James Stallworth

Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA

Objective Evidence suggests that the level of physical activity of physicians can be correlated directly with physician counselling patterns about this behaviour. Our objective was to determine if medical students, resident and fellow physicians and attending physicians meet the physical activity guidelines set forth by the US Department of Health and Human Services. Methods A representative cross-sectional web-based survey was conducted in June 2009–January 2010 throughout the USA (N=1949). Using the short form of the International Physical Activity Questionnaire, the authors gathered demographical data and information related to physical activity, the level of training, the number of work hours per week, body mass index (BMI), confidence about counselling about physical activity and frequency with which the physical activity is encouraged to his/her patients. Results Based on the 1949 respondents, attending physicians (84.8%) and medical students (84%) were more likely than resident (73.2%) and fellow physicians (67.9%) to meet physical activity guidelines. Conclusion Physicians and medical students engage in more physical activity and tend to have a lower BMI than the general population. Resident and fellow physicians engage in less physical activity than attending physicians and medical students.

Cost-effectiveness of adenotonsillectomy in reducing obstructive sleep apnea, cerebrovascular ischemia, vaso-occlusive pain, and ACS episodes in pediatric sickle cell disease

In children with sickle cell disease (SCD), adenotonsillar hypertrophy or recurrent tonsillitis are frequently linked with an increased risk of obstructive sleep apnea, cerebrovascular ischemia, or frequent pain episodes and often require an adenoidectomy and/or tonsillectomy. Interventions designed to prevent these complications, control vaso-occlusive pain episodes, and avoid hospitalizations may reduce the significant personal and economic burden of SCD. This study compares episode recurrence and treatment costs for cerebrovascular ischemia, vaso-occlusive pain, acute chest syndrome (ACS), and obstructive sleep apnea in children who had an adenotonsillectomy (A/T surgery, N = 256; 11.7%) and a matched cohort of those who did not (N = 512; 23.3%) from a cohort of 2,194 children and adolescents with SCD from South Carolina’s Medicaid system. A/T surgery was associated with a significantly reduced rate of visits over time for obstructive sleep apnea and cerebrovascular ischemia (e.g., stroke, transient ischemic attacks), but not with any change in the rate of visits for vaso-occlusive pain or ACS/pneumonia visits. The rate of mean acute (emergency and inpatient) service costs was significantly decreasing over time after an increase about the time the A/T surgery was performed. The cost-effectiveness of adenoidectomy and/or tonsillectomy for treating obstructive sleep apnea and preventing cerebrovascular ischemia without increasing vaso-occlusive pain episodes or long-term acute service costs in routine clinical practice settings was demonstrated. The matched control group of SCD patients without A/T surgery contained more patients with severe vaso-occlusive pain episodes, ACS visits, and higher mean total costs over time and appears to represent a different phenotype of children with SCD.

Factors that Influence Physicians’ and Medical Students’ Confidence in Counseling Patients About Physical Activity

AbstractLess than half of US adults and two-thirds of US high school students do not meet current US guidelines for physical activity. We examined which factors promoted physicians’ and medical students’ confidence in counseling patients about physical activity. We established an online exercise survey targeting attending physicians, resident and fellow physicians, and medical students to determine their current level of physical activity and confidence in counseling patients about physical activity. We compared their personal level of physical activity with the 2008 Physical Activity Guidelines of the US Department of Health and Human Services (USDHHS). We administered a survey in 2009 and 2010 that used the short form of the International Physical Activity Questionnaire. A total of 1,949 individuals responded to the survey, of whom 1,751 (i.e., 566 attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students) were included in this analysis. After adjusting for their BMI, the odds that physicians and medical students who met USDHHS guidelines for vigorous activity would express confidence in their ability to provide exercise counseling were more than twice that of physicians who did not meet these guidelines. Individuals who were overweight were less likely to be confident than those with normal BMI, after adjusting for whether they met the vigorous exercise guidelines. Physicians with obesity were even less likely to express confidence in regards to exercise counseling. We conclude that physicians and medical students who had a normal BMI and met vigorous USDHHS guidelines were more likely to feel confident about counseling their patients about physical activity. Our findings suggest that graduate medical school education should focus on health promotion in their students, as this will likely lead to improved health behaviors in their students’ patient populations.

Cost-effectiveness of hydroxyurea in reducing the frequency of pain episodes and hospitalization in pediatric sickle cell disease.

In a cohort of children with sickle cell disease (SCD) and vaso-occlusive pain visits served through South Carolinas Medicaid system over a 6-year period (N 5 523), we compared the number of vaso-occlusive pain or acute chest syndrome (ACS)/pneumonia episodes, and outpatient or acute service costs in those treated or not treated with hydroxyurea (HU). HU may be an underused intervention for SCD in this practice setting, for a variety of reasons. Treatment with HU varied greatly, appears to have been administered to more severely ill children, but was associated with a reduction in vaso-occlusive pain episodes, hospitalizations,and total costs of care within the HU cohort during a 2-3 year period of active HU treatment. Those receiving care through specialized SCD clinics were less likely to have pain or acute care episodes(RR 5 0.79, P < 0.0001; RR 5 0.90, P 5 0.01). Compared with the non-HU cohort, the HU group evinced a significantly higher risk of experiencing vaso-occlusive pain episodes (RR 5 3.32, P < 0.0001)and ACS/pneumonia episodes (RR 5 2.66, P < 0.0001), and higher outpatient,inpatient/emergency, and total service costs (RR 5 1.85, 2.11,2.10, and P < 0.0001, respectively) over time. HU is clinically effective in reducing pain episodes, hospitalizations, and total care costs, but those receiving it might be more severely ill.

