating pathology. To address these gaps, the current study investigated whether dating app usage moderated the effects of appearance-based rejection sensitivity, fear of negative evaluation, emotion dysregulation, and perceived social rank on DE. We also examined the unique effects of individuals' dating app use motivations on DE. Participants (N = 690) completed baseline measures of demographic and trait variables including dating app usage. DE was positively associated with female gender, higher body mass index, a history of eating disorder (ED) diagnosis, appearance-based rejection sensitivity, and emotion dysregulation. There was a small, positive association between dating app usage and DE, indicating that dating app users were more likely to report DE symptoms, appearance-based rejection sensitivity, and emotion dysregulation. No investigated predictor was moderated by dating app usage, but four of the six measured motivations for using dating apps (love, self-worth, ease of communication, and thrill of excitement motivations) were associated with DE among the dating app user sample (casual sex and trendiness motivations were not). Given that DE behaviours can lead to EDs, the present findings suggest that lifetime dating app usage may increase socio-cultural appearance pressures that confer risk for DE.

A case of migraine treatment in a patient with a clinical diagnosis of CHARGE syndrome using onabotulinum toxin A

CHARGE syndrome is a genetic disorder that affects multiple organ and sensory systems. Cranial nerve involvement is one of the key clinical diagnostic criteria. We present the case of an 8-year-old girl with CHARGE syndrome, associated right-sided facial palsy, and chronic severe migraines, that were intractable to medical treatment. At age 6, onabotulinum toxin A was used to weaken the contralateral non-paralyzed side of her face to address her stigmatizing asymmetry. Onabotulinum toxin A chemodenervation was performed on the left lower lip depressors to relax the muscles and improve left lower lip position. Coincidentally, it was noted that with these treatments, migraine symptoms resolved. As the chemodenervation subsided over the next 3-4 months, the severe migraines returned. Continued treatment with onabotulinum toxin A injections every 3 months has resulted in ongoing improvements in facial symmetry and migraine control. Onabotulinum toxin A is a well-known treatment of chronic migraine. Injections are usually directed to the occipitalis, frontalis, and corrugator muscles. The literature has no reports of injections to the lower lip depressors as a useful therapy for migraine, making the results from this case unique.

Canadian medical schools' preclerkship paediatric clinical skills curricula: How can we improve?

Background

Little is known about how Canadian medical schools teach paediatric clinical skills (history and physical exam) to preclerkship students, or its cost to the institutions.

Methods

Clinical skills program directors from all 17 Canadian medical schools were contacted to complete a questionnaire focused on teaching methods, and barriers/strengths of their Preclerkship Paediatric Clinical Skills program.

Results

Seventeen schools (100% response rate) participated. Seven schools (41%) do not introduce paediatric clinical skills until the second year of medicine. Half of the schools (53%) dedicate <10 total hours to preclerkship paediatric clinical skills. Fifty-nine per cent have ≤6 total hours of hands-on paediatric patient interaction (real or simulated). Medical students were least likely to be exposed to the infant age group (age 1 to 24 months). Twelve schools (71%) used simulated parent/child dyads. The most significant barriers identified by programs were limited time for sessions and patient availability. We describe one sample medical school's simulated parent/paediatric patient program where every student has hands-on learning with paediatric patients of all ages (program cost $938/student).

Discussion

This study is the first to summarize Canadian preclerkship paediatric clinical skills programs, among which there is great variability and commonly experienced barriers. Many students are not being exposed to all age groups of paediatric patients before their clerkship years. Medical schools can use this information to strengthen this important and challenging aspect of the curriculum, while being mindful of its fiscal implications.

