Use of the AAP CATCH Grant Process to Increase Healthcare Provider Support for Breastfeeding in Rural Appalachia

Purpose Breastfeeding affords numerous benefits for mothers, infants, families, and communities. Rates of breastfeeding are disproportionately low in rural Appalachia. We will describe how use of the AAP CATCH Grant process aided in building a community breastfeeding coalition, conducting a breastfeeding support needs assessment, and developing interventions to promote and support breastfeeding in the region. Methods In 2005, members of a multidisciplinary regional breastfeeding coalition in Northeast Tennessee wrote and received an AAP CATCH Planning Grant. Funds supported regular meetings of the coalition, a needs assessment consisting of surveys and focus groups conducted with patients and healthcare providers in the region during 2007-2008, and dissemination of the group\u27s findings and recommendations. Patient participants were recruited from three health departments and one Pediatric clinic in the region. Provider participants were recruited from three regional professional conferences. Surveys were entered into and analyzed using SPSS 17. Recordings of focus groups were transcribed and transcripts were reviewed to identify themes. Results 19 pregnant women in their second and third trimesters of pregnancy, 38 new mothers, and 58 healthcare providers completed a survey. Fifty five percent of new mothers reported ever having breastfed their baby. Thirty seven percent of healthcare providers identified Pediatrics, 21% Obstetrics and Gynecology, and 37% Family Medicine/Primary Care as their primary specialty. 52.6% and 81.6% of pregnant women and new mothers, respectively, reported that their healthcare provider had encouraged breastfeeding. Patients described that their healthcare providers discussed little about breastfeeding other than its benefits. Eighty-four percent of providers reported usually recommending exclusive breastfeeding during the first month of life. Only forty-eight percent of providers considered their advice on breastfeeding to be very important to mothers. Twenty-five percent of providers felt that exclusive breastfeeding for the first sixth months of life is unrealistic for many of their patients. The most commonly cited barrier by providers was that mothers had already decided not to breastfeed before they encountered them. Lack of time and lack of referral resources were other common barriers reported. Providers expressed the lowest levels of confidence in their own skills in evaluating latch, resolving problems of low milk production and breast tenderness, and knowing what referral services exist. Conclusion Patients in this sample described receiving little information about breastfeeding from their healthcare provider. Many health care providers in this region do not recognize the importance of their advice on breastfeeding and feel that breastfeeding is unrealistic for many of their patients. The use of study results by a community breastfeeding coalition to increase community awareness of the importance of breastfeeding promotion and support and to address provider concerns about barriers and educational needs will be discussed

The Role of Glutathione and Its Precursors in Type 2 Diabetes

Type 2 diabetes (T2D) is a major worldwide health crisis affecting about 6.2% of the world’s population. Alarmingly, about one in five children in the USA have prediabetes. Glutathione (GSH) and its precursors play a promising role in the prevention and management of type T2D. Oxidative stress (OxS) is a probable factor in both T2D initiation and progression. GSH is the major cytosolic water-soluble chemical antioxidant and emerging evidence supports its role in improving T2D outcomes. Dietary supplementation with N-acetyl-cysteine (NAC) and/or glycine (GLY), which are GSH precursors, has also been studied for possible beneficial effects on T2D. This review will focus on the underlying pathophysiological and molecular mechanisms linking GSH and its precursors with T2D and OxS. In addition to their traditional antioxidant roles, the in vivo effects of GSH/NAC/GLY supplements will be evaluated for their potential abilities to modulate the complex pro-oxidant pathophysiological factors (e.g., hyperglycemia) driving T2D progression. Positive feedback loops that amplify OxS over long time intervals are likely to result in irreversible T2D micro- and macro-vascular damage. Most clinical studies with GSH/NAC/GLY have focused on adults or the elderly. Future research with pediatric populations should be a high priority since early intervention is critical

Evaluation and Utilization of a Pediatric Internet Curriculum

Background: In recent years, the Accreditation Council for Graduate Medical Education (ACGME), and the Ambulatory Pediatric Association (APA) have developed detailed resident learning objectives and competencies. Maintaining adequate documentation that residents are fulfilling these objectives and competencies is a challenge. Objectives: To develop and evaluate use of an internet based curriculum, EPIC (East Tennessee Pediatric Internet Curriculum) to facilitate teaching and evaluation of the core competencies. Methods: Goals and content for the site were developed based on literature review and input from a pediatric internet committee. Resident internet-based learning is being evaluated using pre- and post- surveys over a six month period. Results: EPIC is a central location for residents to access information, including announcements, phone lists, and scheduling information. Educational content is organized around the six core competencies for resident education. For example, “Medical Knowledge”consists of a portfolio system developed for the ambulatory clinic. Portfolios include a checklist of pertinent information to be covered during a patient encounter and a related downloadable article to enhance resident knowledge. The section also includes links to other learning resources. An interactive discussion forum exists to facilitate discourse on medical and residency-related topics. Residents also complete online pre- and post- test questions during every clinical rotation and receive instant feedback on their responses. All 11 residents completed the pre-survey. Frequent or very frequent internet use was reported by 54% of residents to answer specific clinical questions and 45% of residents for general medical learning during the work day. Conclusion: Pediatric residents already utilize the internet to access medical information. EPIC accommodates residents’varying schedules and is a useful adjunct to other teaching and evaluation methods

