Laurie N. Fishman

Transition of adolescents with inflammatory bowel disease from pediatric to adult care: a survey of adult gastroenterologists.

Objectives: Transition of patients with inflammatory bowel disease (IBD) from pediatric to adult providers requires preparation. Gastroenterologists for adult patients (“adult gastroenterologists”) may have expectations of patients that are different from those of pediatric patients. We sought to explore the perspectives of adult gastroenterologists caring for adolescents and young adults with IBD, to improve preparation for transition. Materials and Methods: A survey sent to 1132 adult gastroenterologists caring for patients with IBD asked physicians to rank the importance of patient competencies thought necessary in successful transition to an adult practice. Providers reported which problems occurred in patients with IBD transitioning to their own practice. Adult gastroenterologists were asked about medical and developmental issues that are unique to adolescence. Results: A response rate of 34% was achieved. Adult gastroenterologists reported that young adults with IBD often demonstrated deficits in knowledge of their medical history (55%) and medication regimens (69%). In addition, 51% of adult gastroenterologists reported receiving inadequate medical history from pediatric providers. Adult providers were less concerned about the ability of patients to identify previous and current health care providers (19%), or attend office visits by themselves (15%). Knowledge of adolescent medical and developmental issues was perceived as important by adult gastroenterologists; however, only 46% felt competent addressing the developmental aspects of adolescents. Conclusions: For successful transition, adolescents and young adults with IBD need improved education about their medical history and medications. Pediatric providers need to improve communication with the receiving physicians. In addition, adult providers may benefit from further training in adolescent issues. Formal transition checklists and programs may improve the transition of patients with IBD from pediatric to adult care.

Educate, communicate, anticipate-practical recommendations for transitioning adolescents with IBD to adult health care

&NA; The cyclical nature of chronic illness requires that children with inflammatory bowel disease be transitioned to the adult medical system with as much continuity of care as possible. Transition from pediatric to adult medical care continues to present significant barriers. The philosophy of transition centers on a process, with the actual transfer to adult care as a point along this clinical pathway. Concrete steps can be taken to help patients prepare for new responsibilities. The aim of this review is to propose a clinical and developmental timeline for both patients and their medical team, including specific responsibilities for both, so that the partnership can best promote a successful transition.

Self-Management of Older Adolescents with Inflammatory Bowel Disease: A Pilot Study of Behavior and Knowledge as Prelude to Transition

Objective: Patients gradually assume responsibility for self-management. This study sought to determine whether adolescents with inflammatory bowel disease (IBD) have developed key skills of self-management prior to the age at which many transfer to adult care. Patients and Methods: Adolescents aged 16 to 18 years old in the Children’s Hospital Boston IBD database (94 total) received a mailed survey assessing knowledge and confidence of their own health information and behaviors. Results: Respondents (43%) could name medication and dose with confidence but had very poor knowledge of important side effects. Most patients deferred responsibility mostly or completely to parents for scheduling appointments (85%), requesting refills (75%), or contacting provider between visits (74%). Conclusions: Older adolescents with IBD have good recall of medications but not of side effects. Parents remain responsible for the majority of tasks related to clinic visits and the acquisition of medications.

REFERRAL PATTERNS AND PERCEIVED BARRIERS TO ADULT CONGENITAL HEART DISEASE CARE: RESULTS OF A SURVEY OF U.S. PEDIATRIC CARDIOLOGISTS

OBJECTIVES This study sought to elucidate referral patterns and barriers to adult congenital heart disease (ACHD) care, as perceived by pediatric cardiologists (PCs). BACKGROUND Management guidelines recommend that care of adults with moderate/complex congenital heart disease be guided by clinicians trained in ACHD. METHODS A cross-sectional survey was distributed to randomly selected U.S. PCs. RESULTS Overall response rate was 48% (291 of 610); 88% (257 of 291) of respondents met inclusion criteria (outpatient care to patients >11 years of age). Participants were in practice for 18.2 ± 10.7 years; 70% were male, and 72% were affiliated with an academic institution; 79% stated that they provide care to adults (>18 years). The most commonly perceived patient characteristic prompting referral to ACHD care was adult comorbidities (83%). The most perceived barrier to ACHD care was emotional attachment of parents and patients to the PC (87% and 86%, respectively). Clinician attachment to the patient/family was indicated as a barrier by 70% of PCs and was more commonly identified by responders with an academic institutional affiliation (p = 0.001). A lack of qualified ACHD care providers was noted by 76% of PCs. Those affiliated with an academic institution were less likely to identify this barrier to ACHD care (p = 0.002). CONCLUSIONS Most PC respondents in the United States provide care to ACHD patients. Common triggers that prompt referral and perceived barriers to ACHD care were identified. These findings might assist ACHD programs in developing strategies to identify and retain patients, improve collaborative care, and address emotional needs during the transition and transfer process.

