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1.  Transitional Care in Inflammatory Bowel Disease 
Gastroenterology & Hepatology  2011;7(1):26-32.
Transitional care is an organized effort to provide pediatric patients with the tools and resources they need to assume personal responsibility for their medical care while facilitating their transfer from a pediatrician to an adult practitioner. Since inflammatory bowel disease (IBD) is usually chronic and up to 25% of IBD patients are diagnosed before the age of 18 years, transitional care is an important consideration for adolescent and young adult patients. The importance of transitional care for chronic diseases that begin in childhood has been recognized in a number of published recommendations. However, most of these recommendations arise from intuitive reasoning, as physicians lack information regarding the need for transitional care, optimal delivery protocols, and the efficacy of transition programs. Even fewer studies have been published regarding transitional care in IBD. Current guidelines stress the importance of providing patients with educational resources to help them develop the skills they need to manage their care as independent adults, introducing the concept of transfer to adult care in advance of the actual transfer, and developing routes of communication to facilitate the transfer from pediatric to adult care providers. Future studies should aim to elucidate which programs are effective and how they should be implemented.
PMCID: PMC3038313  PMID: 21346849
Adolescent healthcare; inflammatory bowel disease; pediatrics; transition to adult medicine
2.  Transition to adult care: Systematic assessment of adolescents with a chronic illness and their medical teams 
The Journal of pediatrics  2011;159(6):994-998.e2.
Objective
To examine the process of transition from pediatric to adult healthcare services from the perspectives of young adults with chronic disease and pediatric and adult healthcare providers.
Study design
A qualitative approach using focus group interviews was performed to investigate transition experiences. Novel innovation games were also utilized to generate data. Content and narrative analyses of interview transcripts were performed.
Results
Six focus groups were conducted with 10 young adults with chronic disease and 24 healthcare providers. Content analysis yielded 3 content domains: transition experiences in the context of relationships between patients, parents, and healthcare providers; differences between pediatric and adult-oriented medicine and how these differences inhibit or facilitate transition; and identifying transition services that should be provided to young patients with chronic disease.
Conclusion
This study demonstrates the need for gradual transfer of disease management from parent to child and better communication between adult and pediatric services during the transition process. Pediatric medicine and adult medicine represent different subcultures; acknowledging these differences may improve cooperation during transition from pediatric to adult providers. Young adult patients with chronic disease embrace the use of technology for specific interventions to improve the transition experience.
doi:10.1016/j.jpeds.2011.05.038
PMCID: PMC3215794  PMID: 21784450
3.  Errors of Diagnosis in Pediatric Practice: A Multi-Site Survey 
Pediatrics  2010;126(1):70-79.
Objectives
Despite their significance, little is known about diagnostic errors in general pediatric practice other than data from malpractice claims. We surveyed pediatricians to elicit their perceptions about frequency, contributing factors and potential systems and provider-based solutions to address diagnostic errors.
Methods
Academic, community, and trainee pediatricians at three tertiary care institutions and affiliated 109 clinics (N=1,362) were invited to complete the survey anonymously via an Internet survey administration service between November 2008 and May 2009.
Results
Overall response rate was 53% (N=726). Over half (54%) of respondents reported that they made a diagnostic error at least once or twice per month; this frequency was markedly higher (77%) among trainees. Almost half (45%) reported diagnostic errors that harmed patients at least once or twice per year. Failure to gather information through history, physical examination or chart-review was the most common reported process breakdown, whereas inadequate care coordination and teamwork was the most common system factor reported. Viral illnesses being diagnosed as a bacterial illness was the most commonly reported diagnostic error followed by misdiagnosis of medication side-effects, psychiatric disorders, and appendicitis. Physicians ranked access to electronic health records and close follow-up of patients as strategies most likely to be effective in preventing diagnostic errors.
Conclusions
Pediatricians reported making diagnostic errors relatively frequently and patient harm from these errors was not uncommon. Our survey provides new data about the types of diagnostic errors and their causes and lays the groundwork for a concerted, multifaceted approach to reduce these errors in children.
doi:10.1542/peds.2009-3218
PMCID: PMC2921702  PMID: 20566604
diagnostic errors; children; patient safety; missed and delayed diagnosis; misdiagnosis; malpractice
4.  A Pilot Study Exploring the Role of Physical Therapists and Transition in Care of Pediatric Patients with Cystic Fibrosis to the Adult Setting 
Background
Cystic fibrosis (CF) is a disease that requires intensive multidisciplinary care, including care by physical therapists (PTs). People with CF are now living well into adulthood, necessitating a transfer of care from the pediatric setting to an adult one. Physical therapists play a large role in the care of the person with CF; however, there is little known about the PT role in transition of care.