Let’s Give Them Something to Talk About: Assessment of Communication Skills in Pediatric Residents

Objective To assess whether utilization of a validated communication tool corresponds with faculty assessment and resident self-assessment on the pediatric communication milestone continuum. Methods Pediatric residents were recruited to participate in the communication skills assessment. Continuity clinic faculty completed an assessment of each residents communication skills utilizing the 6 pediatric milestones that address interpersonal and communication skills. Each participating resident completed a self-assessment of their own communication skills utilizing the same milestones. After being placed on the milestones, the residents participated in a standardized patient interview that was recorded and subsequently evaluated by a faculty observer utilizing the Common Ground Instrument. Results 16/16 of pediatric residents participated in the study. The milestones and common ground instrument were scored on a scale from 1 to 5 with 5 representing an expert rating. For PGY-1 residents, the average faculty score on the milestones was 3.17, self-assessed average score was 2.92 and common ground average score was 3.67. For PGY-2 residents, the average faculty score on the milestones was 4.40, self-assessed score average was 4.10 and common ground average score was 3.20. For PGY-3 residents, the average faculty score on the milestones was 4.70, self-assessed score average was 4.10 and common ground average score was 3.60. PGY-1s had significantly lower self and faculty assessments than PGY-2s or -3s. There were no significant differences among PGYs on the Common Ground Interview score. Faculty rated residents significantly higher than they rated themselves. Previous clinical skills training, standardized patient training, and English as a first language had no significant effect on the self-assessment, faculty assessment or Common Ground Instrument score. Conclusion Faculty and residents observe an improvement in communication skills as residents progress through training; however, scores on a validated communication tool do not reflect this improvement

Evaluation and Utilization of a Pediatric Internet Curriculum

Background: In recent years, the Accreditation Council for Graduate Medical Education (ACGME), and the Ambulatory Pediatric Association (APA) have developed detailed resident learning objectives and competencies. Maintaining adequate documentation that residents are fulfilling these objectives and competencies is a challenge. Objectives: To develop and evaluate use of an internet based curriculum, EPIC (East Tennessee Pediatric Internet Curriculum) to facilitate teaching and evaluation of the core competencies. Methods: Goals and content for the site were developed based on literature review and input from a pediatric internet committee. Resident internet-based learning is being evaluated using pre- and post- surveys over a six month period. Results: EPIC is a central location for residents to access information, including announcements, phone lists, and scheduling information. Educational content is organized around the six core competencies for resident education. For example, “Medical Knowledge”consists of a portfolio system developed for the ambulatory clinic. Portfolios include a checklist of pertinent information to be covered during a patient encounter and a related downloadable article to enhance resident knowledge. The section also includes links to other learning resources. An interactive discussion forum exists to facilitate discourse on medical and residency-related topics. Residents also complete online pre- and post- test questions during every clinical rotation and receive instant feedback on their responses. All 11 residents completed the pre-survey. Frequent or very frequent internet use was reported by 54% of residents to answer specific clinical questions and 45% of residents for general medical learning during the work day. Conclusion: Pediatric residents already utilize the internet to access medical information. EPIC accommodates residents’varying schedules and is a useful adjunct to other teaching and evaluation methods

The Role of Natural Antioxidant Products That Optimize Redox Status in the Prevention and Management of Type 2 Diabetes

The worldwide prevalence of type 2 diabetes (T2D) and prediabetes is rapidly increasing, particularly in children, adolescents, and young adults. Oxidative stress (OxS) has emerged as a likely initiating factor in T2D. Natural antioxidant products may act to slow or prevent T2D by multiple mechanisms, i.e., (1) reducing mitochondrial oxidative stress, (2) preventing the damaging effects of lipid peroxidation, and (3) acting as essential cofactors for antioxidant enzymes. Natural antioxidant products should also be evaluated in the context of the complex physiological processes that modulate T2D-OxS such as glycemic control, postprandial OxS, the polyol pathway, high-calorie, high-fat diets, exercise, and sleep. Minimizing processes that induce chronic damaging OxS and maximizing the intake of natural antioxidant products may provide a means of preventing or slowing T2D progression. This “optimal redox” (OptRedox) approach also provides a framework in which to discuss the potential benefits of natural antioxidant products such as vitamin E, vitamin C, beta-carotene, selenium, and manganese. Although there is a consensus that early effective intervention is critical for preventing or reversing T2D progression, most research has focused on adults. It is critical, therefore, that future research include pediatric populations

