Abstracts - Annual Eastern Society for Pediatric Research Meeting
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- An Innovative Model for the PBLI Competency in a Pediatric Residency
- Outcomes In Macrosomic Newborns Of Non-Diabetic Mothers
- Should inner-city adolescents be seen every 6 months for well-visits?
- Why do some adolescents lose weight and others not?: A qualitative study
- Vaginal Wet Mounts on Asymptomatic Adolescent females; Is it beneficial?
- Improving Access to Behavioral Health Care in an Inner City Teen Clinic
Title: An Innovative Model for the PBLI Competency in a Pediatric Residency
Authors: Barbara A. Kelly, MD, Alexis S. Lieberman, MD, Alan M. Schindler, MD, and Anna Marie Carr, MD, Department of Pediatrics,
Albert Einstein Medical Center, Philadelphia, PA.
Background: The practice-based learning and improvement (PBLI) competency focuses on clinical quality assessment and improvement (QA/QI)
and residents’ development of evidence-based medicine skills and self-reflective practices. Most residents and many faculty
lack both experience and comfort with the PBLI competencies. Thus, integrating PBLI into pediatric residency training has
created exciting new challenges.
Objective: We describe an innovative model for integrating the PBLI competency into a pediatric residency program.
Design/Methods: We developed a PBLI model that included didactic presentations, experiential team learning, and evaluation.
The program began with a lecture series on QA/QI and development of a Resident QA/QI Manual. We then organized PBLI teams
of 3-4 residents with a faculty mentor. Teams were assigned the task of developing a QA/QI project of their choice. QA/QI
data and outcomes were assessed by comparison to evidence-based practice. Each team worked over a period of 1-4 months and
reported on their project at a departmental grand rounds. Residents completed self-evaluation forms and were evaluated by
faculty mentors.
Results: During the 2005-2006 academic year, six PBLI teams developed and presented QA/QI projects, with 19/35 (54%) residents
participating. After completion of their projects, most residents (72%) felt they were more able to implement meaningful strategies
to continually improve fund of knowledge and processes of care. Faculty expressed increased ability to mentor in the PBLI
competency and high satisfaction with resident participation. Faculty perceived changes in the culture of the residency program:
residents now incorporate principles of evidence-based medicine more thoroughly into their clinical practice and they are
more proactive in identifying processes of patient care and developing strategies for improving outcomes. In addition, this
PBLI project led to two award-winning poster presentations at a local meeting; one was of such high quality that it was submitted
for publication.
Conclusions: An innovative PBLI model led to broad faculty and resident participation in QA/QI, improved QA/QI skills for
both faculty and residents, helped residents to become more proactive in QA/QI activities, and enhanced scholarly activity.
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Title: Outcomes In Macrosomic Newborns Of Non-Diabetic Mothers
Authors: Srikant Das, MD, Marybeth Patterson, MD, David Schutzman, MD and Agnes Salvador, MD. (Sponsored by Agnes Salvador,) (Eastern
SPR Sponsored by Vineet Bhandari,)1Pediatrics, Division of Neonatology, Albert Einstein Medical Center, Philadelphia, PA,
United States.
Background: While macrosomia is well studied in diabetic women, outcomes of macrosomic neonates born to diabetic and non-diabetic women
have not been compared.
Objective: 1. To describe the characteristics and compare outcomes of macrosomic infants born to diabetic and non-diabetic women.
2. To evaluate morbidities in big infants according to birth weight categories.
Design/Methods: Maternal and neonatal records of all infants with birth weights 4000 g from 2003 through 2005 were reviewed.
Outcome variables included neonatal complications in relation to maternal diabetic status, mode of delivery and birth weight
categories.
Results: We reviewed 262 macrosomic infants of non-diabetic mothers (non-IDM) and 41 macrosomic infants of diabetic mothers (IDM).
Nearly half of the non-IDM group (130/262) had at least one complication.
Hypoglycemia was the most common complication in non-IDM (75/262, 29%) and IDM (23/41, 56%). When controlled for gestational
age and birth weight, there was statistically no difference in the incidence of hypoglycemia between IDM and non-IDM (p>0.05).
Among macrosomics, infants with birth weights 4500 g developed hypoglycemia significantly more often (50% vs 30%, p=0.004)
and had a significantly higher rate of complications (p<0.03).
