Quality Improvement for Well Child Care

Presented to the Faculty of University of Alaska Anchorage in Partial Fulfillment of Requirements for the Degree of MASTER OF SCIENCEThe American Academy of Pediatrics (AAP) Bright Futures (BF) guidelines for well child care were designed to provide quality pediatric care. Adherence to AAP-BF guidelines improves: screenings, identification of developmental delay, immunization rates, and early identification of children with special healthcare needs. The current guideline set is comprehensive and includes thirty one well child exams, thirty three universal screening exams and one hundred seventeen selective screening exams. Many providers have difficulty meeting all guideline requirements and are at risk of committing Medicaid fraud if a well exam is coded and requirements are not met. The goal of this quality improvement project was to design open source and adaptable templates for each pediatric age group to improve provider adherence to the BF guidelines. A Plan-Do-Study-Act (PDSA) quality improvement model was used to implement the project. Templates were created for ages twelve months to eighteen years and disseminated to a pilot clinic in Anchorage, Alaska. The providers were given pre-implementation and postimplementation surveys to determine the efficacy and usefulness of the templates. Templates were determined to be useful and efficient means in providing Bright Futures focused well child care. The templates are in the process of being disseminated on a large scale to assist other providers in meeting BF guideline requirements.Title Page / Table of Contents / List of Tables / List of Appendices / Abstract / Introduction / Background / Clinical Significance / Current Clinical Practice / Research Question / Literature Review / Framework: Evidence Based Practice Model/ Ethical Considerations and Institutional Review Board / Methods / Implementation Barriers / Findings / Discussion / Disseminatio

Pressures and Preferences Affecting Willingness to Apply Beef Manure on Crops in the Colorado High Plains

Little is known about producers' willingness to use manure. Past studies have focused on substitutability for fertilizers. We surveyed crop producers in a cattle-dense region of the Colorado Plains about whether and why they apply manure, focusing on how pressures (like owning cattle) or preferences (pro and con) affect their adoption. Using logistic regression, findings show that pressure and preference (PS/PF) significantly affect adoption. A producer with high PS/PF was 10 times more likely to use manure than one with low PS/PF. Policy and decision makers can use such findings to inform education and policy aimed at increasing the land application of manure.cattle, economic benefits, economic costs, management, manure application, Crop Production/Industries,

Role of Social Media in Adolescent-Parent Relationships Among At-Risk Youths

This study aimed to understand the role of adolescent and parent social media use on adolescents reported at-risk behaviors, as well as the role of social media among at-risk youths and their parents. Semi-structured interviews, based on interpretive phenomenological analysis, were utilized with six pairs of individuals resulting in 12 total participants. Each pair consisted of an adolescent between the ages of 13 and 17 along with their parent. Data analysis resulted in three themes: encountering negativity on social media did not refrain the adolescent from social media usage, misunderstanding of the parent regarding social media and technology caused challenges in parental monitoring, and the quality of time spent together differed in the perception of the adolescent participants and parent participants. The findings of this study suggest that even though participant pairs reported encountering negativity on social media, they continue to use social media, and parent participants are unaware of the amount of time their adolescent spends on social media, which could be contributed to the lack of quality time they spend with one another. The findings of this research add to the current literature regarding social media and the impact it has on the parent-adolescent relationship among at-risk youth

Exploring root rot pathogens in wheat-pea rotations in Kansas

In 2018, over 277,000 bushels of wheat were produced on 7.7 million acres of land in Kansas alone. Based on the price of wheat by the end of 2018, this accounted for $1.44 million. This wheat is normally rotated with soybeans or fallow, but recent interest has arisen regarding the growth of peas in northern Kansas. As of 2019, there are both research and commercial growing operations underway. Many plant diseases have been especially prevalent during the summer because of the high rainfall and heat. In order to assess the severity of pea disease in Kansas, as well as explore potential interconnectivity between wheat and pea pathogens, a survey was conducted, and efforts were made to isolate and culture fungal pathogens of both wheat and pea

Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt.

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement

Metastatic Pancreatic Adenocarcinoma During Pregnancy.

