Kathlyn E. Fletcher

Clonidine treatment of hyperactive and impulsive children with autistic disorder.

Many autistic children have associated problems of inattention, impulsivity, and hyperactivity that limit the effectiveness of educational and behavioral interventions. Few controlled psyehophar-macologic trials have been conducted in autistic children to determine which agents may be effective for these associated features. Eight male children (8.1 ± 2.8 years) with autistic disorder, diagnosed by DSM-III-R criteria, completed a placebo-controlled, double-blind crossover trial of clonidine. Subjects were included in the study if they had inattention, impulsivity, and hyperactivity that was excessive for their developmental level. Subjects had not tolerated or responded to other psychopharmacologic treatments (neuroleptics, methylphenidate, or desipramine). Teacher ratings on the Aberrant Behavior Checklist irritability, stereotypy, hyperactivity, and inappropriate speech factors were lower during treatment with clonidine than during treatment with placebo. Attention deficit disorder with hyperactivity: Comprehensive Teachers Rating Scale ratings were not significantly improved during the study, except for oppositional behavior. Parent Conners Abbreviated Parent-Teacher Questionnaire ratings significantly improved during clonidine treatment. Clonidine led to increased ratings of the side effects of drowsiness and decreased activity. Clinician ratings (Childrens Psychiatric Rating Scale Autism, Hyperactivity, Anger and Speech Deviance factors; Childrens Global Assessment Scale; Clinical Global Impressions efficacy) of videotaped sessions were not significantly different between clonidine and placebo. Clonidine was modestly effective in the short-term treatment of irritability and hyperactivity in some children with autistic disorder.

Primary Structure of the Human Platelet Serotonin 5‐HT2A Receptor: Identity with Frontal Cortex Serotonin 5‐HT2A Receptor

Abstract: Previous radioligand binding studies have demonstrated human platelet serotonin2A (5‐HT2A) receptor binding sites. Pharmacological similarities between platelet and frontal cortex 5‐HT2A receptor binding parameters have been demonstrated. However, it is not clear whether the platelet 5‐HT2A receptor primary structure is identical to that of the brain receptor. Three overlapping cDNAs were obtained to span completely the coding region of the 5‐HT2A receptor. These clones were sequenced with external and internal primers. The nucleotide sequence of human platelet 5‐HT2A cDNA was identical to that reported for the human frontal cortex 5‐HT2A receptor, except for nucleotide 102 (T → C), which has been reported to represent a normal DNA polymorphism that does not alter the amino acid sequence. This finding may have implications in the study of neuropsychiatric disorders for which altered platelet 5‐HT2A receptor binding has been demonstrated.

Balancing continuity of care with residents' limited work hours: defining the implications.

The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents’ fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.

Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules

The ACGME-released revisions to the 2003 duty hour standards. To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes. Medline (1989–May 2010), Embase (1989–June 2010), bibliographies, pertinent reviews, and meeting abstracts. We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies. One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality. Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I2 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies. Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible. Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.ContextThe ACGME-released revisions to the 2003 duty hour standards.ObjectiveTo review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.Data SourcesMedline (1989–May 2010), Embase (1989–June 2010), bibliographies, pertinent reviews, and meeting abstracts.Study SelectionWe included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.Data ExtractionOne rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.ResultsOf 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I2 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.LimitationsMost studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.ConclusionsSince 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.

A framework for health numeracy: how patients use quantitative skills in health care.

Our objective of this study is to develop a conceptual framework for the construct of health numeracy based on patient perceptions, using a cross-sectional, qualitative design. Interested participants (n = 59) meeting eligibility criteria (age 40–74, English speaking) were assigned to one of six focus groups stratified by gender and educational level (low, medium, high). Fifty-three percent were male, and 47% were female. Sixty-one percent were white non-Hispanic, and 39% were of minority race or ethnicity. Participants were randomly selected from three primary care sites associated with an academic medical center. Focus group discussions were held in May 2004 and focused on how numbers are used in the health care setting. Data were presented from clinical trials to further explore how quantitative information is used in health communication and decision making. Focus groups were audio and videotaped; verbatim transcripts were prepared and analyzed. A framework of health numeracy was developed to reflect the themes that emerged. Three broad conceptual domains for health numeracy were identified: primary numeric skills, applied health numeracy, and interpretive health numeracy. Across domains, results suggested that numeracy contains an emotional component, with both positive and negative affect reflected in patient numeracy statements. We conclude that health numeracy is a multifaceted construct that includes applied and interpretive components and is influenced by patient affect.