Etiology and functional validation of gastrointestinal motility dysfunction in a zebrafish model of CHARGE syndrome

CHARGE syndrome is linked to autosomal-dominant mutations in the CHD7 gene and results in a number of physiological and structural abnormalities, including heart defects, hearing and vision loss, and gastrointestinal (GI) problems. Of these challenges, GI problems have a profound impact throughout an individual's life, resulting in increased morbidity and mortality. A homolog of CHD7 has been identified in the zebrafish, the loss of which recapitulates many of the features of the human disease. Using a morpholino chd7 knockdown model complemented by a chd7 null mutant zebrafish line, we examined GI structure, innervation, and motility in larval zebrafish. Loss of chd7 resulted in physically smaller GI tracts with normal epithelial and muscular histology, but decreased and disorganized vagal projections, particularly in the foregut. chd7 morphant larvae had significantly less ability to empty their GI tract of gavaged fluorescent beads, and this condition was only minimally improved by the prokinetic agents, domperidone and erythromycin, in keeping with mixed responses to these agents in patients with CHARGE syndrome. The conserved genetics and transparency of the zebrafish have provided new insights into the consequences of chd7 gene dysfunction on the GI system and cranial nerve patterning. These findings highlight the opportunity of the zebrafish to serve as a preclinical model for studying compounds that may improve GI motility in individuals with CHARGE syndrome.

Adolescent interviewing skills: effect of feedback

BACKGROUND

Communicating with adolescent patients can be challenging. Our study assessed the effect of structured feedback following a standardised patient (SP) encounter on postgraduate year-1 (PGY1) residents' adolescent-specific communication skills. Communicating with adolescent patients can be challenging METHODS: A two-group, prospective, double-blind randomised control study design was employed. Measures were taken before and after the intervention. PGY1 residents conducted a 30-minute interview with an SP adolescent-mother pair, who then individually scored the resident's performance using the validated Structured Communication Adolescent Guide (SCAG). PGY1s were randomised to receive either structured feedback following the interview (feedback group) or no feedback (no feedback group). All residents completed a second interview 4-6 weeks later. Scores were analysed using unpaired t-tests.

RESULTS

Thirty-eight residents completed both interviews. The mean total-item and mean global scores for the first interview did not differ significantly between the feedback (n = 21) and no-feedback group (n = 17). The mean total-item scores for the feedback group [first interview: 34.19 ± 10.19 (adolescent); 36.33 ± 9.77 (mother)] improved significantly for the second interview [45.17 ± 6.22 (adolescent); 44.71 ± 6.72 (mother); p = 0.002 and 0.003, respectively]. The mean global scores also improved significantly from the first interview [27.00 ± 6.49 (adolescent); 27.47 ± 6.50 (mother)] to the second interview [34.05 ± 3.30 (adolescent); 31.19 ± 3.85 (mother); p = 0.001 and 0.03, respectively]. No significant improvement in the mean total-item or mean global rating was observed in the no feedback group.

CONCLUSIONS

Structured feedback following a single adolescent and mother SP encounter resulted in significant improvement in the adolescent-specific communication skills of PGY1s in performing an adolescent interview.

Physiologically based pharmacokinetic modeling in regulatory decision-making at the European Medicines Agency

Physiologically based pharmacokinetic (PBPK) modeling is a valuable tool in drug development and regulatory assessment, as it offers the opportunity to simulate the pharmacokinetics of a compound, with a mechanistic understanding, in a variety of populations and situations. This work reviews the use and impact of such modeling in selected regulatory procedures submitted to the European Medicines Agency (EMA) before the end of 2015, together with its subsequent reflection in public documents relating to the assessment of these procedures. It is apparent that the reference to PBPK modeling in regulatory public documents underrepresents its use. A positive trend over time of the number of PBPK models submitted is shown, and in a number of cases the results of these may impact the decision-making process or lead to recommendations in the product labeling. These results confirm the need for regulatory guidance in this field, which is currently under development by the EMA.

Skills for Interviewing Adolescent Patients: Sustainability of Structured Feedback in Undergraduate Education on Performance in Residency

BACKGROUND

Effective adolescent (10 to 19 years) interviewing by physicians is an essential skill that many trainees can find challenging.

OBJECTIVE

We assessed whether structured adolescent interviewing using standardized patients (SPs) and feedback in undergraduate medical education (UME) has a sustained effect on residents' skills.