We present a rare case of metastatic pancreatic adenocarcinoma diagnosed antepartum. A high index of suspicion must be maintained to diagnose pancreatic cancer during pregnancy. We recommend a thorough history and physical and aggressive pursuit of sensitive imaging in patients with persistent symptoms. If pancreatic adenocarcinoma is diagnosed, a multidisciplinary approach that focuses on patient goals should be undertaken. The effect of pregnancy on tumor growth rates is unknown

Sexual Wellness and Rare Disease Considerations: A Behavioral Case Conceptualization and Approach to Counseling Treatment

Sexual wellness is infrequently addressed with individuals with a rare disease. Counselors must be competent in working with sexual wellness issues, especially those related to medical conditions, since clients may not share those concerns with healthcare providers. This article presents a case scenario involving a client living with a rare disease called Hereditary Angioedema, the symptoms of which present challenges to her intimate and sexual relationship with her partner due to unpredictable and painful swelling. A behavioral theoretical lens is used to conceptualize the case scenario and inform treatment. Implications for counselor competency, interdisciplinary collaboration, and client empowerment toward advocacy are discussed

Increasing Social Interaction Using Prelinguistic Milieu Teaching With Nonverbal School-Age Children With Autism

Purpose: Children with autism display marked deficits in initiating and maintaining social interaction. Intervention using play routines can create a framework for developing and maintaining social interaction between these children and their communication partners. Method: Six nonverbal 5- to 8-year-olds with autism were taught to engage in social interaction within salient play routines. Prelinguistic milieu teaching (PMT) techniques were used to teach the children to communicate intentionally during these routines. Intervention focused on the children's social interaction with an adult. The effects of intervention were evaluated using a multiple baseline design across participants. Results: At study onset, the participants demonstrated few consistent interaction with others. With intervention, all of the children improved their ability to sustain social interactions, as evidenced by an increase in the number of communicative interactions during play routines. Participants also increased their overall rate of initiated intentional communication. Conclusion: Development of intentional prelinguistic communication within salient social routines creates opportunities for an adult to teach social and communication skills to young school-age children with autism who function at a nonverbal level.Communication Sciences and Disorder

Efficacy of Marketing Strategy for REACH Vitamins

According to the 2009 Global Report, Vitamin A supplementation in children reduces the death rate by 23% in populations at risk of deficiency. REACH Vitamins is a for-profit business that provides a one-year supply of vitamin A to children in underprivileged countries for each bottle of vitamins A, B, C, D, or the multivitamin purchased. The primary objective of this exploratory, qualitative study is to determine if there is a more appropriate marketing strategy for REACH Vitamins compared to the current marketing strategy used. The secondary objective is to determine if REACH Vitamins’ charity motivates consumers to purchase their products. Sample size will not be determined before testing is underway. Participants must be 18 years or older and be able to read and understand English. Physicians, pharmacists, and consumers from southern Ohio will be interviewed in focus groups for their opinions on the best vitamin marketing strategies. Questions will be open-ended and intended to invoke discussion in the group. Notes from the focus group will be written and recorded using Livescribe software. Data will be entered into the program NVivo. Data collection begins in the Fall of 2014

Loss of the PTCH1 tumor suppressor defines a new subset of plexiform fibromyxoma.

BackgroundPlexiform fibromyxoma (PF) is a rare gastric tumor often confused with gastrointestinal stromal tumor. These so-called "benign" tumors often present with upper GI bleeding and gastric outlet obstruction. It was recently demonstrated that approximately one-third of PF have activation of the GLI1 oncogene, a transcription factor in the hedgehog (Hh) pathway, via a MALAT1-GLI1 fusion protein or GLI1 up-regulation. Despite this discovery, the biology of most PFs remains unknown.MethodsNext generation sequencing (NGS) was performed on formalin-fixed paraffin-embedded (FFPE) samples of PF specimens collected from three institutions (UCSD, NCI and OHSU). Fresh frozen tissue from one tumor was utilized for in vitro assays, including quantitative RT-PCR and cell viability assays following drug treatment.ResultsEight patients with PF were identified and 5 patients' tumors were analyzed by NGS. An index case had a mono-allelic PTCH1 deletion of exons 15-24 and a second case, identified in a validation cohort, also had a PTCH1 gene loss associated with a suspected long-range chromosome 9 deletion. Building on the role of Hh signaling in PF, PTCH1, a tumor suppressor protein, functions upstream of GLI1. Loss of PTCH1 induces GLI1 activation and downstream gene transcription. Utilizing fresh tissue from the index PF case, RT-qPCR analysis demonstrated expression of Hh pathway components, SMO and GLI1, as well as GLI1 transcriptional targets, CCND1 and HHIP. In turn, short-term in vitro treatment with a Hh pathway inhibitor, sonidegib, resulted in dose-dependent cell killing.ConclusionsFor the first time, we report a novel association between PTCH1 inactivation and the development of plexiform fibromyxoma. Hh pathway inhibition with SMO antagonists may represent a target to study for treating a subset of plexiform fibromyxomas