Perceptions and Use of E-cigarettes among Young Adults with Cystic Fibrosis: An Observational Study.

While smoking prevalence has decreased among the general population, the use of electronic cigarettes (E- cigarettes) has risen significantly and can cause significant lung injury. We sought to determine if persons with cystic fibrosis (PwCF) have similar rates of E-cigarette use as compared with age-matched peers, and to understand perceptions of E-cigarette safety through a survey-based study. A total of 29 PwCF and 26 age-matched control patients participated in this study. There was no significant difference between PwCF and control patients regarding perceptions of the negative impact of E-cigarette use on one's health. Overall, both PwCF and control patients reported a good quality of life. PwCF were equally likely to identify E-cigarettes as harmful to one's lung health as healthy controls but were significantly more likely to have heard of EVALI. While small, our study has demonstrated the need for further education of both PwCF and healthy young adults.

Combined Medicine-Pediatrics Fellowships: A Guide for Fellowship Directors and Residents.

Dual training in Internal Medicine-Pediatrics (MedPeds) was recognized by the American Board of Medical Specialties in 1967. Residents complete 24 months each in Internal Medicine and Pediatrics and are board-eligible for both at the conclusion of training. Graduates are eligible for fellowships in either or both fields. Many graduates pursue fellowship training. A small absolute number of graduates apply for dual training in adult and pediatric subspecialties, but those that do bring direct, in-depth clinical experience across the lifespan, and familiarity with care in both pediatric and adult settings. As such, they contribute unique perspectives and capabilities to their fellowship and future practice. This includes the ability to provide subspecialty care in settings with limited resources, where they are able to address needs without age restrictions, and in the transition of subspecialty care for emerging adults with childhood-onset conditions. Due to the small number of applicants pursuing joint adult and pediatric fellowships, many fellowship directors may have limited experience with dual fellowships but may want to create opportunities for these unique trainees. This summary was developed jointly by residents, fellows, MedPeds program directors, and fellowship directors in Pediatrics and Internal Medicine subspecialties, and approved by their respective leadership councils to offer some key points on common questions, suggest additional resources, and share best practices, with a goal of facilitating this process for fellowship programs and residents alike.

AAIM Recommendations for the 2020-2021 Internal Medicine Residency Application Cycle in Response to the COVID-19 Pandemic.

This statement was released in June 2020 by the Alliance for Academic Internal Medicine to provide guidance for the 2020-2021 residency application cycle in light of the COVID-19 pandemic. While many of the recommendations are specific to this cycle, others, such as the Department Summary Letter of Evaluation, are meant to be an enduring change to the internal medicine residency application process. AAIM realizes that some schools may not yet have the tools or resources to implement the template fully this cycle and look toward collaboration within the internal medicine education community to facilitate adoption in the cycles to come.

Double Crossed: A Case of La Crosse Encephalitis.

CASE REPORT: A 10-year-old male with T1DM and recent travel to North Carolina presented to an ED with 1 day of fever, vomiting, and headaches. He was discharged home with the presumptive diagnosis of viral gastroenteritis but returned nine hours later, agitated, and unable to speak. CSF showed pleocytosis. MRI brain was normal, and EEG showed intermittent seizures. He was started on antiepileptics. Antibiotics were discontinued after negative bacterial work-up. Repeat MRI brain one week later showed enhancement in the left cerebral cortex. IVIG was started due to concern for autoimmune encephalitis. Repeat lumbar puncture was positive for La Crosse virus IgM. DISCUSSION: This is the first case of La Crosse encephalitis (LACe) reported in Rhode Island.1 La Crosse virus (LACv) is a ssRNA Bunyavirus transmitted by the eastern tree-hole mosquito typically between July and September. LACv is endemic to the upper Midwestern US and Appalachia. In 2018, 81 of 86 total cases reported by the CDC were pediatric. Children are more likely to present with vomiting, seizures, and focal cortical inflammation or cerebral edema on brain imaging. IgM may be negative early in the disease course. Treatment is antiepileptics and supportive care.

Here, There and Nowhere: Following Adult Survivors of Childhood Cancer A Case Report of Recurrent Osteosarcoma in a Young Adult.