Lone Ranger or Pit Crew? Evaluating the Impact of a Team-Based Care Curriculum for Pediatric Residents

Introduction: Efforts to improve health care in the US are focusing on the Quadruple Aim which targets enhanced patient experiences, population health management, control of costs and improved provider satisfaction. Traditional academic centers have fallen behind in preparing pediatricians to practice in this new milieu; pediatric residents consistently report feeling least competent in systems-based practice. To better prepare residents to enter the work force, we introduced a team based care curriculum for pediatric residents in the 2016-2017 academic year. Methods: Participants in the new curriculum included all 21 residents in our academic based residency program. An inter-professional team developed a curriculum consisting of six core modules: team care, team communication, quality improvement, health care roles, champion teams and advanced communications. Prior to participation, residents completed a pre-test of knowledge and the validated Attitudes Toward Health Care Teams scale. The same instruments were administered after completion of the modules. Results: All 21 pediatric residents completed the pre and post-tests. Resident knowledge significantly improved from a pre-test score of 63% to a post test score of 70% (p\u3c 0.05). The Quality Improvement and Team Roles subtests showed significant improvement (p\u3c0.05). On the Attitudes Towards Health Care Teams scale, the residents had a favorable attitude toward team value and team efficiency; these did not significantly change from pre to post-test. Pediatric residents’ attitudes toward physicians shared role in the team improved significantly (p\u3c0.01). They reported enhanced attitudes regarding two key constructs: 1) shared team leadership and responsibility and 2) limits on physician control of team function. Conclusions: While pediatric residents in general had a favorable view of team-based care, participation in a team-based care curriculum positively affected their views of the physician’s role on a team. Understanding shared labor within a team, may help residents to achieve the fourth Quadruple Aim of satisfaction in healthcare by all providers

The Systems Medicine of Cannabinoids in Pediatrics: The Case for More Pediatric Studies

INTRODUCTION: The legal and illicit use of cannabinoid-containing products is accelerating worldwide and is accompanied by increasing abuse problems. Due to legal issues, the USA will be entering a period of rapidly expanding recreational use of cannabinoids without the benefit of needed basic or clinical research. Most clinical cannabinoid research is focused on adults. However, the pediatric population is particularly vulnerable since the central nervous system is still undergoing developmental changes and is potentially susceptible to cannabinoid-induced alterations. RESEARCH DESIGN AND METHODS: This review focuses on the systems medicine of cannabinoids with emphasis on the need for future studies to include pediatric populations and mother-infant dyads. RESULTS AND CONCLUSION: Systems medicine integrates omics-derived data with traditional clinical medicine with the long-term goal of optimizing individualized patient care and providing proactive medical advice. Omics refers to large-scale data sets primarily derived from genomics, epigenomics, proteomics, and metabolomics

DETERMINING THE EFFICACY FOR TRAINING MEDICAL STUDENTS ON DOMESTIC VIOLENCE AND SEXUAL ASSAULT SURVIVOR SUPPORT

Domestic violence and sexual assault (DVSA) are major health issues on which medical schools across the country fail to adequately educate future physicians. According to the National Coalition Against Domestic Violence, one in three women and one in four men will be a victim of intimate partner violence in their lifetime. The same source reports that one in five women are raped in their lifetime. Because of the widespread nature of these societal problems, the aim of this research was to evaluate the benefit of providing medical students with DVSA education. First and second year medical students at the Quillen College of Medicine attended a mandatory educational lecture on DVSA. We designed a survey to assess the attitudes and knowledge surrounding patient care for DVSA survivors. Students volunteered to complete the same survey before and after the lecture. The surveys were evaluated for statistical significance. A paired t-test showed that the 128 students who took the survey reported a significant increase in comfort level on interviewing, performing a physical exam, and explaining resources to victims of DVSA. Questions regarding knowledge of who should lead exams and the role of emergency contraception in cases of sexual assault also showed statistically significant change by paired t-test analysis following the educational intervention. These findings suggest that medical schools should integrate curriculum on DVSA survivor support in order to increase comfort and knowledge of future physicians in addressing these sensitive topics