METHODS

Postgraduate year (PGY) 1 residents conducted interviews with a SP adolescent-mother pair. The SPs independently scored each PGY-1 interview using the structured communication adolescent guide (SCAG). Unpaired t tests were conducted comparing "Total-Item" and "Global" scores of PGY-1s who received structured SP adolescent interviewing with feedback in UME ("structured training" group) to those who had not ("no structured training" group).

RESULTS

PGY-1s in the structured training group (n = 23) received significantly higher mean Total-Item scores from both the SP adolescent (40.78 ± 7.04 and 32.41 ± 10.12, respectively; P = .001) and the SP mother (40.48 ± 7.90 and 33.34 ± 10.90, respectively; P = .01) than those without structured training (n = 29). Statistically significant results favoring PGY-1s with prior training were also seen with the SP adolescent and mother total Global SCAG scores.

CONCLUSIONS

Structured training in adolescent interviewing with SPs and feedback in UME appears to have a sustained effect on residents' adolescent interviewing skills. PGY-1s will interview adolescents and may benefit from structured adolescent SP interviewing with feedback, especially individuals who did not have this experience during their medical school training.

Quality of life in adolescents and adults with CHARGE syndrome

Health-related Quality of Life and the Impact of Childhood Neurologic Disability Scale were collected for 53 patients with CHARGE syndrome aged 13-39 years with a mean academic level of 4th grade. The most prevalent new and ongoing issues included bone health issues, sleep apnea, retinal detachment, anxiety, and aggression. Sleep issues were significantly correlated with anxiety, self-abuse, conduct problems, and autistic-like behaviors. Problems with overall health, behavior, and balance most affected the number of social activities in the individual's life. Sensory impairment most affected relationships with friends. Two contrasting case studies are presented and demonstrate that the quality of life exists on a broad spectrum in CHARGE syndrome, just as its physical features range from mild to very severe. A multitude of factors, including those beyond the physical manifestations, such as anxiety and sleep problems, influence quality of life and are important areas for intervention. © 2016 Wiley Periodicals, Inc.

Feeding Difficulties and Gastrointestinal Tract Morphology and Innervation in ‘Charge’ Syndrome

BACKGROUND: CHARGE syndrome has been linked to mutations in the CHD7 gene and results in a number of physiological and structural abnormalities. The estimated incidence in the Atlantic Provinces is 1 in 8500 births. Challenges include eating problems, which have a profound impact throughout a child’s life and can lead to complications and even death.

OBJECTIVES: To investigate feeding difficulties and model the morphology and innervation of the gastrointestinal tract in CHARGE syndrome.

DESIGN/METHODS: Three research studies (two clinical, one basic science) were conducted to assess feeding difficulties in CHARGE syndrome. The first study conducted a qualitative analysis of parent interviews to understand packing and problematic feeding behaviors. The second study investigated general eating and GI motility problems by having parents complete a series of feeding questionnaires. The third study modeled CHARGE syndrome in zebrafish by using a morpholino to knock down the expression of CHD7.

RESULTS: Study 1: Twenty parents completed a phone interview, describing their child/adult’s (2-32 years) adverse feeding behaviors. Parents reported food packing most commonly with bread and pasta (33%), and reported that food was held in cheeks for hours after a meal had ended (35%). Packing was reported to prolong mealtimes for over an hour (30%). Parents were worried about choking during eating (30%).Study 2: Sixty-nine parents of children (age 1-18 years) completed the questionnaires. Those who were tube fed had significantly more gastrointestinal symptoms (stomach pain, nausea, etc.) and worse feeding difficulties than those who were orally fed. The CHARGE characteristics of choanal atre-sia/stenosis and cranial nerve IX/X dysfunction were associated with significantly more gastrointestinal symptoms. Parents identified constipation as a major challenge. Study 3: Immunohistochemistry demonstrated changes in the enteric innervation of the gastrointestinal tract in the CHARGE syndrome zebrafish models. There was decreased branching of the gastrointestinal nerve network surrounding the stomach. Use of fluorescent microbeads demonstrated reduced motility and delayed passage of the microbeads through the gastrointestinal tract.