Purpose
To explore transition issues for people with CF from the perspective of PTs.
Methods
An 18-question online survey was sent to PTs via an electronic CF listserv. Questions were derived from an analysis of transition literature in CF and other chronic childhood conditions. Physical therapists who reported treating people with CF gave their opinions on issues impacting transition from their perspective as well as their perception of patient and parent concerns. Descriptive statistics were used for data analysis.
Results
A total of 26 PTs completed the survey. A majority, 61.5%, reported that there was a transition program at their facility, with 42.3% involving physical therapy. Common themes for patients and parents included feeling uncertain about: knowledge of the adult physician, acquiring pulmonary infections in the adult setting, and pace of the adult clinic. Physical therapists were concerned about adherence with airway clearance and exercise following transfer to the adult clinic.
Conclusions
The role of PT in transition programs is quite varied. Physical therapists should address common concerns of their patients and families to improve the transition process and possibly impact adherence to the PT plan of care.
PMCID: PMC3677184  PMID: 23754936
transition of care; cystic fibrosis; physical therapy
5.  Comfort of General Internists and General Pediatricians in Providing Care for Young Adults with Chronic Illnesses of Childhood 
Journal of General Internal Medicine  2008;23(10):1621-1627.
Background
As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population.
Objectives
To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort.
Participants
In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%).
Methods
We measured respondents’ comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics.
Results
Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF ( < .001) and 35% for SCD ( > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD.
Conclusions
A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions.
doi:10.1007/s11606-008-0716-8
PMCID: PMC2533372  PMID: 18661191
transitional care; cystic fibrosis; sickle cell disease; young adults; adolescents; children with special health care needs; primary care; childhood diseases; health care transitions
6.  Clinical Effort Against Secondhand Smoke Exposure (CEASE): Development of Framework and Intervention 
Pediatrics  2008;122(2):e363-e375.
Objective
To describe a novel process and present results of formative research to develop a pediatric office intervention that uses available systems of care for addressing parental smoking.
Methodology
The scientific development of the intervention occurred in three stages. In stage one, we designed an office system for parental tobacco control in the pediatric outpatient setting based on complementary conceptual frameworks of preventive services delivery, conceptualized for the child healthcare setting through a process of key interviews with leaders in the field of implementing practice change; existing Public Health Service guidelines that had been shown effective in adult practices; and adaptation of an evidenced-based adult office system for tobacco control. This was an iterative process that yielded a theoretically framed intervention prototype. In stage two, we performed focus group testing in pediatric practices with pediatricians, nurses, clinical assistants, and key office staff. Using qualitative methods, we adapted the intervention prototype based on this feedback to include five key implementation steps for the child healthcare setting. In stage three, we presented the intervention to breakout groups at two national meetings of pediatric practitioners for further refinements.
Results
The main result was a theoretically grounded intervention that was responsive to the barriers and suggestions raised in the focus groups and at the national meetings. The CEASE intervention is designed to be flexible and adaptable to the particular practices' staffing, resources, and physical configuration. Practices can choose materials relevant to their own particular systems of care (www.ceasetobacco.org).
Conclusions
Conceptually-grounded and focus group tested strategies for parental tobacco control are now available for implementation in the pediatric outpatient setting. The tobacco control intervention development process might have particular relevance for other chronic pediatric conditions that have a strong evidence base and have available treatments or resources that are underused.
doi:10.1542/peds.2008-0478
PMCID: PMC2774730  PMID: 18676523
smoking; tobacco; pediatrics; family practice; parent; smoking cessation; secondhand smoke; environmental tobacco smoke; tobacco control; quitline; telephone counseling
7.  Transition From Pediatric to Adult Epilepsy Care: A Difficult Process Marked by Medical and Social Crisis 
Epilepsy Currents  2012;12(Suppl 3):13-21.
