Common in Adults and Often Overlooked in Pediatrics: A Case Report of Primary Hyperparathyroidism in an Adolescent Patient.

Primary hyperparathyroidism (pHPT) is a rare clinical entity in pediatric patients relative to adults. Consequently, the diagnosis is often delayed in pediatric patients, and children and adolescents are more likely to present with symptoms of hypercalcemia and end-organ damage. Here, we present the case of an adolescent patient with chest pain who was found to have a lytic bone lesion secondary to pHPT.

Hospital Discharge Instructions: Characteristics, Accessibility, and National Guideline Adherence.

OBJECTIVES: The content of pediatric hospital discharge instructions is highly variable. This study aimed to describe the characteristics, accessibility per patient literacy level and language, and national guideline adherence of pediatric hospital discharge instructions. METHODS: This retrospective study assessed discharge instructions at a tertiary children's hospital. Patient and instruction characteristics, including patient health literacy level, grade level of instructions, patient language preference, and language of instructions were collected via chart review and electronic medical record query. Standard admission processes assessed health literacy via Brief Health Literacy Screening. The association between demographic and clinical characteristics and adherence to Solutions for Patient Safety guidelines was analyzed by using unadjusted and adjusted analysis methods. RESULTS: Of 240 discharge instructions, 25% were missing at least 1 recommended content area: signs of worsening, where to seek help, or medication reconciliation. A patient health literacy deficit was identified in 15%; the mean grade level of instructions was 10.1. Limited English proficiency was reported among 17% one quarter of whom received language concordant instructions. Use of discharge instruction templates and discharge services were associated with improved guideline adherence (P <.001). Almost one-half of the study population had a complex medical history, which was associated with decreased guideline adherence (P = .04). CONCLUSIONS: One-quarter of discharge instructions for this predominantly medically complex population failed to meet national standards. Accessibility was often limited by the reading grade level or discordant language of instructions. Templates may be a valuable tool for improving discharge instruction content, accessibility, and adherence to national guidelines.

Identifying and Supporting the Needs of Internal Medicine and Pediatrics Residents Interested in Pediatric Hospital Medicine Fellowship.

BACKGROUND: Pediatric hospital medicine (PHM) became a subspecialty of the American Board of Pediatrics (ABP) in 2016. Starting in 2019, residency graduates are required to complete fellowship training to qualify for PHM board eligibility. These requirements pose unique challenges to internal medicine-pediatrics (med-peds) residents interested in practicing combined adult hospital medicine (HM) and PHM. OBJECTIVE: To describe the needs of med-peds residents interested in PHM fellowship training and how the current PHM training environment can meet these needs. METHODS: We conducted two cross-sectional electronic survey studies: one of med-peds residents and one of PHM fellowship program directors (FDs). Surveys were distributed to resident and FD listservs. Questions were designed using an iterative consensus process among authors. Responses were analyzed with descriptive statistics. RESULTS: Four hundred sixty-six residents responded to the resident survey. Ninety-six percent (n = 446) had considered a career in HM. Almost all (n = 456, 97.9%) respondents indicated a preference for a fellowship with both adult HM and PHM clinical training. Subspecialty designation decreased desire to pursue a career including PHM for 90.1% of respondents. Twenty-eight (58.3%) FDs responded to the FD survey. Fifteen (53.6%) programs reported being able to accommodate adult HM and PHM clinical time. CONCLUSION: The majority of resident respondents reported a desire for a PHM fellowship with clinical time in both PHM and adult HM. Approximately 30% of current US PHM fellowship programs can accommodate adult HM practice for med-peds fellows, and many other programs would be willing to explore such opportunities.

Trends in Technology Assistance Among Patients With Childhood Onset Chronic Conditions.