CONCLUSION: These three studies provided a comprehensive analysis of feeding and gastrointestinal difficulties, from mouth to anus, in CHARGE syndrome. They provide a deeper understanding of adverse feeding behaviors, feeding difficulties, and the abnormal morphology of the gastrointestinal system. The information from this study can be useful for general pediatricians and feeding therapy teams who are involved in the care of these individuals starting in infancy. The team-based approach of conducting multiple research projects investigating a common issue may be useful in other genetic disorders.

Newly Emerging Feeding Difficulties in a 33-Year-Old Adult With CHARGE Syndrome

Feeding and swallowing difficulties are common among individuals with CHARGE syndrome. Many children require gastrostomy tube feeding in their early years and often undergo a delay in feeding and oral-motor skill development. There is little information available on adults with CHARGE syndrome, and the feeding difficulties they face. The present case describes newly emerging mouth over-stuffing feeding behaviors and feeding difficulties in a 33-year-old adult with CHARGE syndrome who had not undergone feeding therapy since childhood.

The comprehensive geriatric assessment guide: an exploratory analysis of a medical trainee performance evaluation tool

PURPOSE

Few opportunities exist for medical students and residents to receive feedback on specific geriatric skills because they are frequently unsupervised when assessing elderly patients. Patients and caregivers are currently an untapped source of clinical content feedback. The purpose of this study was to determine whether patients/caregivers could accurately complete a postassessment evaluation of trainees' clinical performance.

METHOD

The authors developed the Comprehensive Geriatric Assessment Guide (CGAG) consisting of 36 yes/no/don't-remember questions that prompt the patient/caregiver to indicate what topics the trainee discussed during clinical assessment. In 2010, two raters independently listened to audio recordings of 10 trainee-administered clinical assessments, scoring them using the CGAG to determine interrater reliability. Next, 32 patients/caregivers completed a CGAG after a trainee-administered clinical assessment. Then, the authors compared the results with a "gold standard" CGAG of the encounter.

RESULTS

Interrater reliability for the CGAG was high (90.4% agreement), indicating that the patients/caregivers were able to accurately complete the postassessment CGAG. Of 36 CGAG questions, 30 had patient/caregiver and gold standard agreement of over 80%; the remaining 6 had low agreement.

CONCLUSIONS

Patients and caregivers were able to recall sufficient clinical assessment detail to potentially provide constructive feedback to medical trainees on their assessment skills via the CGAG. Six questions with low agreement will be reworded to improve clarity on future versions of the CGAG. Future investigations will help determine whether use of the CGAG during medical education may help trainees improve assessment performance and allow educators to track progress in geriatric competencies.

Drug-induced PML: a global agenda for a global challenge

The occurrence of severe adverse events such as progressive multifocal leukoencephalopathy (PML) has the potential to limit the benefits of highly efficacious medicines being developed to fulfill unmet clinical needs across therapeutic areas. Following an Expert meeting in London in July 2011 (http://www.ema.europa.eu/docs/en_GB/document_library/Report/2011/09/WC500111562.pdf), a research agenda, highlighting methodological, clinical, and communication elements, to mitigate the risk and improve the management of drug-induced PML has been agreed upon.

Bioavailability of inhaled fluticasone propionate via chambers/masks in young children