Approximately 1 in 285 children in the United States (US) will be diagnosed with cancer before the age of 20.1 More than 80% of children diagnosed with cancer will become long-term survivors.2 As of January, 2010, there are more than 380,000 adult survivors of childhood cancer in the US.3 More than two-thirds of survivors will develop chronic conditions.4 Professional organizations have advocated for specialized risk-based care of survivors.5 Locally and nationally, lack of transition services and insurance coverage are barriers to care of these adult survivors.6 We describe one such case to illustrate these challenges and their impact. [Full article available at http://rimed.org/rimedicaljournal-2016-08.asp, free with no login].

Transitions to Adult Care for Rhode Island Youth with Special Healthcare Needs.

The transitioning of youth from pediatric to adult care systems is often fraught with discontinuity, miscommunication and gaps in care. This is most significant for youth with special health care needs. A panel discussion on transitioning youth to adult care systems that was part of a learning collaborative held by The RI Care Transformation Collaborative (CTC) is presented here, illustrated by a pertinent case of a youth with type 1 diabetes. [Full article available at http://rimed.org/rimedicaljournal-2016-08.asp, free with no login].

International and Interdisciplinary Identification of Health Care Transition Outcomes.

IMPORTANCE: There is a lack of agreement on what constitutes successful outcomes for the process of health care transition (HCT) among adolescent and young adults with special health care needs. OBJECTIVE: To present HCT outcomes identified by a Delphi process with an interdisciplinary group of participants. DESIGN, SETTING, AND PARTICIPANTS: A Delphi method involving 3 stages was deployed to refine a list of HCT outcomes. This 18-month study (from January 5, 2013, of stage 1 to July 3, 2014, of stage 3) included an initial literature search, expert interviews, and then 2 waves of a web-based survey. On this survey, 93 participants from outpatient, community-based, and primary care clinics rated the importance of the top HCT outcomes identified by the Delphi process. Analyses were performed from July 5, 2014, to December 5, 2014. EXPOSURES: Health care transition outcomes of adolescents and young adults with special health care needs. MAIN OUTCOMES AND MEASURES: Importance ratings of identified HCT outcomes rated on a Likert scale from 1 (not important) to 9 (very important). RESULTS: The 2 waves of surveys included 117 and 93 participants as the list of outcomes was refined. Transition outcomes were refined by the 3 waves of the Delphi process, with quality of life being the highest-rated outcome with broad agreement. The 10 final outcomes identified included individual outcomes (quality of life, understanding the characteristics of conditions and complications, knowledge of medication, self-management, adherence to medication, and understanding health insurance), health services outcomes (attending medical appointments, having a medical home, and avoidance of unnecessary hospitalization), and a social outcome (having a social network). Participants indicated that different outcomes were likely needed for individuals with cognitive disabilities. CONCLUSIONS AND RELEVANCE: Quality of life is an important construct relevant to HCT. Future research should identify valid measures associated with each outcome and further explore the role that quality of life plays in the HCT process. Achieving consensus is a critical step toward the development of reliable and objective comparisons of HCT outcomes across clinical conditions and care delivery locations.

Transition of adolescents with chronic health conditions to adult primary care: factors associated with physician acceptance.

PURPOSE: To assess the willingness of adult primary-care physicians to transfer young adults with special health care needs (YASHCN) into their practices, and the relative impact of patient characteristics and transition supports. METHODS: Survey of primary care internists and family practitioners using randomized patient characteristics and transition supports in clinical vignettes to assess physician willingness to accept a YASHCN into their practice. RESULTS: 404 responses were received from 601 surveys (response rate 67%). Only 44% rated themselves "willing" or "enthusiastic" to accept a YASHCN. Using four-way ANOVA testing, provider and practice characteristics significantly associated with willingness to accept included gender, years in practice, presence of YASHCN in current practice and whether the practice was accepting new patients. Patient condition and transition support significantly affected willingness to accept; training in internal medicine versus family practice did not. CONCLUSION: Physicians providing primary care for adults express limited willingness to accept YASHCN into their practices. Provider, practice and patient characteristics affected willingness to accept. Although transition supports affected willingness to accept, effects varied markedly across diagnoses and physician gender. Findings have implications for patients and healthcare teams and policy planners.

Health care transition for adolescents with special health care needs: a report on the development and use of a clinical transition service.

