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2.  Changes in inflammation and quality of life after a single dose of infliximab during on-going treatment: Differences between patients with and without IBD symptoms at time of administration 
Infliximab is used increasingly as maintenance therapy for inflammatory bowel disease (IBD); however the effects of a single maintenance dose of infliximab are unclear with respect to quality of life and hormones related to growth and puberty.
Determine the time course of inflammatory, hormonal and quality-of-life changes following a single dose of infliximab in the context of on-going therapy, as related to presence of IBD symptoms at time of administration.
Children and adolescents with IBD receiving on-going therapy with infliximab for clinical indications were recruited. Pediatric Crohn’s Disease Activity Index (PCDAI) was determined at baseline and laboratory measures of hsCRP and hormones of growth and puberty were determined on Days 0, 2 and 14. IBD-related quality of life (IMPACT-III questionnaire) was tested on Days 0 and 14. Subjects who had symptoms of IBD were compared to asymptomatic subjects.
Subjects overall and in the symptomatic group exhibited improved hsCRP by Day 2 following treatment. Symptomatic subjects had higher PCDAI scores and lower quality-of-life scores than asymptomatic subjects on Day 0, while at Day 14 there were no significant differences in quality-of-life scores between the two groups.
Even in the context of on-going treatment, a single dose of infliximab results in decreased hsCRP an improvement that is particularly noted among subjects who are symptomatic at the time of treatment. While randomized trials are needed, these observational data may assist clinicians, patients and families regarding expectations about timing and extent of these changes following a single treatment dose.
PMCID: PMC3297691  PMID: 21946833
Inflammatory bowel disease; infliximab; inflammation; quality of life; adolescent
3.  Resident physicians as human information systems: sources yet seekers 
To characterize question types that residents received on overnight shifts and what information sources were used to answer them.
Materials and Methods
Across 30 overnight shifts, questions asked of on-call senior residents, question askers’ roles, and residents’ responses were documented. External sources were noted.
158 of 397 questions (39.8%) related to the plan of care, 53 (13.4%) to medical knowledge, 48 (12.1%) to taskwork knowledge, and 44 (11.1%) to the current condition of patients. For 351 (88.4%) questions residents provided specific, direct answers or visited the patient. For 16 of these, residents modeled or completed the task. For 216 questions, residents used previous knowledge or their own clinical judgment. Residents solicited external information sources for 118 questions and only a single source for 77 (65.3%) of them. For the 118, most questions concerned either the plan of care or the patient's current condition and were asked by interns and nurses (those with direct patient care responsibilities).
Resident physicians serve as an information system and they often specifically answer the question using previous knowledge or their own clinical judgment, suggesting that askers are contacting an appropriately knowledgeable person. However, they do need to access patient information such as the plan of care. They also serve an educator role and answer many knowledge-related questions.
As synchronous verbal communications continue to be important pathways for information flow, informaticians need to consider the relationship between such communications and workflow in the development of healthcare support tools.
PMCID: PMC3721153  PMID: 23268485
Information systems; Information seeking behavior; Information resources; Communication
4.  The Broad Street pump revisited: dairy farms and an ongoing outbreak of inflammatory bowel disease in Forest, Virginia 
Gut Pathogens  2011;3:20.
We report an ongoing outbreak of ulcerative colitis and Crohn's disease in Forest, Virginia involving 15 unrelated children and teenagers who resided in close proximity to dairy farms. Some of our cases demonstrated serologic evidence of Mycobacterium avium subspecies paratuberculosis infection, suggesting its potential role as an etiologic agent.
PMCID: PMC3287103  PMID: 22196128
inflammatory bowel disease; paratuberculosis; cluster; outbreak; aerosolization; fecal-oral waterborne transmission
5.  Collaborating With Physicians to Redesign a Sign-Out Tool 
Physician sign-out is a mechanism for transferring patient information from one group of hospital care-givers to another at shift changes. Support tools are critical to the success of sign-out. To ensure that a tool is effective, designers must collaborate with end users, but collaboration can be difficult when working with users who are busy and have irregular schedules. In this article, we report on a collaborative effort between physicians and engineers to redesign a sign-out support tool. Strategies included focus groups, interviews, “on-the-fly” feedback, and an iterative design process, which engaged end users in the design process. Task analysis methods enabled us to quantify the differences in functionality between the original tool and the prototype.
PMCID: PMC3148712  PMID: 21818174
sign-out; handoff of care; user-centered design; collaborative design; process support tools; medical decision making
6.  The Development of a Web-based Resident Sign-out Training Program 
Patient sign-out is a mechanism for transferring information, responsibility, and/or authority from one set of caregivers to another. Little research has addressed what information should be communicated during sign-out and how sign-out should be conducted and evaluated. As hospital residents conduct many sign-outs and have limited time in general, targeted web-based training and evaluation have the potential to enhance Graduate Medical Education. However there are no web-based training systems for this very important skill. This paper presents the operational concept and system requirements for a web-based sign-out training system. It discusses an initial functional prototype. Results of a heuristic evaluation and an assessment of areas for improvement are presented.
