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2.
J Anal Toxicol ; 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33002141

RESUMO

Cannabis is the most commonly used drug of abuse in pregnancy and after delivery. However, little is known regarding the disposition of cannabinoids in breast milk, although delta-9-tetrahydrocannabinol (THC), the main psychoactive component, is highly lipophilic. Quantification of cannabinoids in breastmilk is essential for clinical monitoring and research studies and breastmilk banks mainly rely on ELISA in terms of screening for cannabinoids. To support clinical studies on disposition of cannabinoids in breastmilk, we validated a high-performance liquid chromatography-tandem mass spectrometry (LC-MS-MS) assay for the simultaneous quantification of 12 cannabinoids and their metabolites in human breast milk. Said assay was based upon a simple one-step protein precipitation, online column extraction and detection in the positive multiple reaction monitoring mode. After successful validation, the assay was used to analyze 30 samples from a clinical research study that had tested negative using an ELISA kit that is commonly used by breastmilk banks. In human breast milk, depending on the analyte, the lower limits of quantification of the LC-MS-MS assay ranged from 0.39 to 7.81 ng/mL. Acceptance criteria for intra- and inter-batch accuracy (85-115%) and imprecision (<15%) were met for all compounds. Mean extraction efficiencies were above 60% for all analytes. Mean matrix effect ranged from -12.5% to 44.5% except of THC- glucuronide for which significant matrix effects were noted. No carry-over was detected. Although cannabinoid-negative based on the ELISA, all 30 samples tested positive for THC using LC-MS-MS (0.8-130 ng/mL) and several also for 11-OH-THC, THCCOOH, CBD and CBG. We validated a sensitive and specific assay for the quantification of 12 cannabinoids in human breastmilk that outperformed an ELISA commonly used by breastmilk banks.

3.
Acad Pediatr ; 20(5): 595-599, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32045680

RESUMO

OBJECTIVE: Pregnancy is common during residency, yet the duration of allowed paid leave is inadequate and utilizing unpaid family medical leave act (FMLA) time has financial and professional consequences. We evaluated the effectiveness of a novel parenting elective, consistent with educational goals for pediatric residents, on resident parents' financial, academic, and family outcomes. METHODS: In 2010, a 2-4 week structured at-home elective of outpatient neonatal care with full pay was implemented. Data were collected from all new parents in a large academic pediatric residency from 2002 to 2018, including duration of leave, on-time graduation, choice to pursue postresidency training, and unpaid FMLA leave. Data were compared from before/after implementation and by parent type (mothers or resident partners of mothers). RESULTS: Twenty-two pregnancies occurred prior to implementation and 42 afterward. In mothers, leave duration was similar (7.9 ± 3.5 weeks before, 8.0 ± 0.3 after, P = .50) but the minimum time increased from 2 to 6 weeks and those taking ≥7 weeks increased (54% vs 96%, P = .002). Mothers using unpaid FMLA time decreased (38% vs 7%, P = .04) although on-time graduation (69% vs 93%, P = .13) and postresidency training rates were similar. Among partners, leave duration increased (0.8 ± 0.4 weeks vs 4.0 ± 1.7, P < .001) and 79% took ≥4 weeks, compared to 0% pre-elective (P < .001). In partners, postresidency training, FMLA, or on-time graduation rates did not change. CONCLUSIONS: Parenting a neonate provides learning opportunities for pediatric residents that can be encompassed in an elective consistent with training requirements. This elective improved outcomes for mothers and partners and is generalizable to any training program.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31749100

RESUMO

Early identification and treatment of depression during adolescence can contribute to healthier outcomes across the lifespan, yet adolescent depression has been underidentified and undertreated. The American Academy of Pediatrics' (AAP) Guidelines for Adolescent Depression in Primary Care (GLAD-PC) were created to enhance the identification and treatment of adolescent depression. Integrated psychologists in a pediatric primary care setting partnered with providers and clinic staff to implement an adolescent depression screening initiative and transform primary care practice around identification and management. From January 2017 through August 2018, 2107 adolescents between the ages of 11 and 18 were screened using the PHQ-9A. Eleven percent (n = 226) of adolescents had an elevated screen with a score of ≥ 10 and 7% (n = 151) screened positive for suicidal ideation. Identification of depressive symptoms led to increased integrated behavioral health services delivered by psychologists, psychiatrists, and psychology trainees. Psychologists integrated in primary care can support primary care practices to develop service delivery systems aligned with AAP's GLAD-PC and address the diverse implementation barriers associated with incorporating clinical practice guidelines in real-world settings. Universal screening for adolescent depression and response protocols were successfully implemented in a pediatric primary care clinic under the leadership of psychologists and pediatrician partners.