When epilepsy does not remit in childhood, transition and transfer to adult care is eventually required. Youth must leave the family-centered approach of pediatric care for the individual focus of adult medicine. Evidence from population-based studies indicates that many of those with childhood-onset epilepsy have major social difficulties in adulthood even if their epilepsy has resolved. Epilepsy may have major effects on normal adolescent development, and societal attitudes confound this difficult period in the lives of young people with epilepsy. Very little objective data are available to assist in the designing of models of care for youth with epilepsy; however, based on our clinical experience and the limited available literature, it appears that a transition program to prepare children for adult care is best started during childhood and adolescence. The formal transfer to adult services may be assisted by a transition clinic jointly attended by pediatric and adult epilepsy specialists.
doi:10.5698/1535-7511-12.4s.13
PMCID: PMC3588151  PMID: 23476118
8.  Pediatricians’ and Family Physicians’ Weight-Related Care of Children in the U.S. 
Background
Few national data exist to assess primary care physicians’ (PCP) clinical practices with regard to childhood obesity.
Purpose
To survey pediatricians and family practice physicians regarding their assessment, counseling, and management of diet, physical activity, and weight status among pediatric patients in the primary care setting.
Methods
A nationally representative cross-sectional survey of pediatricians and family practice physicians sampled from the American Medical Association (AMA) Masterfile was conducted in 2008 and analyzed in 2010. Outcomes included: Physicians’ self-reported practice behaviors regarding assessments of pediatric patients’ weight status, counseling of diet and physical activity, and referrals and follow-ups.
Results
Response rate excluding physicians listed as “no-contact” by the AMA was 73.7% among pediatricians and 66.9% among family physicians. Less than 50% of all PCPs assessed BMI percentiles regularly in children. Eighteen percent of all PCPs reported referring children for further evaluation or management. Fifty-eight percent of all PCPs reported never, rarely, or only sometimes tracking patients over time concerning weight or weight-related behaviors. Pediatricians were more likely than family physicians to assess weight status and provide behavioral counseling (Ps<0.001).
Conclusions
Active PCP participation in assessing or managing childhood obesity in the primary care setting appears low relative to the frequency of the problem in the U.S.
doi:10.1016/j.amepre.2011.03.016
PMCID: PMC3115545  PMID: 21665060
9.  Multicentre randomized controlled trial of structured transition on diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes (Transition Trial) 
BMC Pediatrics  2013;13:163.
Background
Transition from pediatric to adult diabetes care is a high risk period during which there is an increased rate of disengagement from care. Suboptimal transition has been associated with higher risks for acute and chronic diabetes-related complications. The period of emerging adulthood challenges current systems of healthcare delivery as many young adults with type 1 diabetes (T1D) default from diabetes care and are at risk for diabetes complications which are undetected and therefore untreated. Despite the importance of minimizing loss to follow-up there are no randomized control trials evaluating models of transition from pediatric to adult diabetes care.
Methods/Design
This is a multicentre randomized controlled trial. A minimum of 188 subjects with T1D aged between 17 and 20 years will be evaluated. Eligible subjects will be recruited from three pediatric care centres and randomly assigned in a 1:1 ratio to a structured transition program that will span 18 months or to receive standard diabetes care. The structured transition program is a multidisciplinary, complex intervention aiming to provide additional support in the transition period. A Transition Coordinator will provide transition support and will provide the link between pediatric and adult diabetes care. The Transition Coordinator is central to the intervention to facilitate ongoing contact with the medical system as well as education and clinical support where appropriate. Subjects will be seen in the pediatric care setting for 6 months and will then be transferred to the adult care setting where they will be seen for one year. There will then be a one-year follow-up period for outcome assessment. The primary outcome is the proportion of subjects who fail to attend at least one outpatient adult diabetes specialist visit during the second year after transition to adult diabetes care. Secondary outcome measures include A1C frequency measurement and levels, diabetes related emergency room visits and hospital admissions, frequency of complication screening, and subject perception and satisfaction with care.
Discussion
This trial will determine if the support of a Transition Coordinator improves health outcomes for this at-risk population of young adults.
Trial registration
Trial Registration Number: NCT01351857
doi:10.1186/1471-2431-13-163
PMCID: PMC3879408  PMID: 24106787
Transition care; Adolescents and young adults; Transition intervention; Chronic illness; Type 1 diabetes; Healthcare systems
10.  Perspectives on vaccine injury compensation program in Korea: the pediatricians' view 
Purpose
Since National Immunization Program (NIP) was implemented recently in Korea, public attention on vaccine safety is increasing. This study was aimed to investigate perceptions of pediatricians on the vaccine injury compensation program and to acquire their suggestions to improve the program.
