Enhancing the practice of medicine with embedded multi-disciplinary researchers in a model of change.

Successfully embedding researchers in a health care setting brings unique challenges and opportunities. Through a joint clinical and academic partnership, we have developed a novel approach to problem-solving in the health care context, by employing a model for leading through change to embed researchers in transformative initiatives. Using the model, we have been able to leverage our local environment and resources to engage multi-disciplinary researchers in solving complex issues. An example is our initiative, Enhancing the Practice of Medicine, to address burnout among health care providers. Through this work, we have identified 3 primary factors critical to the successful deployment of embedded researchers. First and foremost, a multi-disciplinary team with diverse expertise is necessary to truly understand the root causes and potential solutions for complex issues. Second, this diverse team of embedded researchers must be involved from the initial stages of project design and have a voice throughout all phases of planning and assessing the initiative. Finally, embedded researchers will be most successful when they are supported to build relationships, navigate the system, and conduct research as part of an integrated and comprehensive effort that aligns with health system priorities.

Adolescent Trichomonas vaginalis in a High-burdened Region of the Southern United States.

BACKGROUND: We evaluated the clinical management and risk factors for Trichomonas vaginalis-positive adolescents in upstate South Carolina. METHODS: An Epic electronic medical record report was generated to identify any physician-ordered T. vaginalis test from February 2016 to December 2017 for patients aged 12 to 18 years within the Prisma Health Upstate system. Utilizing a case-control study design of patients with a documented T. vaginalis diagnostic result, we reviewed records of patients with physician-ordered T. vaginalis tests for demographics, clinical disease course, sexually transmitted infection test results, treatment order and dosage, infection risk factors, comorbidities, pregnancy term, and neonatal birth outcomes. RESULTS: Of 789 male and female adolescents with physician-ordered T. vaginalis tests, 44% had a documented result. Of those with a document test result, 13% were T. vaginalis positive. Cases (n = 45) and randomly selected negative controls (n = 45) were all girls. Cases were more likely to be African American, symptomatic, and present with vaginal discharge, pain, and vulvar itch. T. vaginalis patients were more likely to have documented histories of chlamydia (P < 0.0001) and gonorrhea (P = 0.0191), with 18% having concurrent triple infections (T. vaginalis, chlamydia, and gonorrhea). All 26 pregnant girls with T. vaginalis delivered full-term, healthy infants. CONCLUSIONS: We identified a disproportionally high burden of T. vaginalis infection, with an alarmingly high rate of triple infections, among a population of suspected high-risk adolescents. Our results indicate the need to clarify infection prevalence, develop pediatrician-focused education campaigns, and elucidate potentially modifiable risk factors for these high-risk patients.

Exploratory Study of rTMS Neuromodulation Effects on Electrocortical Functional Measures of Performance in an Oddball Test and Behavioral Symptoms in Autism.

There is no accepted pathology to autism spectrum disorders (ASD) but research suggests the presence of an altered excitatory/inhibitory (E/I) bias in the cerebral cortex. Repetitive transcranial magnetic stimulation (rTMS) offers a non-invasive means of modulating the E/I cortical bias with little in terms of side effects. In this study, 124 high functioning ASD children (IQ > 80, <18 years of age) were recruited and assigned using randomization to either a waitlist group or one of three different number of weekly rTMS sessions (i.e., 6, 12, and 18). TMS consisted of trains of 1.0 Hz frequency pulses applied over the dorsolateral prefrontal cortex (DLPFC). The experimental task was a visual oddball with illusory Kanizsa figures. Behavioral response variables included reaction time and error rate along with such neurophysiological indices such as stimulus and response-locked event-related potentials (ERP). One hundred and twelve patients completed the assigned number of TMS sessions. Results showed significant changes from baseline to posttest period in the following measures: motor responses accuracy [lower percentage of committed errors, slower latency of commission errors and restored normative post-error reaction time slowing in both early and later-stage ERP indices, enhanced magnitude of error-related negativity (ERN), improved error monitoring and post-error correction functions]. In addition, screening surveys showed significant reductions in aberrant behavior ratings and in both repetitive and stereotypic behaviors. These differences increased with the total number of treatment sessions. Our results suggest that rTMS, particularly after 18 sessions, facilitates cognitive control, attention and target stimuli recognition by improving discrimination between task-relevant and task-irrelevant illusory figures in an oddball test. The noted improvement in executive functions of behavioral performance monitoring further suggests that TMS has the potential to target core features of ASD.

A Cohort Study Comparing Women with Autism Spectrum Disorder with and without Generalized Joint Hypermobility.

Reports suggest comorbidity between autism spectrum disorder (ASD) and the connective tissue disorder, Ehlers-Danlos syndrome (EDS). People with EDS and the broader spectrum of Generalized Joint Hypermobility (GJH) often present with immune- and endocrine-mediated conditions. Meanwhile, immune/endocrine dysregulation is a popular theme in autism research. We surveyed a group of ASD women with/without GJH to determine differences in immune/endocrine exophenotypes. ASD women 25 years or older were invited to participate in an online survey. Respondents completed a questionnaire concerning diagnoses, immune/endocrine symptom history, experiences with pain, and seizure history. ASD women with GJH (ASD/GJH) reported more immune- and endocrine-mediated conditions than their non-GJH counterparts (p = 0.001). Autoimmune conditions were especially prominent in the ASD/GJH group (p = 0.027). Presence of immune-mediated symptoms often co-occurred with one another (p < 0.001-0.020), as did endocrine-mediated symptoms (p < 0.001-0.045), irrespective of the group. Finally, the numbers of immune- and endocrine-mediated symptoms shared a strong inter-relationship (p < 0.001), suggesting potential system crosstalk. While our results cannot estimate comorbidity, they reinforce concepts of an etiological relationship between ASD and GJH. Meanwhile, women with ASD/GJH have complex immune/endocrine exophenotypes compared to their non-GJH counterparts. Further, we discuss how connective tissue regulates the immune system and how the immune/endocrine systems in turn may modulate collagen synthesis, potentially leading to higher rates of GJH in this subpopulation.