The Validity of Peer Review in a General Medicine Journal

All the opinions in this article are those of the authors and should not be construed to reflect, in any way, those of the Department of Veterans Affairs. Background Our study purpose was to assess the predictive validity of reviewer quality ratings and editorial decisions in a general medicine journal. Methods Submissions to the Journal of General Internal Medicine (JGIM) between July 2004 and June 2005 were included. We abstracted JGIM peer review quality ratings, verified the publication status of all articles and calculated an impact factor for published articles (Rw) by dividing the 3-year citation rate by the average for this group of papers; an Rw>1 indicates a greater than average impact. Results Of 507 submissions, 128 (25%) were published in JGIM, 331 rejected (128 with review) and 48 were either not resubmitted after revision was requested or were withdrawn by the author. Of 331 rejections, 243 were published elsewhere. Articles published in JGIM had a higher citation rate than those published elsewhere (Rw: 1.6 vs. 1.1, p = 0.002). Reviewer quality ratings of article quality had good internal consistency and reviewer recommendations markedly influenced publication decisions. There was no quality rating cutpoint that accurately distinguished high from low impact articles. There was a stepwise increase in Rw for articles rejected without review, rejected after review or accepted by JGIM (Rw 0.60 vs. 0.87 vs. 1.56, p<0.0005). However, there was low agreement between reviewers for quality ratings and publication recommendations. The editorial publication decision accurately discriminated high and low impact articles in 68% of submissions. We found evidence of better accuracy with a greater number of reviewers. Conclusions The peer review process largely succeeds in selecting high impact articles and dispatching lower impact ones, but the process is far from perfect. While the inter-rater reliability between individual reviewers is low, the accuracy of sorting is improved with a greater number of reviewers.

The numeracy understanding in medicine instrument: a measure of health numeracy developed using item response theory.

Background: Health numeracy can be defined as the ability to understand and apply information conveyed with numbers, tables and graphs, probabilities, and statistics to effectively communicate with health care providers, take care of one’s health, and participate in medical decisions. Objective: To develop the Numeracy Understanding in Medicine Instrument (NUMi) using item response theory scaling methods. Design: A 20-item test was formed drawing from an item bank of numeracy questions. Items were calibrated using responses from 1000 participants and a 2-parameter item response theory model. Construct validity was assessed by comparing scores on the NUMi to established measures of print and numeric health literacy, mathematic achievement, and cognitive aptitude. Participants: Community and clinical populations in the Milwaukee and Chicago metropolitan areas. Results: Twenty-nine percent of the 1000 respondents were Hispanic, 24% were non-Hispanic white, and 42% were non-Hispanic black. Forty-one percent had no more than a high school education. The mean score on the NUMi was 13.2 (s = 4.6) with a Cronbach α of 0.86. Difficulty and discrimination item response theory parameters of the 20 items ranged from −1.70 to 1.45 and 0.39 to 1.98, respectively. Performance on the NUMi was strongly correlated with the Wide Range Achievement Test–Arithmetic (0.73, P < 0.001), the Lipkus Expanded Numeracy Scale (0.69, P < 0.001), the Medical Data Interpretation Test (0.75, P < 0.001), and the Wonderlic Cognitive Ability Test (0.82, P < 0.001). Performance was moderately correlated to the Short Test of Functional Health Literacy (0.43, P < 0.001). Limitations: The NUMi was found to be most discriminating among respondents with a lower-than-average level of health numeracy. Conclusions: The NUMi can be applied in research and clinical settings as a robust measure of the health numeracy construct.