5.
Child Adolesc Psychiatr Clin N Am ; 26(4): 703-715, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28916009

RESUMO

Integrated behavioral and mental health systems of care for children require multidisciplinary team members to have specific competencies and knowledge of the other disciplines' strengths and practice needs. Training models for multidisciplinary professionals should consider the developmental level of trainees. The authors describe a model of flexible scaffolding, increasing intensity, and depth of experience as trainees gain skills and knowledge.


Assuntos
Psiquiatria Infantil/educação , Internato e Residência , Pediatria/educação , Competência Clínica , Prestação Integrada de Cuidados de Saúde , Humanos , Atenção Primária à Saúde/organização & administração
7.
Front Public Health ; 5: 60, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28405582

RESUMO

Telehealth education has the potential to serve as an important, low-cost method of expanding healthcare worker education and support, especially in rural settings of low- and middle-income countries. We describe an innovative educational strategy to strengthen a long-term health professional capacity building partnership between Guatemalan and US-based partners. In this pilot evaluation, community health nurses in rural Guatemala received customized, interactive education via telehealth from faculty at the supporting US-based institution. Program evaluation of this 10 lecture series demonstrated high levels of satisfaction among learners and instructors as well as knowledge gain by learners. An average of 5.5 learners and 2 instructors attended the 10 lectures and completed surveys using a Likert scale to rate statements regarding lecture content, technology, and personal connection. Positive statements about lecture content and the applicability to daily work had 98% or greater agreement as did statements regarding ease of technology and convenience. The learners agreed with feeling connected to the instructors 100% of the time, while instructors had 86.4% agreement with connection related statements. Instructors, joining at their respective work locations, rated convenience statements at 100% agreement. This evaluation also demonstrated effectiveness with an average 10.7% increase in pre- to posttest knowledge scores by learners. As the global health community considers efficiency in time, money, and our environment, telehealth education is a critical method to consider and develop for health worker education. Our pilot program evaluation shows that telehealth may be an effective method of delivering education to frontline health workers in rural Guatemala. While larger studies are needed to quantify the duration and benefits of specific knowledge gains and to perform a cost-effectiveness analysis of the program, our initial pilot results are encouraging and show that a telehealth program between a US-based university and a rural community health program in a low- and middle-income country is both feasible and acceptable.

8.
J Pediatr Psychol ; 41(10): 1120-1132, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27424483

RESUMO

OBJECTIVE: The current study examines the scope of integrated behavioral health services provided by behavioral health clinicians in pediatric primary care. METHODS: A cross-sectional electronic health record review was conducted to characterize integrated behavioral health services including consultation types, recommendations, and medical diagnoses. Services were provided over a 6-year period in an urban, residency-training clinic serving a primarily publicly insured population. RESULTS: Of the 4,440 patients seen by behavioral health clinicians (BHCs), 2,829 (63.7%) were seen during well-child checks to address a wide array of presenting problems. The five consultation types "Healthy Steps (6%), pregnancy-related depression (17.7%), developmental (19.2%), mental health (53.2%), and psychopharmacology (5%)" were characterized by differences in demographics, presenting problems, recommendations, and medical diagnoses. CONCLUSIONS: Pediatric BHCs provide a wide range of services to pediatric populations in the context of integrated behavioral health programs. Implications for workforce capacity development, evaluation of outcomes and impact, and sustainability are discussed.