Atypical Processing of Novel Distracters in a Visual Oddball Task in Autism Spectrum Disorder.

Several studies have shown that children with autism spectrum disorder (ASD) show abnormalities in P3b to targets in standard oddball tasks. The present study employed a three-stimulus visual oddball task with novel distracters that analyzed event-related potentials (ERP) to both target and non-target items at frontal and parietal sites. The task tested the hypothesis that children with autism are abnormally orienting attention to distracters probably due to impaired habituation to novelty. We predicted a lower selectivity in early ERPs to target, frequent non-target, and rare distracters. We also expected delayed late ERPs in autism. The study enrolled 32 ASD and 24 typically developing (TD) children. Reaction time (RT) and accuracy were analyzed as behavioral measures, while ERPs were recorded with a dense-array EEG system. Children with ASD showed higher error rate without normative post-error RT slowing and had lower error-related negativity. Parietal P1, frontal N1, as well as P3a and P3b components were higher to novels in ASD. Augmented exogenous ERPs suggest low selectivity in pre-processing of stimuli resulting in their excessive processing at later stages. The results suggest an impaired habituation to unattended stimuli that incurs a high load at the later stages of perceptual and cognitive processing and response selection when novel distracter stimuli are differentiated from targets.

Training the Motor Aspects of Pre-driving Skills of Young Adults With and Without Autism Spectrum Disorder.

The purpose of this study was to investigate the utility of using a driving simulator to address the motor aspects of pre-driving skills with young adults with Autism Spectrum Disorder (ASD). A group of neurotypical control participants and ten participants with ASD completed 18 interactive steering and pedal exercises with the goal to achieve error-free performance. Most participants were able to achieve this goal within five trials for all exercises except for the two most difficult ones. Minimal performance differences were observed between the two groups. Participants with ASD needed more time to complete the tasks. Overall, the interactive exercises and the process used worked well to address motor related aspects of pre-driving skills in young adults with ASD.

Learning disorders in adolescence: the role of the primary care physician.

Adolescents with learning disorders are at significantly increased risk for negative outcomes in regard to their emotional, behavioral, and academic functioning. Primary care physicians should be alert to the effect of neurodevelopmental dysfunctions that might be taking their toll as academic demands increase or as new manifestations of previously identified problems emerge. The physician should review emotional, family, and environmental factors and rule out underlying or associated medical causes and can participate in the assessment process. He or she can advise and assist parents with obtaining necessary evaluations through the school or by referral to independent clinicians and should assist with the interpretation of the findings, ensuring appropriate understanding of the challenges by the adolescent and parents and coordinating care if other medical specialists are involved. The physician can direct students and their families to appropriate resources in the community and advocate for appropriate educational services at school. Brief office-based counseling can help in dealing with the stresses associated with learning challenges and ensuring that students are afforded regular opportunities to pursue their affinities and build on their strengths.

Identifying school performance problems in the pediatric office.

The AAP has underscored the role and responsibility of pediatricians in screening their patients for developmental and learning problems and working with parents, schools, and other professionals to ensure that students with these problems receive appropriate educational and therapeutic interventions. We have proposed a model that is time-efficient and can be tailored to the level of interest and experience of the pediatrician. At a minimum, the primary care physician should elicit any parental concerns about school performance, affirm these, and direct the student and parents to appropriate resources in the community for further evaluation and intervention as necessary. Pediatricians who wish to understand more fully the nature and underpinnings of their patients' learning difficulties can formulate a preliminary diagnosis and develop a plan for treatment using a structured system of information gathering that can be combined with information about the child's medical status and supplemented by brief direct testing in the office setting. By following these approaches, primary care pediatricians can provide comprehensive care for their patients and their families in their medical home and also can derive considerable professional satisfaction.

Developmental and behavioral pediatric practice patterns and implications for the workforce: results of the Future of Pediatric Education II Survey of Sections Project.

A survey of developmental-behavioral pediatricians was conducted to obtain data and insights on their current practice. As part of the Future of Pediatric Education (FOPE) II Survey of Sections Project, questionnaires were sent to individuals who were most likely to represent those pediatricians engaged in the subspecialty of developmental-behavioral pediatrics. Four groups of physicians were compared within the survey: developmental-behavioral fellowship group (n = 272), developmental disabilities fellowship group (n = 139), general academic pediatrics or other fellowship group (n = 57), and a nonfellowship group (n = 224). A majority of respondents indicated a need for an increased number of subspecialists in developmental-behavioral pediatrics in their community during the next 3 to 5 years. There were significant differences in the survey results of a variety of practice issues between those who had and had not received formal fellowship training. The survey data illustrate a developmental-behavioral pediatrician workforce that is becoming increasingly fellowship trained, receiving more referrals, and encountering constraints to seeing more patients in an era of declining reimbursement for services. To overcome these obstacles, stakeholders in child health, including health care payers, will need to be educated about the unique skills and clinical expertise of physicians in developmental-behavioral pediatrics and neurodevelopmental disabilities.