We determined lung bioavailability of a fluticasone propionate (FP) pressurised metred-dose inhaler (Flovent HFA; GlaxoSmithKline, Research Triangle Park, NC, USA) administered via AeroChamber Plus (Monaghan Medical, Plattsburgh, NY, USA) with Facemask and Babyhaler (GlaxoSmithKline) valved holding chambers (VHCs) using a population pharmacokinetic approach. Children from 1 to <4 yrs of age with stable asthma but a clinical need for inhaled corticosteroid therapy were administered 88 μg FP hydrofluoroalkane (2 × 44 μg) twice daily delivered through the two devices in an open-label, randomised crossover manner for 8 days each. Patients were randomised to one of three sparse sampling schedules for blood collection throughout the 12-h dosing interval on the 8th day of each treatment for pharmacokinetic analysis. The area under the FP plasma concentration-time curve (AUC) was determined for each regimen. 17 children completed the study. The population mean AUC following FP with AeroChamber Plus with Facemask was 97.45 pg·h·mL(-1) (95% CI 85.49-113.32 pg·h·mL(-1)) and with Babyhaler was 51.55 pg·h·mL(-1) (95% CI 34.45-64.46 pg·h·mL(-1)). The relative bioavailability (Babyhaler/AeroChamber Plus) was 0.53 (95% CI 0.30-0.75). Clinically significant differences in lung bioavailability were observed between the devices. VHCs are not interchangeable, as differences in drug delivery to the lung may occur. A population pharmacokinetic approach can be used to determine lung bioavailability of FP.

Postoperative airway events of individuals with CHARGE syndrome

OBJECTIVE

CHARGE syndrome is a heterogeneous genetic disorder comprising multiple congenital anomalies. Major clinical diagnostic criteria include ocular coloboma, choanal atresia/stenosis, characteristic ear abnormalities, and cranial nerve abnormalities. CHARGE syndrome is caused by a mutation in the gene CHD7 located on chromosome 8. Patients with CHARGE syndrome require multiple anesthetics for surgical and otorhinolaryngology procedures. This study describes the postoperative anesthetic related airway events (i.e. re-intubations for apneas and desaturations, airway obstruction due to excessive secretions) of nine individuals with CHARGE syndrome.

METHODS

Detailed chart audits were performed on nine patients diagnosed clinically with CHARGE syndrome who had undergone surgery at a single tertiary health centre. The CHARGE characteristics present in each individual, the number and types of surgeries and anesthetics, and the related postoperative airway events were determined.

RESULTS

The mean+/-age of the population at chart review was 11.8 years (+/-8.0). The total number of anesthetics was 147, with a mean of 16.2(+/-8.4). Of the 215 surgical procedures (mean 21.9, +/-12.2), 30% were otorhinolaryngological. Postoperative airway events occurred after 35% of anesthetics. Surgeries resulting in the most airway events involved the heart (65%), the gastrointestinal tract (39%), and airway diagnostic scopes, i.e., bronchoscopy, laryngoscopy, and nasopharyngoscopy (36%). Combining multiple surgical procedures under one anesthetic did not increase the risk of postoperative airway events. As individuals aged, they had fewer surgeries and anesthetics, as well as a lower risk of postoperative airway events.

CONCLUSION

Individuals with CHARGE syndrome face a significant risk of postoperative airway events with anesthesia, and this is exacerbated by the high number of surgeries they require. Surgeons and anesthesiologists should be aware of potential for postoperative airway events in individuals with CHARGE syndrome and plan accordingly.

Ocular features of CHARGE syndrome

PURPOSE

To detail the presence and severity of ocular and cranial nerve abnormalities found in individuals with CHARGE syndrome in a distinct geographic area.

METHODS

Nine individuals with CHARGE syndrome from Maritime Canada identified from a Canadian database were prospectively examined. Structural and sensorial defects associated with functional visual deficits were defined with ophthalmic and neurological evaluation.

RESULTS

Consistent with current diagnostic criteria and the literature, colobomas were the major ophthalmic manifestation. These were typically bilateral chorioretinal colobomas involving the optic nerve. All subjects had bilateral severe sensorineural deafness (cranial nerve VIII), and 8 of 9 (89%) had facial nerve (cranial nerve VII) involvement (7 of 9 had unilateral involvement; 1 of 9 had bilateral involvement). Unique to this group of participants were the findings of anisometropia in 8 of the 9 (89%) patients, severe myopic astigmatism in 13 of the 18 eyes (72%), and limited elevation in adduction in 3 of 9 (33%) participants. Associated findings were strabismus, cataracts, microcornea, keratopathy, staphyloma, reduced stereopsis, superior visual field defects, and reduced visual acuity.