Birth related injuries were significantly reduced in infants delivered by cesarean section (p=0.01), when controlled for weight
and maternal diabetic status. Notably, 35 cases of birth related injuries (4 brachial plexus injuries, 17 fractures and 14
cephalhematomas) occurred in the non-IDM group delivered by the vaginal route in contrast with only one case of clavicle fracture
and cephalhematoma in a macrosomic IDM. This appears to be related to a significantly higher rate of cesarean delivery in
diabetic women compared with non-diabetics (66% vs 30%, p=0.001), even after controlling for gestational age and fetal weight.
Of note, 19 of the 20 macrosomic infants with fractures and brachial plexus injuries were in the non-IDM group. They were
all delivered vaginally and had birth weights <4500 g.
Conclusions: Complications among macrosomic neonates correlate with higher birth weights. Increased birth trauma in non-IDM macrosomic
infants supports a similar approach for perinatal management and cesarean delivery as for macrosomic IDM based on fetal weight.
* * *
Title: Should inner-city adolescents be seen every 6 months for well-visits?
Authors: By Jerico Alvaran MD, and Alexis S. Lieberman MD
Background: There is scant evidence to support the periodicity for health supervision visits for inner-city adolescents. While national
guidelines recommend annual visits, our clinic offers health supervision visits every 6 months, instead.
Objective: To determine the usefulness of semi-annual health supervision for inner-city adolescents.
Methods: We conducted a systematic chart review of 301 6-month-visits made by 231 adolescents at an inner-city adolescent clinic
between 2003 and 2006. Data collected included assessments by the clinician and health educator, and themes identified through
HEADSS screening. Outcomes included new or relevant diagnoses that merited medical attention. The quantitative data were analyzed
by univariate analysis. The summary notes on each visit were independently reviewed for the usefulness of the visit by the
two authors.
Results: Patients age was 13- 21 years, mean 16.8, 82% female, 60% Medicaid capitated to our clinic and 40% seen through a Federal
family planning grant. The reviewers agreed on the usefulness of the visit in 88% of the visits. 77% of visits yielded a relevant
diagnosis, such as 56 visits (19% of all visits) in which a sexually transmitted infection was diagnosed, 24 visits (8%) in
which contraception was provided, 12 visits (4%) in which asthma was managed, 3 visits (1%) in which substance use was diagnosed,
and 5 visits (2%) in which depression or other mental health diagnoses were made. Sexual health and family planning issues
were addressed in 47% of visits, medical issues in 40%, and psychiatric issues in 3%.
Conclusion: The semi-annual health supervision visit often identifies important diagnoses that need attention or management, and provides
a venue for preventive health counseling. More frequent periodicity for well-visits should be considered for inner-city adolescents.
* * *
Title: Why do some adolescents lose weight and others not?: A qualitative study
Authors: Diana Harris MA, Alexis Lieberman MD, and Jessica Robbins PhD
Background: The experiences of overweight adolescents who have lost weight may be useful in the creation of effective weight loss programs.
Objectives: To identify qualitative differences between the experiences of overweight, inner city adolescents who lost weight compared
to those who gained weight over time.
Methods: A qualitative study of a convenience sample of 10 at-risk and overweight inner-city teens who decreased BMI-for-age, compared
to 12 who increased, over 2 or more years. Audio-taped and transcribed focus groups and in-depth interviews were subjected
to the constant comparative method among researchers to identify themes re: eating patterns, habits, school and home, the
experience of being overweight. Thematic responses were noted by the number of interviews in which they appeared; frequencies
for each group were compared.
Results: Multiple similarities and several important differences were found. Adolescents in both groups had poor diets, similar rates
of eating with parents, complex effects of monetary constraints, “mixed” dislike but acceptance of being overweight, and similarly
unsafe neighborhoods. “Decreasing” adolescents were more likely to describe a “transformative experience” which changed their
view of themselves in the world with regard to weight and activity, i.e. being recruited to a city-wide basketball team, being
sent to boot camp or noticing other basketball players had more stamina: They sweat a lot, but they don’t get tired, and I
get tired. Other transformative experiences were medical: She (doctor) said I had a chance… I don’t want to have diabetes.
8/10 of those who lost weight engaged in intense, daily exercise, only 1 who gained weight did. Weight-losers had family members
who educate them in healthy dietary behavior: My grandmother tells me… don’t just grab soda, cake. Grab… a piece of fruit.
In contrast, weight gainers often had family members who supported them to accept their weights: My mom will say, I don’t
think you-all are fat, I just think you are thick.
Conclusion: Overweight adolescents who lose weight were more likely to have transformative experiences, engage in intense daily exercise,
and have family members who support them in healthy eating. This may guide the development of new weight loss strategies.
* * *
Title: Vaginal Wet Mounts on Asymptomatic Adolescent females; Is it beneficial?
