Well-Child Visits for Early Detection and Management of Maternal Postpartum Hypertensive Disorders.

Importance: Innovative approaches are needed to address the increasing rate of postpartum morbidity and mortality associated with hypertensive disorders. Objective: To determine whether assessing maternal blood pressure (BP) and associated symptoms at time of well-child visits is associated with increased detection of postpartum preeclampsia and need for hospitalization for medical management. Design, Setting, and Participants: This is a pre-post quality improvement (QI) study. Individuals who attended the well-child visits between preimplementation (December 2017 to December 2018) were compared with individuals who enrolled after the implementation of the QI program (March 2019 to December 2019). Individuals were enrolled at an academic pediatric clinic. Eligible participants included birth mothers who delivered at the hospital and brought their newborn for well-child check at 2 days, 2 weeks, and 2 months. A total of 620 individuals were screened in the preintervention cohort and 680 individuals were screened in the QI program. Data was analyzed from March to July 2022. Exposures: BP evaluation and preeclampsia symptoms screening were performed at the time of the well-child visit. A management algorithm-with criteria for routine or early postpartum visits, or prompt referral to the obstetric emergency department-was followed. Main Outcome and Measures: Readmission due to postpartum preeclampsia. Comparisons across groups were performed using a Fisher exact test for categorical variables, and t tests or Mann-Whitney tests for continuous variables. Results: A total of 595 individuals (mean [SD] age, 27.2 [6.1] years) were eligible for analysis in the preintervention cohort and 565 individuals (mean [SD] age, 27.0 [5.8] years) were eligible in the postintervention cohort. Baseline demographic information including age, race and ethnicity, body mass index, nulliparity, and factors associated with increased risk for preeclampsia were not significantly different in the preintervention cohort and postintervention QI program. The rate of readmission for postpartum preeclampsia differed significantly in the preintervention cohort (13 individuals [2.1%]) and the postintervention cohort (29 individuals [5.6%]) (P = .007). In the postintervention QI cohort, there was a significantly earlier time frame of readmission (median [IQR] 10.0 [10.0-11.0] days post partum for preintervention vs 7.0 [6.0-10.5] days post partum for postintervention; P = .001). In both time periods, a total of 42 patients were readmitted due to postpartum preeclampsia, of which 21 (50%) had de novo postpartum preeclampsia. Conclusions and Relevance: This QI program allowed for increased and earlier readmission due to postpartum preeclampsia. Further studies confirming generalizability and mitigating associated adverse outcomes are needed.

Trichomonas Vaginalis Infections Among Youth in Detention in the Southeastern United States.

Most juvenile detention facilities do not screen for Trichomonas Vaginalis (TV) despite being the most common parasitic STI. We aimed to assess TV prevalence and risk factors among young women in a large urban juvenile detention center. We evaluated a retrospective cohort from April to December 2016. Youth submitted an intake urine sample for gonorrhea and chlamydia testing; we tested remnant urine for TV. Outcomes included prevalence of TV and risk factors for infection. A total of 1009 samples were collected, 374 from young women ages 13 - 17 years old. Among females, 8% tested positive for TV with co-infection of either gonorrhea, chlamydia or both occurring in 12/29 (41%) patients. Compared to youth without TV females with TV were more likely to be African American (76%) and report symptoms (41%) (p<0.05). In our study population, prevalence of TV was 8%. As nearly half of those with TV were asymptomatic, we recommend routine screening among this population.

Fluoride Intake of Infants from Formula.

OBJECTIVE: This study aimed to assess fluoride intake in infants from formula reconstituted with water, with fluorosis risk in mind. STUDY DESIGN: Data on water source, formula brand/type, volume of formula consumption and infant weight were collected for infants at two-, four-, six-, nine- and twelve-month pediatrician well child visits. Identified formula brands and water types were reconstituted and analyzed for fluoride concentration. Patient body mass and volume consumed/day were used to estimate fluoride intake from reconstituted formula. Descriptive statistics, one-way analysis of variance and chi-square tests were utilized. RESULTS: All infants consumed formula reconstituted with minimally fluoridated water (0.0- 0.3 ppm). 4.4% of infants exceeded the recommended upper limit (UL) of 0.1mg/kg/day. Although mean daily fluoride consumption significantly differed among all groups, the proportion of infants at each visit milestone that exceeded daily fluoride intake of 0.1mg/kg/day was not statistically significantly different (p>0.05) for any age group. Predicted values calculated with optimally fluoridated water (0.7ppm) resulted in 36.8% of infants exceeding the UL. CONCLUSIONS: Optimally fluoridated water may increase fluorosis risk for patients younger than six months. Future investigation should include multiple sites and multi-year follow-up to assess actual fluorosis incidence.