Pain management in children and adolescents with sickle cell disease

In a cohort of 2,194 children with sickle cell disease (SCD) treated in community-based services, we explored the types of medications used to treat vaso-occlusive (VOC) pain episodes, and the relative effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjunctive antidepressants or anticonvulsant medications on reducing acute VOC pain visits over time. Pharmacologic treatments for VOC pain consisted mainly of NSAIDs and weak opioids. Significantly more patients with more than 3 inpatient or ER VOC pain visits during their first year of SCD treatment were prescribed stronger opioids, SSRIs, SNRI/heterocyclics, and anticonvulsants. Prescription of both stronger opioids and SSRI antidepressants or anticonvulsants was significantly associated with lower cumulative rates of acute VOC pain visits over time. Using an observational study design and existing clinical data, these findings are intended to illustrate the potential clinical advantages of combining adjunctive antidepressants or anticonvulsants with primary pain medications for relief of acute VOC pain over time.

Professionalism in Practice: Strategies for Assessment, Remediation, and Promotion

The Council on Medical Student Education in Pediatrics continues its series on great clinical teachers, focusing on professionalism in practice. The Council on Medical Student Education in Pediatrics is in agreement with the Liaison Committee on Medical Education, Accreditation Council on Graduate Medical Education, and the CanMEDS Physician Competency Framework, that professionalism is essential to the practice of medicine, regardless of the level of training. Clinical teachers are in an excellent position to promote and assess professional behaviors in students but are often hesitant to address lapses in professionalism; however, addressing professionalism early is critical, as professional misbehavior in medical school is a major risk factor for subsequent censure by state medical boards.1 This article discusses tools and strategies for the assessment, remediation, and promotion of professionalism in medical students. Many practitioners say, “I know it when I see it,” but defining professionalism can be challenging. Professionalism is built on the principles of excellence, humanism, accountability, and altruism and is demonstrated through clinical competence, communication, and ethical understanding.2 Humanism and altruism encompass beneficence, respect, truthfulness, and placing the needs of the patient above ones own. Excellence and accountability include striving for high-quality patient care, making a commitment to lifelong learning, and exhibiting responsibility to duty. Professional maturity requires the development of these behaviors through deliberate practice so that they become the habits that define a good physician. Evaluating professionalism is the responsibility of every clinical teacher. Assessable components include adherence to ethical practice principles, effective interactions with patients and the people who are important to these patients, effective interactions with individuals within the health care system, reliability and accountability, and commitment to improvement.3 The development of professionalism in medical … Address correspondence to April O. Buchanan, MD, Department of Pediatrics, University of South Carolina School of Medicine, Greenville Hospital System University Medical Center, 701 Grove Rd, 4th Floor Balcony Suites, Greenville, SC 29605. E-mail: abuchanan{at}ghs.org

Systemic lupus erythematosus and thrombotic thrombocytopenic purpura: a case and review

Abstract  Thrombotic thrombocytopenic purpura (TTP) is rare in children with systemic lupus erythematosus (SLE). We report a 15-year-old female who simultaneously presented with TTP and SLE. Kidney biopsy showed membranous nephropathy. Her condition improved with plasmapheresis, intravenous cyclophosphamide, and prednisone pulse therapy. We also reviewed the literature for this association in pediatric patients comparing presenting sequence and renal pathology with cases documented in the adult literature.

Clinical complications in severe pediatric sickle cell disease and the impact of hydroxyurea

More evidence of the safety and effectiveness of hydroxyurea (HU) in community‐based cohorts of pediatric patients with sickle cell disease (SCD) are needed. The association of HU with organ‐specific clinical complications and adverse events is examined herein.

Antibiotic-induced recurring interstitial nephritis

Abstract. Acute interstitial nephritis (AIN) is often induced by drug therapy and accounts for 1%–3% of adult cases of renal failure. A 13-year-old white female with cystic fibrosis developed two episodes of biopsy proven AIN following antibiotic use over a 5-year period. The first episode resolved with pulse steroid therapy and the second resolved without intervention. Steroid therapy may play a role in aborting subsequent AIN attacks.

Tissue plasminogen activator for occluded peritoneal dialysis catheter

Abstract Inadequate flow in a peritoneal catheter is a common problem in pediatric patients. We report the effectiveness of the intra-catheter application of tissue plasminogen activator for the resolution of a malfunctioning peritoneal dialysis catheter in a child.