Materials and Methods
Pediatricians working in primary care were surveyed at the sites of the annual Korean Pediatric Society meeting or its regular regional branch meetings during September and October 2012. A questionnaire consisted of 15 items about the Korean National Vaccine Injury Compensation Program (KNVICP) was distributed and collected directly from the pediatricians.
Results
A total of 340 responses were collected. While only 16% of responded pediatricians answered they knew the program well, 11% answered they did not. Twenty-six percent answered a need to expand the types of vaccines and its injuries. Most responders (82%) wished the compensation program to cover the injuries of non-NIP vaccines. On the filing procedures for compensation, they preferred reducing the minimum medical cost limit to claim (94%).
Conclusion
On the basis of this survey, it is suggested to provide more active informative education on KNVICP to primary care pediatricians and to improve the program considering the pediatricians' opinions.
doi:10.7774/cevr.2013.2.1.53
PMCID: PMC3623502  PMID: 23596591
Pediatrics; Data collection; Vaccines
11.  Up against the System: A Case Study of Young Adult Perspectives Transitioning from Pediatric Palliative Care 
Nursing Research and Practice  2013;2013:286751.
Advances in pediatric care have not provided the interdisciplinary support services required by those young adults with pediatric life-threatening conditions (pedLTCs) who live beyond childhood but have limited expectations to live past early adulthood. These young adults, the first generation to live into adulthood, face multiple challenges transitioning from a plethora of pediatric palliative services to scant adult health services. In a case study, using an innovative bulletin board focus group, we describe the complex interplay of the health, education, and social service sectors in this transition. Our descriptions include system deficits and strengths and the young adults' resilience and coping strategies to overcome those deficits and move forward with their lives. Young adults with pedLTC need knowledgeable providers, coordinated and accessible services, being respected and valued, and services and supports that promote independence. We recommend implementation of multidisciplinary solutions that are focused on young adult priorities to ensure seamless access to resources to support these young adults' health, educational, vocational, and social goals. The input and voice of young adults in the development of these services are imperative to ensure that multisystem services support their needs and life goals.
doi:10.1155/2013/286751
PMCID: PMC3753759  PMID: 23997951
12.  Management of acute gastroenteritis in healthy children in Lebanon - A national survey 
Background:
Acute gastroenteritis remains a common condition among infants and children throughout the world. In 1996, The American Academy of Pediatrics (AAP) revised its recommendations for the treatment of infants and children with acute gastroenteritis.
Aim:
The purpose of this survey was to determine how closely current treatment among Lebanese pediatricians compares with the AAP recommendations and to determine the impact of such management on the healthcare system.
Patients and Methods:
The outline of the study was based on a telephone questionnaire that addressed the management of healthy infants and children below five years of age with acute gastroenteritis complicated by mild to moderate dehydration. In addition, the costs of medical treatment and requested laboratory studies were calculated.
Results:
A total of 238 pediatricians completed the questionnaire. Most pediatricians prescribed Oral Rehydration Solutions (ORS) for rehydration (92.4%), advised breastfeeding during acute gastroenteritis (81.5%), and avoided parenteral rehydration for mild to moderate dehydration (89.1%). In addition to ORS, oral fluids such as soda, juices, and rice water were allowed for rehydration by 43.7% of pediatricians. Thirty-one percent of pediatricians delayed re-feeding for more than 6 hours after initiation of rehydration. Only 32.8% of pediatricians kept their patients on regular full-strength formulas, and only 21.8% permitted full-calorie meals for their patients. 75.4% of pediatricians did not order any laboratory studies in cases of mild dehydration and 50.4% did not order any laboratory studies for moderate dehydration. Stool analysis and culture were ordered by almost half of the pediatricians surveyed. Seventy-seven percent prescribed anti-emetics, 61% prescribed probiotics, 26.3% prescribed antibiotics systematically and local antiseptic agents, 16.9% prescribed zinc supplements, and 11% percent prescribed antidiarrheal agents.
Conclusion:
Pediatricians in Lebanon are aware of the importance of ORS and the positive role of breastfeeding in acute gastroenteritis. However, they do not follow optimal recommendations from the AAP concerning nutrition, laboratory examinations and drug prescriptions. Consequently, this poses significant financial losses and economic burden.
doi:10.4297/najms.2010.2512
PMCID: PMC3338213  PMID: 22558558
Acute gastroenteritis; Lebanese pediatricians; laboratory studies in acute gastroenteritis in children; oral rehydration solutions
13.  Adult outcomes of childhood-onset rheumatic diseases 
Nature reviews. Rheumatology  2011;7(5):290-295.