Are Incoming Pediatric Interns Ready to Obtain the Essential Components of an Informed Consent for Lumbar Puncture?

OBJECTIVE: In 2013, the Association of American Medical Colleges created the "Core Entrustable Professional Activities (EPAs) for Entering Residency" to more clearly define the set of activities that entering residents should be able to perform on day 1 of residency without direct supervision. EPA #11 is obtaining informed consent for tests and/or procedures. This EPA acknowledges that an entrustable learner should be able to document a complete consent among other components. The aim of this study is to explore whether incoming pediatric interns demonstrated the behaviors of an "entrustable learner" in the domain of documenting informed consent for a common pediatric procedure. METHODS: All incoming interns in our program (2007-2017) completed a 6-station Objective Structured Clinical Examination during residency orientation. One of the scenarios involves obtaining parental consent for a lumbar puncture (LP). The researchers determined and agreed what components would be important for a complete and accurately documented consent. A retrospective review of the resident's written informed consents occurred looking for accuracy of documented components. RESULTS: Of the 258 consents reviewed, 8 were complete and accurate. Incoming interns appear to be skilled when completing the basics of the informed consent form such as documenting names, obtaining signatures, and correctly identifying the procedure. However, detailing all the risks of the LP were areas for which they did not demonstrate proficiency. CONCLUSIONS: Documenting informed consent is not adequately demonstrated by our learners prior to the beginning of internship. We would recommend specific training before entrusting pediatric interns to obtain LP consent independently.

Influence of Ethnicity on Parental Preference for Pediatric Dental Behavioral Management Techniques.

Purpose: The purpose of this study was to determine how ethnicity influences parental acceptability of behavior management techniques (BMTs) used during dental treatment of children. This is the first known study to compare ethnic differences in acceptance levels of the BMTs. Methods: Parental acceptance of 10 BMTs (tell-show-do, voice control, non-verbal communication, positive reinforcement, distraction, parental presence/absence, nitrous oxide, protective stabilization, sedation, and general anesthesia) was rated using a visual analogue scale (VAS) after watching vignettes of each technique. Parental preferences were stratified by ethnicity and analyzed. Results: Among the 104 parents (21 Caucasians, 29 Hispanics, 30 Asians, and 24 African Americans) who qualified and completed the study, we observed that, overall, non-invasive techniques (positive reinforcement and tell-show-do) were most accepted by parents, while invasive techniques (voice control and protective stabilization) were least accepted (P<0.001). Within each ethnicity, there were significant differences between the BMTs (P<0.001). Additionally, conscious sedation was the only BMT to show a significant difference between the ethnic groups (P=0.047), with Asian parents having a lower mean score than Caucasian and Hispanic parents. Conclusions: Our results suggest that considering the ethnic/cultural differences of patients and their parents is an instrumental component for pediatric dentists to provide quality care to children patients.

Epidemiology of Childhood Onset Essential Hypertension.

The knowledge of epidemiology of a disease is paramount in identifying preventive measures. Currently there is a paucity of literature on the epidemiologic determinants of childhood onset essential hypertension (EH). We evaluated children with EH, ascertained in a rigorous manner, in a large multiethnic population in a tertiary pediatric hypertension clinic. We enrolled children with and without EH and obtained data by in-person interview of their parents and by direct anthropometric measurements including blood pressures. A total of 148 children (76 hypertension probands, 72 control probands, and males 53%, mean age 12.2 ± 4.3 years) were enrolled. Of these 148 children, 51 pairs were matched 1:1 on ethnicity, gender and age (±2.5 years). In this study we evaluated the demographics, genetic predisposition and a variety of exposures including, socioeconomic, perinatal, lifestyle and environmental, between cases and controls. All measures were similar between cases and controls other than a significantly higher BMI (p = 0.01) and rates of obesity (p = 0.03), and a difference of near-significance in any family history of EH (p = 0.05) higher in cases compared to controls. The odds of obesity was 3.5 times higher among cases than controls. In this study, we evaluated a variety of prenatal and postnatal exposures that could potentially contributed to the EH phenotype in childhood. The findings of the study elucidate the epidemiology of EH in children and two important associated risk factors, any family history of hypertension and a higher body weight.