Authors: K Stampler MS, A Lieberman MD, M Fraga MD, A Cohen MD
Background: Wet mounts are commonly performed at the time of pelvic exam. However, there is a paucity of data on the usefulness of wet
mounts in asymptomatic teen patients.
Objective: To determine if wet mounts in asymptomatic teen women are useful in detecting Gonorrhea or Chlamydia, compared to DNA amplification
testing.
Design/Methods: We retrospectively reviewed charts for 93 consecutive asymptomatic patients seen between March and September, 2006 for a
routine visit. Data was collected re: patients' previous STI history, week in menstrual cycle, date of last coitus, use and
type of contraceptives; vaginal pH, presence or absence of discharge, appearance of cervix, wet mount results and cervical
testing results. Outcome measures were findings on wet mount and result of DNA amplification test on cervical sample for Gonorrhea
and Chlamydia.
Results: Wet mounts were abnormal in 29 (31.2%) patients. T vaginalis was diagnosed in 8 (8.8%) patients, bacterial vaginosis in
11 (12.1%), Candida in 5 (5.5%). N gonorrhoeae was diagnosed by DNA amplification in 2 (2.2%) patients and C trachomatis in
9 (9.7%). There was no significant relationship between abnormal wet mount and positive N gonorrhoeae and C trachomatis (p=0.083).
After excluding the patients with abnormal wet mounts who had T vaginalis, BV or Candida, all the remaining patients with
positive N gonorrhoeae and C trachomatis had normal wet mounts. For N gonorrhoeae, the wet mount had a sensitivity of 0%,
specificity of 92.6%, PPV of 0%, and a NPV of 95%. For C trachomatis, the wet mount had a sensitivity of 0%, specificity of
92.1%, PPV of 0%, and a NPV of 89%.
Conclusion: Wet mounts were not useful to detect N gonorrhoeae and C trachomatis in asymptomatic teen patients. The finding of T vaginalis
and BV in these asymptomatic patients may justify continuing wet mount evaluation but this practice needs further study to
determine if treatment in this asymptomatic population will result in clinically significant effects.
* * *
Title: Improving Access to Behavioral Health Care in an Inner City Teen Clinic
Authors: Alexis Lieberman, MD, Associate Chief for Ambulatory Pediatrics, Director of the Teen Program, Albert Einstein Medical Center,
Philadelphia, PA
Michael DeStefano, Ph.D., Director, Child and Teen Service, Belmont Center for Comprehensive Treatment, Philadelphia, PA
Background: Innovative approaches are needed to enhance teen follow-through with behavioral health referrals. In our previous study,
only 3% of teens referred for off-site behavioral health care kept a first appointment, and none a second.
Objective: To describe an innovative, interdisciplinary project linking inner-city teens to behavioral health care.
Method: We implemented a collaborative psychiatric/pediatric program linking teens seen in an ambulatory Teen clinic to community
psychiatric, social service and educational resources, an expansion of an existing psychiatric inpatient discharge program,
the Bridge. Patients, aged 13-21 years, seen at a Teen clinic between November 2004 and July 2006, were routinely screened
using the HEADSS screen by clinicians. Those deemed to need behavioral health services met immediately with Bridge staff,
co-located at the Teen clinic, for education, support and referral to appropriate outpatient and community services. Primary
outcome was attendance at a first and second behavioral health appointment.
Results: This inner-city Teen clinic had 4748 visits in the most recent fiscal year. Providers screen all patients for psychosocial
issues. 321 teens were deemed in need of referral for behavioral health care. 252 (92%) agreed to referral to the Bridge and,
of these, 85% enrolled. 73% of enrollees were female, 91% were African-American, median age was 16, 62% were enrolled in school,
and 79% had Medicaid, 9% no insurance. 25% had a history of rape or sexual abuse; 17% had previous mental health care. Of
252 enrollees, 154 needed psychiatric care (150 outpatient, 4 inpatient), 5 drug treatment, 16 academic-related referrals,
8 teen parent support group, 69 other community support agencies. Referrals were made to over 40 community agencies.
22% (n=55) of those who enrolled attended a first behavioral health services appointment, and half of these (n=27) attended
a second appointment.
Difficulties encountered were timely access to agency appointments; disconnected telephones; discomfort with the idea of behavioral
health care, and concerns with being labeled as mentally ill.
Conclusion: An interdisciplinary collaboration between primary care pediatrics and psychiatry linking teens to outpatient behavioral
health care services led to improved rates of attendance to behavioral health care. However, the majority of teens needing
services still did not receive them. Other approaches, such as on-site mental health care, may be more successful.
Publish date: March 9, 2007