A number of studies published over the past 10 years have examined the long-term health, functional and quality of life outcomes of adults with childhood-onset rheumatic diseases such as juvenile idiopathic arthritis, systemic lupus erythematosus, juvenile dermatomyositis and localized scleroderma. As increasing numbers of patients with these conditions survive into adulthood, understanding the adult outcomes of these pediatric conditions has become ever-more important. Identifying modifiable risk factors for poor outcomes is vital to improving care for these patients. In addition, as these conditions and their treatments can affect cardiovascular health, bone health and fertility, particular attention needs to be paid to these outcomes. Preparing patients and their families for a successful transition from pediatric to adult rheumatology care is an important first-step in the long-term management strategy for this expanding patient population.
doi:10.1038/nrrheum.2011.38
PMCID: PMC3705738  PMID: 21487383
14.  Transition of Adolescents With HIV to Adult Care: Characteristics and Current Practices of the Adolescent Trials Network for HIV/AIDS Interventions 
The transition process from pediatric to adult health care for adolescents with chronic diseases is always challenging and can be even more so for adolescents with HIV disease. The purpose of this study was to describe characteristics and current practices surrounding the transition of adolescents from the clinics of the Adolescent Trials Network for HIV/AIDS Interventions to adult medical care. This report focuses on the processes of transition, perceived barriers and facilitators, and anecdotal reports of successes and failures. Practice models used to assist adolescents during transition to adult medical care are described. Interviews were conducted with 19 key informants from 14 Adolescent Trials Network clinics. Findings revealed no consistent definition of “successful” transition, little consensus among the sites regarding specific elements of a transition program, and a lack of mechanisms to assess outcomes. Sites that viewed transition as a process rather than an event consistently described more structured program elements.
doi:10.1016/j.jana.2010.04.003
PMCID: PMC3315706  PMID: 20541443
adolescent; AIDS; developmental; HIV; transition
15.  Transitioning the Adolescent Inflammatory Bowel Disease Patient: Guidelines for the Adult and Pediatric Gastroenterologist 
Inflammatory bowel diseases  2010;17(10):2169-2173.
Twenty percent of inflammatory bowel disease (IBD) patients present in the pediatric years, with recent reports suggesting a rising incidence in the pediatric age group. This highlights the need for both pediatric and adult gastroenterologists to better understand issues related to the process of transition from pediatric to adult care. Research from other disciplines outside of IBD provide evidence that the transition period can be associated with poorer health outcomes and that a structured transition program may improve patient compliance and disease control. Recent data from the IBD literature support a need for transition clinics. The ideal model of a transition program has not been established. Controlled trials are not available to measure the impact of a structured transition program on clinically relevant endpoints such as disease control and hospital admissions. As local resources and availability of staffing and funding are highly variable, we have summarized some practical guidelines for the adult and pediatric gastroenterologist that can be used as an aid to help adolescents through the transition process even without the support of an established transition clinic.
doi:10.1002/ibd.21576
PMCID: PMC3320668  PMID: 21910179
inflammatory bowel disease; pediatrics; transition process
16.  Who Will Care for Me Next? Transitioning to Adulthood With Hydrocephalus 
Pediatrics  2009;124(5):1431-1437.
OBJECTIVES
Hydrocephalus is a prototypical chronic condition that follows children into adulthood. The objectives of this study were to (1) review how the health care needs of young adults with hydrocephalus are not being met, (2) estimate the numbers of adults with childhood-onset hydrocephalus, (3) describe a novel program to provide care for young adults with hydrocephalus and other chronic pediatric conditions, and (4) propose national strategies to promote successful hydrocephalus transition care.
RESULTS
Adults with hydrocephalus need continuous access to expert surgical and medical providers. Existing care models fail to meet this need. The number of young adults who have hydrocephalus, are aged 18 to 35 and need treatment in the United States is predicted to exceed 40 000 annually within the next 2 decades. We are developing integrated teams of pediatric and adult medical and surgical specialists to provide continuous, coordinated, comprehensive care for individuals with hydrocephalus in a pediatric setting. This setting will train our future physician workforce on optimal transition care. Coordinated national efforts are also needed.