Familial aggregation of first degree relatives of children with essential hypertension.

PURPOSE: Determining familial aggregation is an important first step in narrowing the search for disease-causing genes and hence we determined the familial aggregation of EH among first degree relatives of children with EH. MATERIALS AND METHODS: We prospectively enrolled children with EH along with their first degree relatives from a tertiary pediatric hypertension clinic in a large ambulatory care center. We utilized rigorous methodology for blood pressure (BP) measurements and diagnoses of EH to reduce the heterogeneity in the phenotype. For those enrolled, parental BP status was confirmed by in-clinic direct BP measurements. We also enrolled control children without EH along with their first degree relatives from the same pediatric ambulatory center. RESULTS: In our case-control study of 153 families, the odds of having familial EH was more than 3 times higher among the cases than in controls (OR: 3.63, 95% CI: 1.85-7.12) with 71% of the cases and 41% of the controls reporting familial EH. One parent with EH was seen in 88% of the cases and 52% of the controls (OR: 6.92, 95% CI: 2.68-17.84). The odds of at least one parent (compared to neither) with EH was almost 7-fold higher, and odds of having two parents with EH was 14-fold higher among cases versus controls. The risk of EH did not go back from the first degree relative to the second degree relatives. CONCLUSIONS: We identified familial aggregation with an increased liability of childhood onset EH with parental EH. The risk of childhood onset EH is more than doubled in the presence of EH in both parents versus in a single parent. Prediction for childhood-onset EH is improved by obtaining a family history of EH in the first degree relatives.

Cross Talk: Evaluation of a Curriculum to Teach Medical Students How to Use Telephone Interpreter Services.

PURPOSE: Telephone interpretation and recent technology advances assist patients with more timely access to rare languages, but no one has examined the role of this technology in the medical setting and how medical students can be prepared for their use. We sought to determine if structured curriculum on interpretation would promote learners self-reported competency in these encounters and if proficiency would be demonstrated in actual patient encounters. METHODS: Training on the principles of interpreter use with a focus on communication technology was added to medical student education. The students later voluntarily completed a retrospective pre/post training competency self-assessment. A cohort of students rotating at a clinical site had a blinded review of their telephone interpretation encounters scored on a modified validated scale and compared to scored encounters with preintervention learners. Nested ANOVA models were used for audio file analysis. RESULTS: A total of 176 students who completed the training reported a statistically significant improvement in all 4 interpretation competency domains. Eighty-three audio files were analyzed from students before and after intervention. These scored encounters showed no statistical difference between the scores of the 2 groups. However, plotting the mean scores over time from each encounter suggests that those who received the curriculum started their rotation with higher scores and maintained those scores. CONCLUSIONS: In an evaluation of learners' ability to use interpreters in actual patient encounters, focused education led to earlier proficiency of using interpreters compared to peers who received no training.

Impact of individualized learning plans on United States senior medical students advanced clinical rotations.

The individualized learning plan (ILP) is a tool that promotes self-directed learning. The aim of this pilot study was to look at the perception of the ILPs in United States senior medical school students as a way to improve their learning experience during their advanced practice clerkship. We conducted a survey of graduating medical students that contained both quantitative and open-ended questions regarding the students' experiences with the ILP during their advanced practice clerkship from July 2014 to March 2016. We systematically identified and compiled themes among the qualitative responses. Responses from 294 out of 460 subjects were included for analysis (63.9%). Ninety students (30.6%) reported that the ILP was definitely reviewed at the midpoint and 88 (29.9%) at the final evaluation. One hundred sixty one students (54.8%) felt the ILP provided a framework for learning. One hundred sixty one students (61.6%) felt it was a useful tool in helping open a discussion between the student and faculty. The qualitative data was grouped by areas most mentioned and these areas of concern centered on lack of faculty knowledge about ILP, time to complete ILP, and uncertainty of appropriate goal setting. The majority of students perceive the ILP to be helpful. Our results suggest that active intervention is needed by dedicated and trained faculty to improve ILP utilization. It is recommended that faculty gives students examples of learning goals to create their own learning framework and encourages them to discuss and review the ILP.

