Betty B. Staples

Drug compliance in adolescents: assessing and managing modifiable risk factors.

Many studies have found that adolescence represents a problem in compliance with prescribed drug regimens. Multiple factors contribute to this problem, including the developmental evolution taking place in the adolescent physique and psyche. Health belief and patient demographic factors, inherent disease and regimen factors, as well as the dynamics between patient and provider may also contribute to problems with compliance to treatment.Simple interventions such as working with the teen to construct a tolerable treatment regimen, assessing anticipated compliance, discussing potential adverse effects, and establishing cues from the adolescent’s daily routine can positively impact treatment compliance.Healthcare providers should recognize the fact that psychosocial changes in an adolescent’s life can impact upon compliance with medications and enlist the help of their patients in constructing treatment regimens taking into account the individual’s lifestyle that may impact upon compliance. In particular, the healthcare provider should ask the adolescents what they anticipate their success with compliance to treatment might be, adverse effects they are concerned about and what cues could best aid the treatment plan. The healthcare provider should then synthesize this information to create the best treatment plan for that patient.

Milestone-Based Assessments Are Superior to Likert-Type Assessments in Illustrating Trainee Progression

BACKGROUND The Pediatrics Milestone Project uses behavioral anchors, narrative descriptions of observable behaviors, to describe learner progression through the Accreditation Council for Graduate Medical Education competencies. Starting June 2014, pediatrics programs were required to submit milestone reports for their trainees semiannually. Likert-type scale assessment tools were not designed to inform milestone reporting, creating a challenge for Clinical Competency Committees. OBJECTIVE To determine if milestone-based assessments better stratify trainees by training level compared to Likert-type assessments. METHODS We compared assessment results for 3 subcompetencies after changing from a 5-point Likert scale to milestone-based behavioral anchors in July 2013. Program leadership evaluated the new system by (1) comparing PGY-1 mean scores on Likert-type versus milestone-based assessments; and (2) comparing mean scores on the Likert-type versus milestone-based assessments across PGY levels. RESULTS Mean scores for PGY-1 residents were significantly higher on the prior years Likert-type assessments than milestone-based assessments for all 3 subcompetencies (P < .01). Stratification by PGY level was not observed with Likert-type assessments (eg, interpersonal and communication skills 1 [ICS1] mean score for PGY-1, 3.99 versus PGY-3, 3.98; P  =  .98). In contrast, milestone-based assessments demonstrated stratification by PGY level (eg, the ICS1 mean score was 3.06 for PGY-1, 3.83 for PGY-2, and 3.99 for PGY-3; P < .01 for PGY-1 versus PGY-3). Significantly different means by trainee level were noted across 21 subcompetencies on milestone-based assessments (P < .01 for PGY-1 versus PGY-3). CONCLUSIONS Initial results indicate milestone-based assessments stratify trainee performance by level better than Likert-type assessments. Average PGY-level scores from milestone-based assessments may ultimately provide guidance for determining whether trainees are progressing at the expected pace.

Using an Innovative Curriculum Evaluation Tool to Inform Program Improvement: The Clinical Skills Fair

BACKGROUND Program evaluation is important for assessing the effectiveness of the residency curriculum. Limited resources are available, however, and curriculum evaluation processes must be sustainable and well integrated into program improvement efforts. INTERVENTION We describe the pediatric Clinical Skills Fair, an innovative method for evaluating the effectiveness of residency curriculum through assessment of trainees in 2 domains: medical knowledge/patient care and procedure. Each year from 2008 to 2011, interns completed the Clinical Skills Fair as rising interns in postgraduate year (PGY)-1 (R1s) and again at the end of the year, as rising residents in PGY-2 (R2s). Trainees completed the Clinical Skills Fair at the beginning and end of the intern year for each cohort to assess how well the curriculum prepared them to meet the intern goals and objectives. RESULTS Participants were 48 R1s and 47 R2s. In the medical knowledge/patient care domain, intern scores improved from 48% to 65% correct (P < .001). Significant improvement was demonstrated in the following subdomains: jaundice (41% to 65% correct; P < .001), fever (67% to 94% correct; P < .001), and asthma (43% to 62% correct; P  =  .002). No significant change was noted within the arrhythmia subdomain. There was significant improvement in the procedure domain for all interns (χ(2)  =  32.82, P < .001). CONCLUSIONS The Clinical Skills Fair is a readily implemented and sustainable method for our residency program curriculum assessment. Its feasibility may allow other programs to assess their curriculum and track the impact of programmatic changes; it may be particularly useful for program evaluation committees.

National Landscape of Interventions to Improve Pediatric Resident Wellness and Reduce Burnout

From the Department of Pediatrics, Division of Emergency Medicine, University of Pittsburgh, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pa (Dr Wilson); Department of Pediatrics and Center for Integrative Health and Wellness (Dr Kemper), Department of Pediatrics and Nephrology (Dr Mahan), Nationwide Children’s Hospital, Columbus, Ohio; Department of Pediatrics, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr Schubert); Department of Neonatology and Pediatrics, University of Washington, Seattle Children’s Hospital (Dr Batra); Department of Pediatrics, Duke University Medical Center, Durham, NC (Dr Staples); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md (Dr Serwint); and Department of Medicine, University of Arizona College of Medicine, Tucson, Ariz (Dr McClafferty) The authors have no conflicts of interest to disclose. Address correspondence to Paria M. Wilson, MD, MEd, Division of Emergency Medicine, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 (e-mail: paria.wilson@gmail.com).