CONCLUSIONS
Providers need to implement appropriate management and transition care for individuals with hydrocephalus. We must work at local and national levels to transform the care model, improve the quality of health care delivery, and improve outcomes for young adults with hydrocephalus.
doi:10.1542/peds.2008-3834
PMCID: PMC2895548  PMID: 19841113
hydrocephalus; health transition; medical education; advocacy
17.  Colorado pediatricians' involvement in community activities. 
Western Journal of Medicine  1995;163(5):451-453.
To determine Colorado American Academy of Pediatrics (AAP) pediatricians' involvement in community-based activities and awareness of and interest in the AAP Community Access to Child Health (CATCH) program, a 22-item survey was mailed to all general pediatrician AAP fellows and candidate fellows practicing in Colorado (n = 434). The return rate was 65%. Of the respondents, 73% provide direct patient care as their primary professional activity, 58% reported either current or past involvement in community-based programs outside of their practices, 91% of this community-based work was voluntary, and 80% of the respondents described this work as moderate to very rewarding. Half of the respondents (51%) were aware of the AAP CATCH program, and 68% were interested in attending a statewide CATCH meeting. We conclude that Colorado AAP pediatrician survey respondents participate heavily in community programs outside of their clinical practices and that among this group there is substantial interest in the AAP CATCH program.
PMCID: PMC1303169  PMID: 8533408
18.  Barriers in transition from pediatrics to adult medicine in sickle cell anemia 
Journal of Blood Medicine  2012;3:105-112.
Transition of care from pediatric to adult providers is an essential step in the care of young adults with sickle cell anemia. Transition programs should be developed by individual institutions to systematically enhance the transition process for their patients. Prior to transfer, patients must be educated about their disease and personal medical history and develop skill sets required to navigate the adult health care setting. The objective of this literature review is to identify key concepts associated with transition of care for patients with sickle cell anemia. First, transition programs should be developed so that education about transition can begin at an early age. The readiness of patients and families should be assessed and education tailored to meet individual patient needs. Finally, the emotions and fears about transition should be recognized and addressed prior to transition.
doi:10.2147/JBM.S32588
PMCID: PMC3460672  PMID: 23055784
anemia; sickle cell; transition to adult care; health transition; adult care
19.  Canadian pediatricians: demographic characteristics, perceptions of training, and continuing medical education. 
A nationwide survey of Canadian pediatricians was undertaken to answer questions about demographic and practice characteristics, perceptions of the quantity and quality of residency training in relation to the realities of practice, and the patterns of use and the value of continuing medical education. The findings included a lower average age of pediatricians from that determined 10 years earlier, a higher proportion of women practising pediatrics, and higher proportions of pediatricians entering practice in smaller communities, doing geographic full-time university work and doing mainly consulting work. Pediatrics is still perceived as an attractive discipline, but there is dissatisfaction with the quantity and quality of training in adolescent medicine, ophthalmology, dermatology, psychosocial pediatrics and orthopedics. The changing patterns of continuing medical education among the most recent certificants suggest a need for journals and professional societies to assess how they can better meet the needs of Canadian pediatricians in this area.
PMCID: PMC1704726  PMID: 7260758
20.  Low-income parents’ perceptions of pediatrician advice on early childhood education 
Journal of community health  2013;38(1):195-204.
BACKGROUND
The American Academy of Pediatrics recommends that pediatricians promote early childhood education (ECE). However, pediatricians have met resistance from low-income parents when providing anticipatory guidance on some topics outside the realm of physical health. Parents’ views on discussing ECE with the pediatrician have not been studied.
OBJECTIVES
We sought to understand low-income parents’ experiences and attitudes with regard to discussing early childhood education (ECE) with the pediatrician and to identify opportunities for pediatrician input.
METHODS
We conducted 27 in-depth, semi-structured, qualitative interviews with parents of 3- and 4-year-old patients (100% Medicaid, 78% African American) at an urban primary care center. Interviews were audio-recorded, transcribed verbatim, and reviewed for themes by a multidisciplinary team.
RESULTS
Most low-income parents in our study reported they primarily sought ECE advice from family and friends but were open to talking about ECE with the pediatrician. They considered their children’s individual behavior and development to be important factors in ECE decisions and appreciated pediatricians’ advice about developmental readiness for ECE. Participants’ decisions about ECE were often driven by fears that their children would be abused or neglected. Many viewed 3 years as the age at which children had sufficient language skills to report mistreatment and could be safely enrolled in ECE.