Biobehavioral Factors in Child Health Outcomes: The Roles of Maternal Stress, Maternal-Child Engagement, Salivary Cortisol, and Salivary Testosterone.

BACKGROUND: Exposure to high levels of maternal stress and ineffective maternal-child engagement (MC-E) may adversely affect child health-related outcomes. OBJECTIVE: The aim of this study was to examine the impact of maternal stress and MC-E on maternal and child biological responses (salivary cortisol and testosterone) and child health outcome in mother-child dyads of preschool children (3-5.9 years) in a low socioeconomic setting. METHODS: Observational and biobehavioral data were collected from 50 mother-child dyads in a preschool setting. Assessments included maternal stress with the Perceived Stress Scale, child health outcomes with the Pediatric Quality of Life Inventory, and MC-E with videotaped mother-child interactions and scored with the Keys to Interactive Parenting Scale. Morning and evening saliva samples were collected from mother and child for biological assays. RESULTS: Maternal stress was negatively correlated with MC-E (r = -.32, p < .05) and child health outcome (r = -.33, p < .05). Lower levels of MC-E predicted higher morning cortisol (p = .02) and higher morning and bedtime testosterone levels in children (p = .03 and p = .04, respectively). Child biological responses did not predict child health outcome. DISCUSSION: Maternal stress and MC-E during mother-child interactions play a significant role in the regulation of child stress physiology and child health outcome. Elevated cortisol and testosterone related to high maternal stress and low MC-E may increase the child's vulnerability to negative health outcomes-if sustained. More biobehavioral research is needed to understand how parent-child interactions affect child development and health outcomes in early childhood.

Childhood-Onset Essential Hypertension and the Family Structure.

The prevalence and effect of single-parent families in childhood-onset essential hypertension (EH) is unknown. Children with EH and age-, sex-, and ethnicity-matched controls were enrolled. Family structure data were obtained by in-person interview. A total of 148 families (76 hypertension probands, 72 control probands; median 14 years) were prospective-ly enrolled in the study. Single-parent status was seen in 42% of the families--with and without EH (38% vs 46%, P=.41; odds ratio, 0.7; 95% confidence interval, 0.4-1.4). After multivariable analysis, a statistically significant sociofamilial contributor to the development of childhood-onset EH was not identified. A significant number of single-parent families (42%), the majority with single mothers, were found in our pedigree study. Sociofamilial factors are known to contribute to the expression of adult-onset EH, but findings in our study suggest that they appear to contribute less in the expression of childhood-onset EH.

Essential hypertension vs. secondary hypertension among children.

BACKGROUND: The aim was to determine the proportions and correlates of essential hypertension among children in a tertiary pediatric hypertension clinic. METHODS: We evaluated 423 consecutive children and collected demographic and clinical history by retrospective chart review. RESULTS: We identified 275 (65%) hypertensive children (blood pressure >95th percentile per the "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents") from 423 children referred to the clinic for history of elevated blood pressure. The remainder of the patients had normotension (11%), white coat hypertension (11%), prehypertension (10%), and pending diagnosis (3%). Among the 275 hypertensive children, 43% (n = 119; boys = 56%; median age = 12 years; range = 3-17 years) had essential hypertension and 57% (n = 156; boys = 66%; median age = 9 years; range = 0.08-19 years) had secondary hypertension. When compared with those with secondary hypertension, those with essential hypertension had a significantly older age at diagnosis (P = 0.0002), stronger family history of hypertension (94% vs. 68%; P < 0.0001), and lower prevalence of preterm birth (20% vs. 46%; P < 0.001). There was a bimodal distribution of age of diagnosis in those with secondary hypertension. CONCLUSIONS: The phenotype of essential hypertension can present as early as 3 years of age and is the predominant form of hypertension in children after age of 6 years. Among children with hypertension, those with essential hypertension present at an older age, have a stronger family history of hypertension, and have lower prevalence of preterm birth.