OBJECTIVE: To describe the prevalence, types, and trends over time of medical technology assistance (TA) in patients at the age of transition to adult care with childhood onset chronic conditions (COCCs) cared for at children's hospitals. PATIENTS AND METHODS: In this retrospective repeated annual cross-sectional cohort study of the Pediatric Health Information Systems inpatient data, patients with at least 1 hospitalization from January 1, 2008, to December 31, 2018 with a selected COCC were included. The COCCs investigated were brain and spinal cord malformation, cerebral palsy, heart and great vessel malformation, cystic fibrosis, sickle cell anemia, and chronic renal failure. TA was defined as requiring an indwelling medical device to maintain health status. Trends over time in TA were analyzed with the Cochran-Armitage test and generalized linear models. RESULTS: During the study, 381 289 unique patients accounted for 940 816 hospitalizations. Transition-aged patients (19-21 years old) represented 2.4% of all included hospitalizations over the 11-year period, whereas patients ages 21 and above represented 2.7%. The annual proportion of patients with TA increased significantly from 31.3% in 2008 to 36.9% in 2018, a 17.9% increase (P < .001). CONCLUSIONS: In this cohort of patients with select COCCs hospitalized at children's hospitals, a substantial and growing number of patients at the age of transition to adult care required TA. Identifying adult providers with resources to manage COCCs and maintain medical devices placed in childhood is challenging. These trends warrant special attention to support the timely and successful transition of medically complex patients from pediatric to adult care.

Performance of commonly used respiratory questionnaire items in a cohort of infants born preterm.

BACKGROUND: Items from respiratory questionnaires validated in older children are often used in research studies of preterm infants, although they have not been validated in this population. We aimed to assess both test-retest reliability and convergent validity of a group of commonly used respiratory questionnaire items in a cohort of preterm infants. METHODS: The health status of 300 preterm infants was assessed by telephone questionnaire as part of a prospective cohort study. The questionnaire items analyzed in this study included six commonly used respiratory questions. The questionnaire responses used in this analysis were from the telephone follow-up in this cohort at six months of age adjusted for prematurity. A repeat interview one to two weeks after this interview was performed in a subset of subjects to assess test-retest reliability. The convergent validity of the respiratory items was also assessed by calculating the associations among the responses to the respiratory questions. RESULTS: A total of 43 infants were singletons that met the criteria for test-retest reliability analysis. All of the respiratory questions demonstrated fair to strong test-retest reliability. Among 206 respondents, respiratory questionnaire items also demonstrated strong convergent validity, in that caretakers reporting wheezing or whistling in the chest were significantly more likely to also report other respiratory events. CONCLUSIONS: This selection of standard respiratory questionnaire items performed well for research purposes in this population.

Keratinizing squamous dysplasia pap test: a case for colposcopy.

OBJECTIVE: This study characterized women with Pap tests showing keratinizing squamous dysplasia (KSD) and helped develop management strategies in these patients. METHODS: This is a retrospective chart review of women presenting to Palmetto Health Women's Center with KSD on a Pap test from 1999 to 2009. Data analysis was performed with standard statistical computer programming; null hypothesis was rejected for p values .05 or less. RESULTS: A total of 65 Pap tests with KSD were identified. We found that women with KSD were statistically older (35 vs 26.8 y) and were more likely African American and less likely Hispanic than the general clinic population at Palmetto Health Women's Center. There were no statistical differences in body mass index or history of teen pregnancy. Interestingly, 41% of the women with KSD were immunosuppressed (e.g., human immunodeficiency virus infection, end-stage renal disease, long-term steroid use). All women with KSD were referred for colposcopy; 24% of patients failed to follow-up. Pathology distribution on cervical biopsies were similar to what is found after high-grade squamous intraepithelial lesion findings in Pap tests, with 58% cervical intraepithelial neoplasia (CIN) 2/3 or cancer, 32% CIN 1, and 10% negative biopsies. Of the women who had CIN 1 on cervical biopsy, 80% had persistent dysplasia or abnormal Pap test. Also, 60% had CIN 1 and 20% progressed to CIN 2/3 or carcinoma in situ. CONCLUSIONS: Our data suggest that women with KSD on Pap test should be managed aggressively with immediate colposcopy and cervical biopsies and not with expectant management.