CONCLUSIONS

The presence of coloboma plus another CHARGE feature warrants further investigation, including genetic screening for the CHD7 gene. Early recognition and management of sensory problems (visual, auditory, and vestibular) are crucial to ensure best psychomotor and cognitive development.

What makes a physician an exemplary communicator with patients?

OBJECTIVE

A pilot study was conducted to examine the characteristics, capacities (beliefs, values and intentions) and skills that distinguish exemplary communicators from less exemplary communicators in patient-physician encounters.

METHODS

Forty physicians participated in a four-station videotaped OSCE focusing on a variety of adolescent sexual health issues and assessed using seven quantitative measures. Results determined the top 15%, and the bottom 15%. An interviewer reviewed and discussed two of the videotaped scenarios with physicians in both groups. Interviews were analyzed to determine differences between groups.

RESULTS

Results consistently identified the top 15% (6) and bottom 15% (6) physicians. The t-tests showed statistically significant differences on all skills and capacity measures. "Notable" differences (25% or higher) were found on two quantitative instruments assessing skills. There were no notable differences in capacities. The qualitative inquiry confirmed notable differences in skills and identified capacities of empathy, non-judgement and self-reflection as restricted to the exemplary group.

CONCLUSION

Using quantitative and qualitative measures, it is possible to determine skills and capacities that distinguish exemplary communicators from less exemplary communicators.

PRACTICE IMPLICATIONS

In addition to effective skills, physician empathy, non-judgement and self-reflection appear to be necessary components for exemplary physician communication with adolescents.

Early oral sensory experiences and feeding development in children with CHARGE syndrome: a report of five cases

Children with CHARGE syndrome commonly experience feeding and swallowing problems. Difficulties may be associated with congenital structural anomalies, motor impairment, and/or oral sensory impairment. For many children with CHARGE syndrome, the introduction of functional oral feeding is delayed and there are often long-term feeding complications. Oral aversion or defensiveness is a frequent serious issue; however, it is uncertain whether this is a primary sensory disorder or secondary to delayed and/or negative oral sensory and feeding experiences. This article examines in detail the early oral sensory and feeding experiences of five children with CHARGE syndrome, through a review of medical records and caregiver questionnaires. Findings indicate variable early oral sensory experiences in this group of children, with all of the children having some difficulty or delay in the development of oral feeding and swallowing. The nature of these difficulties and the potential contributory factors are discussed.

Scoliosis in CHARGE: a prospective survey and two case reports

CHARGE syndrome was first identified as a cluster of congenital anomalies in 1979 and has since undergone diagnostic criteria modifications to include the major and minor characteristics that occur during infancy and childhood. As the individuals with CHARGE syndrome have aged into their adolescents and adulthood, it has become increasingly common for them to develop scoliosis. This article presents an older population of individuals with CHARGE syndrome and describes the prevalence of scoliosis, and identifiable risk factors for scoliosis. Two case reports demonstrate the variability of scoliosis in CHARGE syndrome. A survey of adults and adolescents with CHARGE syndrome was completed to collect information about late onset medical issues, and those identifying scoliosis as an issue, were further followed for more information. The total population (n=31) and then the subgroup of individuals with scoliosis (n=19) were analyzed. Sixty one percent (19 of 31) of this population was diagnosed with scoliosis. The age of CHARGE syndrome diagnosis was later in the scoliosis population (6.3 years compared to 3.7 years in the no scoliosis population). Growth hormone use was reported in 7 of 31 of the individuals; 6 of these subsequently were diagnosed with scoliosis (32% of the scoliosis group). Of the scoliosis subgroup, most were mild scoliosis but eight were diagnosed with moderate to severe scoliosis, and all of these were treated with either a brace (n=5) or with surgical fusion (n=2) and one individual had both. Scoliosis in CHARGE syndrome individuals is more common than previously reported, and the age of onset is earlier than when routine monitoring for scoliosis is recommended. The prevalence of scoliosis in the CHARGE syndrome population is higher than in the general population therefore, it is very important for physicians to carefully monitor the spine for the development of scoliosis in children with CHARGE syndrome, especially if they are being treated with growth hormone.