CONCLUSIONS
Participants were generally accepting of discussions about ECE during well child visits. There may be opportunity for the pediatrician to frame ECE discussions in the context of development, behavior, and safety and to promote high-quality ECE at an earlier age.
doi:10.1007/s10900-012-9642-0
PMCID: PMC3910351  PMID: 23324946
early childhood education; anticipatory guidance; well child care
21.  Survey assessment on pediatricians’ attitudes on head lice management 
Background
Pediculosis capitis is a worldwide health problem. One of the most important factor in effective head lice eradication is to ensure that infestation is adequately recognized and treated. Our survey investigated the knowledge and practice among primary care Italian pediatricians regarding to the prevention and treatment of head lice.
Methods
The questionnaire was distributed to all the pediatricians registered at the Annual Congress of Practice in Pediatrics held in Florence, Italy, November 11–12, 2011. It includes 10 questions in a multiple choice format, and one answer for each question was provided. The questionnaire was conceived by pediatricians at the Infectious Disease Unit of the Department of Science for the Health of Woman and Child, University of Florence. Questions were designed according to the guidelines by the Italian Pediatric Society (SIP), and international guidelines, such as the Centers for Disease Control and Prevention (CDC), and the American Academy of Pediatrics (AAP).
Results
Overall, 364/600 pediatricians (60.7% of physicians registered to the Congress) returned the questionnaire. The majority of them (232/364; 63,7%) believe that parents consult their primary care pediatrician only after the failure of other “remedies”. Mostly, they prescribe Malathion (116/364, 31,8%) as first line treatment. Two-hundred-fourty-three (66.7%) of participants consider creams, foams and gels the most effective formulations. Two-hundred-sixty-two of pediatricians interviewed (72.0%) suggest to repeat the treatment after one week, 37/364 (10.2%) after two weeks. The majority of the pediatricians interviewed reported that recurrences occur in less than 30% of cases (279/364; 76,6%). In their own opinion, most of recurrences are the consequence of a reinfestation in the community (259/264; 77%). Three-hundred-thirty-four (91.7%) of them have never prescribed oral therapy for the treatment of head lice. Finally, 289/364 (79.4%) pediatricians believe that no product is effective for prevention.
Conclusions
This is the first study that investigates the clinical practice of family pediatricians about the management and treatment of head lice globally, the Italian pediatricians surveyed proved to be quite informed on the head lice management. However, even in a country where pediatric assistance is free for everybody, a considerable proportion of parents do not seek advice to their own family pediatrician. Therefore, educations of parents, other than continuous updating of pediatricians, may contribute to a better management of head lice in the community.
doi:10.1186/1824-7288-39-62
PMCID: PMC3853107  PMID: 24090319
Head lice; Infestation; Children; Pediatrics
22.  Prepare the patient for future challenges when facing hemodialysis: nurses' experiences 
Chronic kidney disease is a major health problem due to the significant financial burden for the healthcare system and likewise for the patient who needs the treatment. The patient's whole life situation is turned upside down with chronic kidney disease when they are confronted with the forced change to start treatment with hemodialysis. Patients with chronic kidney disease experience a lack of adequate emotional support from nurses during the transition to hemodialysis. The purpose of this study was to explore nurses’ experiences of giving support to patients during the transition to hospital-bound hemodialysis. The study had a qualitative descriptive design with a content analysis approach; eight nurses from four hospitals in the south of Sweden participated. The results showed that the nurses gave threshold support with an openness and awareness of the patient's individual needs during the transition, except that there seemed to be a lack of knowledge and ability to provide emotional support. Patient support during the transition could therefore be absent. Education, at local and national levels, is needed for the nurse to be able to give professional emotional support. Further research is also desired in order to provide nurses with the tools they need to give emotional support, which is of utmost importance.
doi:10.3402/qhw.v9.22952
PMCID: PMC3982113  PMID: 24717268
Qualitative content analysis; support; transition; hemodialysis; chronic kidney disease
23.  Community and Healthcare Providers' Perspectives on Male Circumcision: A Multi-Centric Qualitative Study in India 
PLoS ONE  2014;9(3):e91213.
Background
Although male circumcision (MC) is recommended as an HIV prevention option, the religious, cultural and biomedical dimensions of its feasibility, acceptability and practice in India have not been explored till date. This study explores beliefs, experiences and understanding of the community and healthcare providers (HCPs) about adult MC as an HIV prevention option in India.