Bedside Interactions from the Other Side of the Bedrail

OBJECTIVE: To assess the importance to patients of various aspects of bedside interactions with physician teams. DESIGN: Cross-sectional survey. SETTING: VA hospital. PATIENTS: Ninety-seven medical inpatients. INTERVENTION: Survey of 44 questions including short answer, multiple choice, and Likert-type questions. MEASUREMENTS AND MAIN RESULTS: Data analysis included descriptive statistics. The sample was predominantly male, with a mean age of 62. Overall satisfaction with the hospital experience and with the team of doctors were both high (95% and 96% reported being very or mostly satisfied, respectively). Patients reported learning about several issues during their interactions with the teams; the 3 most highly rated areas were new problems, tests that will be done, and treatments that will be done. Most patients (76%) felt that their teams cared about them very much. Patients were made comfortable when the team showed that they cared, listened, and appeared relaxed (reported by 63%, 57%, and 54%, respectively). Patients were made uncomfortable by the team using language they did not understand (22%) and when several people examined them at once (13%). Many (58%) patients felt personally involved in teaching. The majority of patients liked having medical students and residents involved in their care (69% and 64%, respectively). CONCLUSION: Patients have much to teach about what is important about interacting with physician teams. Although patients’ reactions to team interactions are generally positive, patients are different with respect to what makes them comfortable and uncomfortable. Taking their preferences into account could improve the experience of being in a teaching hospital.

Impact of localizing general medical teams to a single nursing unit

BACKGROUND Localization of general medical inpatient teams is an attractive way to improve inpatient care but has not been adequately studied. OBJECTIVE To evaluate the impact of localizing general medical teams to a single nursing unit. DESIGN Quasi-experimental study using historical and concurrent controls. SETTING A 490-bed academic medical center in the midwestern United States. PATIENTS Adult, general medical patients, other than those with sickle cell disease, admitted to medical teams staffed by a hospitalist and a physician assistant (PA). INTERVENTION Localization of patients assigned to 2 teams to a single nursing unit. MEASUREMENTS Length of stay (LOS), 30-day risk of readmission, charges, pages to teams, encounters, relative value units (RVUs), and steps walked by PAs. RESULTS Localized teams had 0.89 (95% confidence interval [CI], 0.37-1.41) more patient encounters and generated 2.20 more RVUs per day (CI, 1.10-3.29) compared to historical controls; and 1.02 (CI, 0.46-1.58) more patient encounters and generated 1.36 more RVUs per day (CI, 0.17-2.55) compared to concurrent controls. Localized teams received 51% (CI, 48-54) fewer pages during the workday. LOS may have been approximately 10% higher for localized teams. Risk of readmission within 30 days and charges incurred were no different. PAs possibly walked fewer steps while localized. CONCLUSION Localization of medical teams led to higher productivity and better workflow, but did not significantly impact readmissions or charges. It may have had an unintended negative impact on hospital efficiency; this finding deserves further study.

Defining, navigating, and negotiating success

Background: We studied female graduates of the Robert Wood Johnson Clinical Scholars Program (CSP, Class of 1984 to 1989) to explore and describe the complexity of creating balance in the life of mid-career academic woman physicians.Methods: We conducted and qualitatively analyzed (κ 0.35 to 1.0 for theme identification among rater pairs) data from a semi-structured survey of 21 women and obtained their curricula vitae to quantify publications and grant support, measures of academic productivity.Results: Sixteen of 21 (76%) women completed the survey. Mean age was 48 (range: 45 to 56). Three were full professors, 10 were associate professors, and 3 had left academic medicine. Eleven women had had children (mean 2.4; range: 1 to 3) and 3 worked part-time. From these data, the conceptual model expands on 3 key themes: (1) defining, navigating, and negotiating success, (2) making life work, and (3) making work work. The women who described themselves as satisfied with their careers (10/16) had clarity of values and goals and a sense of control over their time. Those less satisfied with their careers (6/16) emphasized the personal and professional costs of the struggle to balance their lives and described explicit institutional barriers to fulfillment of their potential.Conclusion: For this group of fellowship-prepared academic women physicians satisfactionis achieving professional and personal balance.