BACKGROUND: A growing population of adolescents with special healthcare needs is aging into adulthood. These emerging adults face the transition challenges of their healthy peers but also potentially heightened risks and challenges related to their conditions. We describe the process of developing a pilot program to support healthcare services for emerging adults with chronic conditions and present preliminary data on utilization. RESULTS: An outpatient multidisciplinary consult model was developed based on patient, family and physician feedback. Patients with diverse conditions were equally referred from primary care, subspecialists and families and community agencies. Services provided included needs assessments (100%), referral to adult physicians (77%), care coordination (52%) and referrals to adult community services (10%). Clinical billing did not fully support the cost of providing services. CONCLUSION: The pilot program offered multidisciplinary transition services that were utilized by a diverse patient population. Local and national resources for health care transition are provided.

Health screening of newly resettled refugees in a primary care setting.

Since October 2008, the Medicine/Pediatrics Primary Care Center (MPPCC) has been working with Rhode Island's refugee resettlement agency to coordinate medial care for newly resettled adults and adolescent refugees. The process includes obtaining extensive screening labs and providing immunizations. This review discusses the results of selected screening tests for latent TB, stool parasites, vitamin D, and vaccine-preventable diseases, such as hepatitis, performed as part of the initial intake exam during the first two years of operation of the MPPCC Refugee Clinic.

Unmet dental needs and barriers to care for children with significant special health care needs.

PURPOSE: The purpose of this study was to conduct the first known large scale survey of parents of children with special health care needs (CSHCN) to determine their child's: oral health status; access to dental care; perceived barriers (environmental/system and nonenvironmental/family); and oral health quality of life, accounting for each child's medical diagnosis and severity of diagnosis. METHODS: A 72-item survey was sent to 3760 families of CSHCN throughout urban and rural Massachusetts. RESULTS: The study yielded 1,128 completed surveys. More than 90% of the children had seen a dentist within the past year; 66% saw a pediatric dentist, and 21% needed intense behavioral interventions. Although most families had high education levels, private dental insurance, and above average incomes, 20% of CSHCN had an unmet dental need. Children with craniofacial anomalies had twice as many unmet needs and children with cystic fibrosis had fewer unmet needs. Children with cerebral palsy, autism, developmental delay, and Down syndrome had more aversions to dental treatment, more treatment complications posed by their medical conditions, and more difficulty finding a dentist willing to provide care. Children with cystic fibrosis, metabolic disorders, or hemophilia encountered fewer barriers to care. CONCLUSIONS: The data paint a picture of high unmet dental needs with subpopulations of children with special health care needs who are more at risk for system barriers and internal family barriers to care based on their medical diagnoses.

Improving transition from pediatric to adult cystic fibrosis care: lessons from a national survey of current practices.

OBJECTIVES: More than 500,000 adolescents with special health care needs age into adulthood each year in the United States, and there is growing recognition of the need for support of their transition to adult-oriented health care. Because of improved survival, cystic fibrosis has experienced this increasing transition need, and cystic fibrosis policy leaders responded by mandating the transition of adults with cystic fibrosis to adult-focused cystic fibrosis care programs by 2000. The primary objective of this study was to characterize in detail recent transition practices at US cystic fibrosis programs, to identify areas for improvement and to serve as a model for other diseases. A secondary objective of this study was to develop and validate a survey for formal assessment of transition practices. METHODS: A 105-question survey on key aspects of transition was administered to cystic fibrosis care team members from all 195 US Cystic Fibrosis Care programs. Rates of adherence to recommended components of transition care were measured. RESULTS: A total of 448 surveys were obtained from 170 (87%) of 195 cystic fibrosis programs. Although transfer of care occurs at a median age of 19 years, initial discussion of transition does not occur until a median age of 17 years, limiting time to foster self-care skills. Only half of programs consistently perform a transition readiness assessment, 28% of centers offer visits focused on transition, and <10% have a written list of desirable self-management skills. CONCLUSIONS: There is significant variability in transition support provided to young adults with cystic fibrosis, but there are simple steps that may lead to more consistent delivery of transition services. Methods of assessment and lessons learned from transitioning young adults at US cystic fibrosis programs may serve to improve transition for individuals with other childhood diseases.