Methods
This qualitative study covered 134 in-depth interviews from Belgaum, Kolkata, Meerut and Mumbai cities of India. Of these, 62 respondents were the members of circumcising (CC)/non-circumcising communities (NCC); including medically and traditionally circumcised men, parents of circumcised children, spouses of circumcised men, and religious clerics. Additionally, 58 registered healthcare providers (RHCPs) such as general and pediatric surgeons, pediatricians, skin and venereal disease specialists, general practitioners, and operation theatre nurses were interviewed. Fourteen traditional circumcisers were also interviewed. The data were coded and analyzed in QSR NUD*IST ver. 6.0. The study has not explored the participants' views about neonatal versus adult circumcision.
Results
Members of CC/NCC, traditional circumcisers and RCHPs expressed sharp religious sensitivities around the issue of MC. Six themes emerged: Male circumcision as the religious rite; Multiple meanings of MC: MC for ‘religious identity/privilege/sacrifice’ or ‘hygiene’; MC inflicts pain and cost; Medical indications outweigh faith; Hesitation exists in accepting ‘foreign’ evidence supporting MC; and communication is the key for acceptance of MCs. Medical indications could make members of NCC accept MC following appropriate counseling. Majority of the RHCPs demanded local in-country evidence.
Conclusion
HCPs must educate high-risk groups regarding the preventive and therapeutic role of MC. Communities need to discuss and create new social norms about male circumcision for better societal acceptance especially among the NCC. Feasibility studies on MC as an individual specific option for the high risk groups in health care setting needs to be explored.
doi:10.1371/journal.pone.0091213
PMCID: PMC3948789  PMID: 24614575
24.  Integrated care in Eindhoven, a challenge for healthcare providers, provider organizations and patients/clients 
Purpose
To share experiences by discussing the necessity, the challenges and the used (implementation) strategies on integrated care.
Context
Integrated care and chronic care by SGE will be described. SGE delivers with 260 professionals integrated primary healthcare, based on protocols, standards and disease programs for 80,000 people. There is a formalized and structural cooperation with hospitals, their specialists, social services and other organizations.
Because half of all the people with chronic illness have multiple conditions, SGE has taken interest in changing the management of diseases, such as heart failure, COPD, diabetes, depression. Deficiencies in current management and the transformation of health care from reactive to proactive are discussed. Approaches, methods and tools used by SGE are focused on. For example: the transition with the Chronic Care Model. This model summarizes the basic elements for improving health care in health systems at the community, organizations, practice and patient levels. Issues like implementation of chronic care programs and how SGE cooperates with the Maastricht University for evaluating outcomes of effectiveness of integrated care by SGE come up for discussion.
Data source
1. Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic applications and implications, a discussion paper. Int J Integr Care 2002 Oct–Dec;2:e12.
2. Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv 2001;27:63–80.
3. Pater L, Dubbeldam S, Verweijen M. Implementeren, het speelveld in de praktijk. Lemma 2005.
4. Grol R, Wensing M, Eccles M. Improving patient care, the implementation of change in clinical practice. Butterworth-Heinemann 2004.
Preliminary conclusion
The multi-problem patients do need a change in health systems. Despite everything already done, there is still a long way to go. Local, national and international collaborations and networks therefore are a must.
Discussion
Is the Chronic Care Model the model to make integrated care for frail elderly, patients with chronic care or long term care needs possible? The do's and the dont's in implementing integrated care.
PMCID: PMC2807094
chronic care model; multiple conditions
25.  Cystic fibrosis: addressing the transition from pediatric to adult-oriented health care 
Survival for patients with cystic fibrosis (CF) increased to nearly 40 years in 2012 from the early childhood years in the 1940s. Therefore, patients are living long enough to require transition from pediatric CF centers to adult CF centers. The goal of transition is for the young adult to be engaged in the adult health care system in ways that optimize health, maximize potential, and increase quality of life. A successful transition promotes autonomy and responsibility with respect to one’s own health. Currently, there is an information gap in the literature with respect to psychological models that can help guide informed transition processes. In this review, we establish the framework in which transition exists in CF; we review some of the published literature from the last 20 years of experience with transition in CF centers around the world; and we discuss psychological models of pediatric illness that can help to explain the current state of transition to adult-oriented care from pediatric-oriented care and help to formulate new models of ascertaining readiness for transition. Finally, we look at our current knowledge gaps and opportunities for future research endeavors.
doi:10.2147/PPA.S37710
PMCID: PMC3864992  PMID: 24376344
cystic fibrosis; transition; adolescent; social-ecological model of AYA readiness for transition; SMART

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