Evaluation of iron intake in preschool children in a setting with high anemia burden.

BACKGROUND: Iron deficiency anemia affects millions of children worldwide. Iron intake assessments can inform targeted interventions. METHODS: This cross-sectional study describes diet and hemoglobin levels of children 1-5 y of age in a resource-limited setting in the Dominican Republic. The study team performed meal observations and measurements, dietary questionnaires, and point-of-care hemoglobin testing. RESULTS: Iron intake and bioavailability were low, with liberal estimates indicating that not more than 40% of subjects consumed the recommended daily allowance for iron. Forty of 80 children had anemia, with 23% demonstrating moderate or severe anemia. CONCLUSIONS: Poor observed iron intake likely contributes to the high prevalence of anemia in this population.

A Better Learning Community: Mixed-Methods Reveal Medical Student Preferences with Implications for Learning Community Design and Implementation.

BACKGROUND: Medical school learning communities benefit students. The College of Medicine (COM) at the University of Arkansas for Medical Sciences (UAMS) provides medical students with academic, professional, and personal support through a learning community (LC) made of 7 academic houses. OBJECTIVES: To evaluate the effectiveness of the academic house model at UAMS utilizing a mixed-methods survey. The aims were to: (1) assess student experience and satisfaction with academic houses, (2) describe the realms of advising and guidance, and (3) identify areas for improvement. METHOD: An online survey was assigned to 723 COM students (all students enrolled, first through fourth years) at UAMS in March 2019. The survey was comprised of 25 items (10 multiple-choice, 8 on the Likert scale, and 7 open-ended questions). Data was depicted using frequency and percentages and/or thematic review of free-form responses. RESULTS: The survey response rate was 31% (227 students). The majority of students responding (132, 58.1%) attended 2 or more face-to-face meetings with the faculty advisor within the preceding year. However, 27 (11.9%) students did not have any meetings. Approximately two-thirds of the respondents were satisfied or very satisfied with the guidance and direction provided by their advisors [very satisfied (n = 83; 36.6%); satisfied (n = 77; 33.9%)]. Themes that emerged from student generated areas for improvement include time constraints, advisor/advisee interest mismatch, and perceived inadequacy of advising content/connections. CONCLUSIONS: This study confirms the effectiveness of the LC model for advising and mentoring in the COM at UAMS. Uniquely, this study identifies not only learners' satisfaction with their LC but also highlights areas for improvement which are widely generalizable and important to consider for institutions with or planning to start an LC.

A differential comes up short in a patient with shortness of breath.

Chronic obstructive pulmonary disease (COPD) exacerbation and allergic bronchopulmonary aspergillosis (ABPA), in spite of sharing common features such as airway inflammation, airflow obstruction, and mucus hypersecretion, differ significantly from each other. We report a case of ABPA that was unsuccessfully treated as a COPD exacerbation. The history of non-exertional progressive dyspnea, absence of a symptom-free interval, and hemoptysis combined with a minimal, distant smoking history and prior employment at a fertilizer plant favor a diagnosis other than COPD exacerbation. The patient's disease progression and delay in diagnosis testify to the sway of cognitive biases. This case serves as a reminder that generating a thorough differential diagnosis early in a patient's care prevents misdiagnoses and hastens the initiation of definitive therapy.

Evaluation of Iron Deficiency Anemia in a Pediatric Clinic in the Dominican Republic.

BACKGROUND: Iron deficiency and iron deficiency anemia affect billions of people worldwide. Infants and young children are the most vulnerable. The Niños Primeros en Salud pediatric clinic aims to follow the American Academy of Pediatrics (AAP) recommendation to screen all children at 12 months of age, a vital period for development and the time of greatest risk. OBJECTIVES: To evaluate the clinic's performance screening for, diagnosing, and treating iron deficiency anemia; and to describe the prevalence and severity of anemia in infants and children attending a perirural clinic in the Dominican Republic. METHODS: A total of 293 charts were reviewed for hemoglobin tests performed between 9 and 15 months of age. If a hemoglobin screening was performed, then sociodemographic characteristics, medical history, and laboratory data were collected. If blood tests revealed anemia, then the presence or absence of documented anemia diagnosis as well as the presence or absence of documented provision of iron therapy were recorded. FINDINGS: Less than one-third (87, 29.7%) of patients had a documented hemoglobin test performed in this age range. Of these, 89.6% indicated anemia and nearly half (48.6%) revealed moderate anemia. One-third (34%) of hemoglobin results revealing anemia were not accompanied by a documented diagnosis. The vast majority (86.5%) of results indicated microcytosis, yet just more than half (50.8%) of anemic patients received iron therapy. CONCLUSIONS: Many children at the clinic were not screened for iron deficiency anemia during the period of highest risk. In the participants screened, iron deficiency anemia was underdiagnosed and often untreated. Anemia is a significant burden in this community-one demanding reliable screening and universal supplementation.

Effectiveness of Computer Automation for the Diagnosis and Management of Childhood Type 2 Diabetes: A Randomized Clinical Trial.