Variability of the institutional review board process within a national research network.

OBJECTIVE: To determine the variability of the institutional review board (IRB) process for a minimal risk multicenter study. METHODS: Participants included 24 Continuity Research Network (CORNET) sites of the Academic Pediatric Association that participated in a cross-sectional study. Each site obtained individual institutional IRB approval. An anonymous questionnaire went to site investigators about the IRB process at their institution. RESULTS: Twenty-two of 24 sites (92%) responded. Preparation time ranged from 1 to 20 hours, mean of 7.1 hours. Individuals submitting ≤3 IRB applications/year required more time for completion than those submitting >3/year (P < .05). Thirteen of 22 (59%) study sites received approval with "exempt" status, and 6 (27%) approved as "expedited" studies. CONCLUSIONS: IRB experiences were highly variable across study sites. These findings indicate that multicenter research projects should anticipate barriers to timely study implementation. Improved IRB standardization or centralization for multicenter clinical studies would facilitate this type of practice-based clinical research.

Junk food seen at pediatric clinic visits: is it a problem?

OBJECTIVE: To document the prevalence of junk foods seen at clinic visits. DESIGN: A cross-sectional 23-item survey of observed food items were completed by medical staff using a convenience sample of families from June 2, 2011 to March 2, 2012. SETTING: The study was conducted in pediatric clinics affiliated with the University of Texas Medical School at Houston. PARTICIPANTS: A convenience sample consisting of 738 families with children from 4 months to 16 years old presenting for visits were included in the study. Children exclusively breast and formula fed was excluded. RESULTS: Junk food was observed 20.9% at the clinic visits. CONCLUSIONS AND RELEVANCE: Junk food was often seen at clinic visits. There was a trend toward higher body mass index in patients whose families had junk food at the visit.

Comparing patients seen in pediatric resident continuity clinics and national ambulatory medical care survey practices: a study from the continuity research network.

OBJECTIVES: The goal was to compare visit data from Continuity Research Network practices with data for a nationally representative sample of pediatric visits in practice settings from the National Ambulatory Medical Care Survey. METHODS: A cross-sectional study comparing data for Continuity Research Network practice visits during a 1-week period in 2002 with data from the 2000 National Ambulatory Medical Care Survey was performed. Continuity Research Network and National Ambulatory Medical Care Survey data were derived from 30 patient visits per practice site for patients < 22 years of age, with the primary care providers being residents and practicing pediatricians, respectively. RESULTS: Eighteen Continuity Research Network practices reported on 540 visits, compared with 32 National Ambulatory Medical Care Survey physicians reporting on 792 visits. Continuity Research Network patients were more likely to be black non-Hispanic or Hispanic/Latino and to have public insurance. The top 5 reasons for visits were the same for Continuity Research Network and National Ambulatory Medical Care Survey visits, although the orders varied slightly. These 5 reasons accounted for 58% of Continuity Research Network visits and 49% of National Ambulatory Medical Care Survey visits. Continuity Research Network visits were more likely to result in patient instructions to return at a specific time (78% vs 52%). CONCLUSIONS: Residents in Continuity Research Network practices provide care to more underserved patients but evaluate problems that are similar to those observed in office practices; the Continuity Research Network practices thus provide important training experiences for residents who will serve both minority and nonminority children.

The epidemiology of sexually transmitted infections in adolescents.

This article addresses the epidemiology of several common sexually transmitted infections (STIs) in adolescents. Chlamydia is a common occurrence in adolescents, more so than is gonorrhea, but both are of particular concern because they may cause pelvic inflammatory disease. Many experts recommend screening for chlamydia in sexually active adolescents, particularly females. Trichomonas vaginalis is significant as a marker for risk of contracting other STIs and because of its association with pregnancy complications and with increased risk of transmission of HIV. Genital herpes simplex virus (HSV) infection, which usually has been caused by HSV-2, is a common finding in adolescents, and it now is caused also by HSV-1 in some populations. Human papillomavirus (HPV), though widespread in adolescents, usually is a self-limited infection, and malignancy resulting from HPV is a rare occurrence in this age group. The least common of the diseases discussed below is syphilis, but a recent sharp increase in incidence has occurred in men who have sex with men.