Lack of Utility of Abdominal X-rays in the Evaluation of Children With Constipation: Comparison of Different Scoring Methods

Background and Aim: Abdominal x-rays are used diagnostically in the evaluation of children with constipation. However, their clinical utility has not been established. The aim of the study was to assess the accuracy of different methods in identifying children with functional constipation (FC) or nonretentive fecal incontinence (NRFI). Patients and Methods: Retrospective review of abdominal x-rays in which colonic transit (CT), Barr, Leech, and fecal loading (FL) scores were blindly measured by blinded pediatric gastroenterologists and a radiologist. Children were classified a priori as FC or NRFI. Results: One hundred sixty patients (125 FC, 35 NRFI) were studied. There were significant differences (P < 0.05) when comparing those with FC and those with NRFI: CT: 51 ± 18 vs 40 ± 21 hours; Barr: 14 ± 5 vs 11 ± 4; Leech: 10 ± 2 vs 8 ± 2; FL: 2 ± 0.5 vs 1.7 ± 0.4. More than 20% of FC had normal Barr and Leech scores, whereas >50% of NRFI had abnormal scores. CT discriminated better between FC and NRFI. There was a significant correlation (P < 0.05) between CT and Barr (0.45), Leech (0.41) and FL scores (0.36), and between Barr and Leech scores (r = 0.94). There was good intraobserver correlation between Barr, Leech, and FL scores but poor interobserver reproducibility. Conclusions: Although significant differences in overall FC and NRFI scores exist, the discriminative value is low for all scores. There is poor interobserver reproducibility of the Barr, Leech, and FL scores. These findings confirm the limited value of the plain abdominal x-ray in the evaluation of children with constipation.

A Faculty Development Program to Train Tutors to Be Discussion Leaders Rather Than Facilitators

Purpose During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made. Method During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students’ overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05. Results In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002. Conclusions The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam’s mean score.

Early constipation and toilet training in children with encopresis.

Objective To evaluate the frequency of predisposing factors for encopresis before and during toilet training, comparing children with primary and secondary encopresis. Methods In this retrospective study, questionnaires from the initial evaluation at an encopresis clinic at a tertiary care pediatric hospital were reviewed for the presence or absence of factors in the first 2 years of life, for toilet training practices, and for disruptive events during the training process. Children younger than 48 months or those with organic defecation disorders were excluded. Results In 411 children with encopresis, the reported frequency of predisposing factors included constipation in 35%, and previous treatment for constipation in 24%. Toilet training was initiated before age 2 years in 26% and after age 3 years in 14%. Interruption of toilet training and punishment were seen more in primary encopresis than in secondary encopresis (50% versus 23%;P < 0.05) and (52% versus 26%;P < 0.05) respectively. Constipation (30% versus 18%;P < 0.05) and abdominal pain (23% versus 9%;P <0.0:5) during toilet training were more common in primary encopresis as was fear of the toilet (47% versus 10%;P < 0.05). Conclusions In children with encopresis, early difficult defecation, previous treatment for constipation, and early initiation of toilet training were less common than expected. Children with primary encopresis did not have an increased incidence of early constipation or invasive treatments compared with those with secondary encopresis. However, children with primary encopresis did have more difficult and disruptive toilet training experiences.

UPDATE ON VIRAL HEPATITIS IN CHILDREN

Recent discovery of the two major agents responsible for non-A, non-B hepatitis has led to rapid progress in the diagnosis and prevention of viral hepatitis. Newly implemented vaccine strategies against hepatitis A and hepatitis B are protecting children from infection, and new immunomodulatory therapy with interferon-alpha is being used to eradicate disease in patients chronically infected with hepatitis virus B or C.

Transition and transfer of childhood cancer survivors to adult care: A national survey of pediatric oncologists.

Pediatric oncologists are responsible for ensuring that adolescent and young adult (AYA) childhood cancer survivors have the knowledge and skills necessary to manage their follow‐up care in adult healthcare systems.

Transition of the Patient with IBD from Pediatric toAdult Care—An Assessment of Current Evidence

Abstract:Inflammatory bowel disease is a chronic disease of remitting and relapsing nature that is increasingly diagnosed in childhood or adolescence. The importance of the transition from pediatric to adult health care is increasingly recognized, yet the preparation of patient and family before transfer and early subsequent care in the adult health care environment can be variable and challenging. Pediatric providers need to start early and prepare patients in a stepwise fashion. However, patients may not have mastered all the steps before transfer or may regress to earlier behaviors during stress. Thus, adult providers will need to understand how to maintain and finish the transition process. This is an updated literature review of the transition process in inflammatory bowel disease, which focuses on the practical ways that both pediatric and adult health care providers can optimize care.