Importance: Type 2 diabetes (T2D) is increasingly common in young individuals. Primary prevention and screening among children and adolescents who are at substantial risk for T2D are recommended, but implementation of T2D screening practices in the pediatric primary care setting is uncommon. Objective: To determine the feasibility and effectiveness of a computerized clinical decision support system to identify pediatric patients at high risk for T2D and to coordinate screening for and diagnosis of prediabetes and T2D. Design, Setting, and Participants: This cluster-randomized clinical trial included patients from 4 primary care pediatric clinics. Two clinics were randomized to the computerized clinical decision support intervention, aimed at physicians, and 2 were randomized to the control condition. Patients of interest included children, adolescents, and young adults 10 years or older. Data were collected from January 1, 2013, through December 1, 2016. Interventions: Comparison of physician screening and follow-up practices after adding a T2D module to an existing computer decision support system. Main Outcomes and Measures: Electronic medical record (EMR) data from patients 10 years or older were reviewed to determine the rates at which pediatric patients were identified as having a body mass index (BMI) at or above the 85th percentile and 2 or more risk factors for T2D and underwent screening for T2D. Results: Medical records were reviewed for 1369 eligible children (712 boys [52.0%] and 657 girls [48.0%]; median [interquartile range] age, 12.9 [11.2-15.3]), of whom 684 were randomized to the control group and 685 to the intervention group. Of these, 663 (48.4%) had a BMI at or above the 85th percentile. Five hundred sixty-five patients (41.3%) met T2D screening criteria, with no difference between control and intervention sites. The T2D module led to a significant increase in the percentage of patients undergoing screening for T2D (89 of 283 [31.4%] vs 26 of 282 [9.2%]; adjusted odds ratio, 4.6; 95% CI, 1.5-14.7) and a greater proportion attending a scheduled follow-up appointment (45 of 153 [29.4%] vs 38 of 201 [18.9%]; adjusted odds ratio, 1.8; 95% CI, 1.5-2.2). Conclusions and Relevance: Use of a computerized clinical decision support system to automate the identification and screening of pediatric patients at high risk for T2D can help overcome barriers to the screening process. The support system significantly increased screening among patients who met the American Diabetes Association criteria and adherence to follow-up appointments with primary care clinicians. Trial Registration: clinicaltrials.gov Identifier: NCT01814787.

Implementation of a Novel, Resident-Led, Nocturnal Curriculum.

BACKGROUND: Duty hour restrictions for resident physicians have led to radical changes in graduate medical education, including a shift to more night float rotations. These rotations have been viewed by residents as predominantly service focused with little opportunity for formalized education. OBJECTIVE: To develop and deliver a resident-driven, nocturnal curriculum to enhance the educational content and value of night float rotations. METHODS: The Hospital of the University of Pennsylvania is a 695-bed, tertiary care academic medical center. Upper-level internal medicine residents developed and peer-reviewed case-based scripts designed to be delivered in 15- to 20-minute teaching sessions. We evaluated the quality of teaching using anonymous, free-response surveys. RESULTS: Twenty-four scripts were developed that explored the differential diagnoses, diagnostic pitfalls, and management of clinical problems that interns frequently encounter on night float rotations. Of 83 eligible residents, 45 (54%) responded to the survey. Teaching occurred an average of 4 nights per week and was uniformly viewed as high yield and topical by night float interns. CONCLUSIONS: A resident-driven, nocturnal curriculum was implemented through the use of case-based teaching scripts, allowing for delivery of a standardized curriculum that capitalizes on the teaching opportunities afforded by the night shift. This intervention may serve as a model for nocturnal education in other departments and institutions.

Halide Effects in the Synthesis of Mixed Uranium(IV) Aryloxide-Halide Compounds.

Several uranium(IV) aryloxide and mixed aryloxide-halide compounds of the formula UX(4)(-)(z)()(OAr)(z)() (X = Cl, Br, I; OAr = 2,6-di-tert-butylphenoxide; z = 2, 3, 4) have been prepared by the reaction of KOAr with the appropriate uranium tetrahalide in tetrahydrofuran (THF). The complex UI(4)(CH(3)CN)(4) reacts with 2 equiv of KOAr in THF to yield the compound I(2)U(OAr)(2) (1). The utility of this reaction is limited by the instability of UI(4)(CH(3)CN)(4) in THF, however, and isolated yields of the THF adduct of 1 do not exceed 50%. In contrast, UBr(4)(CH(3)CN)(4) is stable in THF solution and reacts with 2 equiv of KOAr to yield the dibromide, Br(2)U(OAr)(2)(THF) (4.THF), in 77% yield. Under identical reaction conditions, UCl(4) reacts to yield the complex [K(THF)(4)][UCl(3)(OAr)(2)] (5) in 68% yield. The uranium center in compound 5 is coordinated by two trans aryloxide ligands and three chloride ligands in a trigonal bipyramidal arrangement. Two chloride ligands of each unit are also coordinated to a potassium ion, forming an infinite chain in the lattice. Compounds 1 and 5 will further react with 1 equiv of KOAr to yield the compounds XU(OAr)(3) (2, X = I; 6, X = Cl). Both UI(4)(CH(3)CN)(4) and UCl(4) will react with a 4.2 equiv of KOAr to yield the previously characterized compound U(OAr)(4) (3). The stability of the mixed aryloxide-halide uranium complexes toward ligand redistribution reactions has been investigated.