Behavioral profiles and symptoms of autism in CHARGE syndrome: preliminary Canadian epidemiological data

Individuals with CHARGE syndrome were identified through the Canadian Pediatric Surveillance Program (CPSP). From this population-based cohort (n=78), we present data on developmental and behavioral characteristics for the first 13 individuals (eight males, five females) for whom assessments are complete. Standardized parent questionnaires on development and behavior were followed by a structured telephone interview, with a specific emphasis on symptoms of autistic spectrum disorder (ASD). Preliminary results confirm that individuals with CHARGE syndrome have relatively low adaptive behavior skills, motor impairments being particularly significant. Most individuals did not present with significant behavior problems; however, evidence of ASD symptoms was judged to be moderate to strong in six of the ten children who were above the age of 4-5 years. Results are discussed with reference to the challenges inherent in the diagnosis of autism in individuals with sensory impairments, and to the implications for understanding the etiology of CHARGE syndrome and of ASD.

A structured communication adolescent guide (SCAG): assessment of reliability and validity

PURPOSE

To assess the reliability and validity of a Structured Communication Adolescent Guide (SCAG) in an undergraduate medical education setting using trained adolescent raters.

METHOD

The SCAG is a 49-item, 6-section (A-F), protocol derived from the Calgary Cambridge Observation Guide that incorporates adolescent psychosocial data collection with the physician's communication skills. Four trained female adolescents scored 42 videotaped adolescent clinical encounters using the SCAG; a trained psychologist's rating for each videotape was used as the gold standard.

RESULTS

Agreement among adolescent raters was determined by calculating intraclass correlation coefficients (ICC). The individual SCAG item scores, combined with the global ratings for each section, resulted in an overall ICC value of 0.93, indicating very strong agreement among the 4 raters. The global rating scores for the sections ('initiating the session', 'initiating separation', 'once adolescent is alone--lifestyle' and 'closure') produced an ICC range of 0.58-0.93. However, the ICC values for the 2 remaining sections ('how was information collected' and 'gathering information') global rating scores were below 0.30, signifying low agreement. Overall agreement between the adolescent raters and the gold standard resulted in an ICC value of 0.78. This is evidence of the SCAG's criterion validity.

CONCLUSION

The SCAG is a reasonably valid tool for use in guiding an encounter with an adolescent patient. However, 2 sections require modifications to improve their reliability and thus the SCAG's overall performance. Our results suggest that the SCAG shows promise as a potentially useful teaching resource in undergraduate medical education in adolescent medical interviewing.

Raising our HEADSS: adolescent psychosocial documentation in the emergency department

OBJECTIVES

To determine the effectiveness of a chart stamp featuring the acronym "HEADSS" (Home, Education, Alcohol, Drugs, Smoking, Sex) at improving adolescent psychosocial documentation in the emergency department (ED) chart.

METHODS

The study sample consisted of ten emergency physicians. The ED charts of 306 adolescent patients (aged 13-18 years) completed by these physicians were surveyed. An analysis of ED chart psychosocial documentation was conducted that compared a six-week control phase (with no chart stamp) with a four-week intervention phase (with a chart stamp featuring the HEADSS acronym). Presenting complaints in the ED, psychosocial documentation in the ED, and information from past medical records were compared between the two groups.

RESULTS

The ED charts surveyed consisted of 153 charts from each phase. HEADSS documentation ranged from 8% to 12% in the intervention phase and 0% to 7% in the control phase. Emergency physicians were more likely to document the topics of education (p = 0.029), alcohol (p = 0.045), and smoking (p = 0.009) as well as whether the patient was interviewed alone (p = 0.0001) in the intervention phase charts. Documentation of a detailed psychosocial assessment (>4/6 HEADSS topics addressed; p = 0.003) was more likely during the intervention phase.

CONCLUSIONS

The HEADSS stamp is useful in prompting psychosocial documentation in the ED chart. Further study is needed to determine whether routine use of the HEADSS stamp technique can improve the detection and management of adolescent psychosocial problems.