PMCID: PMC2995253  PMID: 21132053
Handoffof care; sign-out; medical decision making; web-based training
7.  Exploring the Relationship between Parental Worry about their Children's Health and Usage of an Internet Intervention for Pediatric Encopresis 
Journal of Pediatric Psychology  2008;34(5):530-538.
Objective To investigate whether parental worry about their children's health predicts usage of a pediatric Internet intervention for encopresis. Methods Thirty-nine families with a child diagnosed with encopresis completed a national clinical trial of an Internet-based intervention for encopresis ( Parents rated worry about their children's health, encopresis severity, current parent treatment for depression, and parent comfort with the Internet. Usage indicators were collected while participants utilized the intervention. Results Regression analyses showed that parents who reported higher baseline levels of worry about their children's health showed greater subsequent intervention use (β =.52, p =.002), even after accounting for other plausible predictors. Exploratory analyses indicated that this effect may be stronger for families with younger children. Conclusions Characteristics of individuals using Internet-based treatment programs, such as parental worry about their children's health, can influence intervention usage, and should be considered by developers of Internet interventions.
PMCID: PMC2722136  PMID: 18772228
8.  Real World Use of an Internet Intervention for Pediatric Encopresis 
The Internet is a significant source of medical information and is now being shown to be an important conduit for delivering various health-related interventions.
This paper aimed to examine the utility and impact of an Internet intervention for childhood encopresis as part of standard medical care in a “real world” setting.
Patients diagnosed with encopresis were given a Web-based information prescription to use an Internet intervention for pediatric encopresis. A total of 22 families utilized the intervention between July 2004 and June 2006. A chart review and phone interview were undertaken to collect user characteristics; defecation-related information, including frequency of soiling, bowel movements (BMs) in the toilet, and amount of pain associated with defecation; and information on computer/Internet usage. Three questionnaires were used to examine the utility of, impact of, and adherence to the Internet intervention. Program utilization was obtained from a data tracking system that monitored usage in real time.
Overall, parents rated the Internet intervention as enjoyable, understandable, and easy to use. They indicated that the Internet intervention positively affected their children, decreasing overall accidents and increasing child comfort on the toilet at home. Of the 20 children who initially reported fecal accidents, 19 (95%) experienced at least a 50% improvement, with a reduction of accident frequency from one fecal accident per day to one accident per week. Although it is not clear whether this improvement is directly related to the use of the Internet intervention, patient feedback suggests that the program was an important element, further establishing Internet interventions as a viable and desirable addition to standard medical care for pediatric encopresis.
To our knowledge, this is the first time a pediatric Internet intervention has been examined as part of a “real world” setting. This is an important step toward establishing Internet interventions as an adjunctive component to treatment of pediatric patients in a clinical setting, particularly given the positive user feedback, possible cost savings, and significant potential for large-scale dissemination.
PMCID: PMC2483922  PMID: 18653440
Internet; behavioral intervention; encopresis
9.  Impact of a Web-based Diagnosis Reminder System on Errors of Diagnosis 
A large number of medical errors can be attributed to errors in diagnosis. A diagnosis reminder system such as Isabel may lessen the risk of diagnostic error by providing a checklist of possible diagnoses. For this project, resident physicians used Isabel to work through a set of six simulated patient cases. The system had a positive effect on the mean diagnostic quality score and the number of clinically important diagnoses included in the differential.
PMCID: PMC1839669  PMID: 17238463
10.  Information Seeking in the NICU: Resident and Faculty Perspectives 
Little is know about how physicians utilize sources of patient information in complex medical environments such as the NICU. We conducted a qualitative study to investigate what sources of patient information physicians prefer to use in this setting. Results reveal a preference for physicians to use conversations with colleagues and the bedside flowsheet the majority of the time. Notes written by physicians - especially resident physicians - were used less frequently.
PMCID: PMC1480159  PMID: 14728301
11.  Computer-based Speech Recognition as an Alternative to Medical Transcription 
The purpose of this report is to describe the author's experience using computerized dictation during routine outpatient medical practice. During a six-month period, patients seen by the author in the Pediatric Gastroenterology Clinic at the University of Virginia were assigned to human or computer-based transcription. Of 1,129 notes, 580 were completed by a transcriptionist and 549 by computer. The total time spent dictating and editing notes was approximately one minute more for computerized dictation than for a human transcriptionist (379.81 ± 132.69 sec vs. 326.14 ± 126.02 sec; P < 0.0001). Notes generated by computer were slightly longer than notes generated by a transcriptionist (52.42 ± 16.45 lines vs. 50.41 ± 16.73 lines; P = 0.0422). Of notes generated by a transcriptionist, 139 (24 percent) were completed within two days of the visit, whereas all notes generated by computer were completed on the day of the visit.
PMCID: PMC134595  PMID: 11141516

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