Renal Tubular Acidosis

1. Jonathan Pelletier, MD* 2. Rasheed Gbadegesin, MD, MBBS† 3. Betty Staples, MD* 1. *Department of Pediatrics and 2. †Department of Pediatric Nephrology, Duke Childrens Hospital and Health Center, Durham, NC 1. 1. Reddy P Clinical Approach to Renal Tubular Acidosis in Adult Patients. Reddy P Int J Clin Pract. 2011;65(3):350–360 [OpenUrl][1][CrossRef][2][PubMed][3] 2. 1. Batlle D, 2. Haque SK Genetic Causes and Mechanisms of Distal Renal Tubular Acidosis. Batlle D, Haque SK. Nephrol Dial Transplant. 2012;27(10):3691–3704 [OpenUrl][4][CrossRef][5][PubMed][6][Web of Science][7] 3. 1. Karet FE Mechanisms in Hyperkalemic Renal Tubular Acidosis. Karet FE. J Am Soc Nephrol. 2009;20(2):251–254 [OpenUrl][8][Abstract/FREE Full Text][9] 4. 1. Haque SK, 2. Ariceta G, 3. Batlle D Proximal Renal Tubular Acidosis: A Not So Rare Disorder of Multiple Etiologies. Haque SK, Ariceta G, Batlle D Nephrol Dial Transplant. 2012;27(12):4273–4287 [OpenUrl][10][CrossRef][11][PubMed][12][Web of Science][13] 5. 1. Gbadegesin R, 2. Foreman W 1. Chand DH, 2. Valentini RP Renal Tubular Acidosis. Gbadegesin R, Foreman W In: Chand DH, Valentini RP, eds. Clinicians Manual of Pediatric Nephrology. 1st ed. Singapore: World Scientific Publishing Co; 2011 The body temporarily buffers hydrogen ions (H+) with plasma proteins, hemoglobin, and bicarbonate (HCO3−), but H+ must be excreted to prevent acidosis. The major functions of the kidneys in acid-base homeostasis are to excrete H+ and reabsorb HCO3−. Failure to perform these functions results in HCO3− wasting, leading to renal tubular acidosis (RTA), which is categorized into 3 major groups: distal (type I), proximal (type II), and hyperkalemic (type IV) RTA. Excretion of H+ to balance acid production is primarily the function of the distal convoluted tubule and collecting duct (DCT/CD), where α-intercalated cells actively transport H+ into the tubule. Secreted H+ combines with ammonia to form ammonium in the DCT/CD lumen. Because of its positive charge, ammonium cannot diffuse out of the tubular lumen, and it is passed in the urine. In distal RTA, α-intercalated cells cannot secrete sufficient H+ into the tubular lumen, resulting in decreased … [1]: {openurl}?query=rft.jtitle%253DInternational%2Bjournal%2Bof%2Bclinical%2Bpractice%26rft.stitle%253DInt%2BJ%2BClin%2BPract%26rft.aulast%253DReddy%26rft.auinit1%253DP.%26rft.volume%253D65%26rft.issue%253D3%26rft.spage%253D350%26rft.epage%253D360%26rft.atitle%253DClinical%2Bapproach%2Bto%2Brenal%2Btubular%2Bacidosis%2Bin%2Badult%2Bpatients.%26rft_id%253Dinfo%253Adoi%252F10.1111%252Fj.1742-1241.2009.02311.x%26rft_id%253Dinfo%253Apmid%252F21314872%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1111/j.1742-1241.2009.02311.x&link_type=DOI [3]: /lookup/external-ref?access_num=21314872&link_type=MED&atom=%2Fpedsinreview%2F38%2F11%2F537.atom [4]: {openurl}?query=rft.jtitle%253DNephrol%2BDial%2BTransplant%26rft_id%253Dinfo%253Adoi%252F10.1093%252Fndt%252Fgfs442%26rft_id%253Dinfo%253Apmid%252F23114896%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [5]: /lookup/external-ref?access_num=10.1093/ndt/gfs442&link_type=DOI [6]: /lookup/external-ref?access_num=23114896&link_type=MED&atom=%2Fpedsinreview%2F38%2F11%2F537.atom [7]: /lookup/external-ref?access_num=000310631500007&link_type=ISI [8]: {openurl}?query=rft.jtitle%253DJ%2BAm%2BSoc%2BNephrol%26rft_id%253Dinfo%253Adoi%252F10.1681%252FASN.2008020166%26rft_id%253Dinfo%253Apmid%252F19193780%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [9]: /lookup/ijlink?linkType=ABST&journalCode=jnephrol&resid=20/2/251&atom=%2Fpedsinreview%2F38%2F11%2F537.atom [10]: {openurl}?query=rft.jtitle%253DNephrol%2BDial%2BTransplant%26rft_id%253Dinfo%253Adoi%252F10.1093%252Fndt%252Fgfs493%26rft_id%253Dinfo%253Apmid%252F23235953%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [11]: /lookup/external-ref?access_num=10.1093/ndt/gfs493&link_type=DOI [12]: /lookup/external-ref?access_num=23235953&link_type=MED&atom=%2Fpedsinreview%2F38%2F11%2F537.atom [13]: /lookup/external-ref?access_num=000312645800008&link_type=ISI