Assuntos
Serviços de Saúde da Criança/organização & administração , Serviços Comunitários de Saúde Mental/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Transtornos Mentais/diagnóstico , Atenção Primária à Saúde/organização & administração , Adolescente , Criança , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Colorado , Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Estudos Transversais , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Registros Eletrônicos de Saúde , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Atenção Primária à Saúde/estatística & dados numéricos
10.
Pediatrics ; 134(4): e1181-8, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25180272

RESUMO

BACKGROUND AND OBJECTIVES: Screening, early identification, and referral improves outcomes for young children at risk for developmental delays. Effective developmental screening processes should include efforts to ensure referral completion and documentation of evaluation results and service eligibility in the child's medical record. Our objectives were to improve provider documentation of actions taken after an abnormal developmental screening result and increase Early Intervention (State Part C) referrals. METHODS: Various strategies including an electronic medical record template, monthly clinical informatics reporting, and a phone follow-up after an abnormal screening result were implemented to enhance provider documentation of screening results and improve referral actions and outcomes. RESULTS: Of the children eligible for screening (n = 3023), 2610 (86%) were screened, with 382 (15%) scoring in the abnormal range. With phone follow-up, 50% of the abnormal screenings were referred to community resources, including 43% to Early Intervention (EI), in contrast to 20% community referrals and 13% EI referrals with the screening template only (P < .0001). Provider documentation of EI outcomes increased when screening templates and follow-up calls were implemented together (31%) as compared with using the screening template alone (15%). CONCLUSIONS: Enhanced documentation of developmental screening efforts using screening templates and clinical informatics reporting in combination with phone follow-up after an abnormal screening result improved developmental screening outcomes, including referral rates, completed evaluations, and provider documentation of EI services. Such strategies can be effectively used in pediatric primary care settings to improve screening processes and ensure that young children access appropriate services.


Assuntos
Deficiências do Desenvolvimento/diagnóstico , Triagem Neonatal/tendências , Melhoria de Qualidade/tendências , Encaminhamento e Consulta/tendências , Pré-Escolar , Deficiências do Desenvolvimento/epidemiologia , Feminino , Seguimentos , Hospitais Pediátricos/normas , Hospitais Pediátricos/tendências , Humanos , Lactente , Recém-Nascido , Masculino , Triagem Neonatal/normas , Melhoria de Qualidade/normas , Encaminhamento e Consulta/normas , Fatores de Risco
11.
J Hum Lact ; 30(2): 143-7, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24595703

RESUMO

The breastfeeding experience for the mother and infant is often complicated by a constellation of challenges that are difficult for lactation consultants alone to treat. To address this issue, a breastfeeding consultation clinic at Children's Hospital Colorado developed a multidisciplinary team: a pediatrician specializing in breastfeeding medicine, a lactation consultant, and a clinical psychologist specializing in infant mental health and child development. This Trifecta Breastfeeding Approach meets families' needs by addressing the infant's medical care, functional breastfeeding challenges, and the developing mother-infant relationship, and by screening for concurrent pregnancy-related mood disorders. The Approach also recognizes family dynamics and the transition to parenthood within the breastfeeding consultation. Issues of lost expectations, grief, infertility, high-risk infants, and fussiness often need to be addressed. Case examples here illustrate the benefits of this multidisciplinary, integrated health model. This type of integrated care will likely have an increased presence in health care systems as reimbursement for psychologists' fees and innovative models of care continue to emerge.


Assuntos
Aleitamento Materno/métodos , Depressão Pós-Parto/terapia , Saúde Mental , Pediatria/métodos , Consultores , Feminino , Humanos , Gravidez
12.
13.
Breastfeed Med ; 8(6): 469-73, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24320091

RESUMO

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.


Assuntos
Aleitamento Materno , Promoção da Saúde/organização & administração , Centros de Saúde Materno-Infantil , Mães , Período Periparto , Adulto , Protocolos Clínicos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Política de Saúde , Humanos , Recém-Nascido , Masculino , Centros de Saúde Materno-Infantil/organização & administração , Leite Humano , Educação de Pacientes como Assunto , Gravidez , Apoio Social
14.
Acad Pediatr ; 13(6): 551-7, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24238682

RESUMO

OBJECTIVE: To determine whether pediatric continuity clinics integrate mental health (MH) services into care delivery; and to determine whether the level of MH integration is related to access to MH services, types of MH screening performed, self-efficacy, satisfaction with referral sites, and communication with the primary care provider. METHODS: Pediatric Residency Integrated Survey of Mental Health in Primary Care (PRISM_PC) is a newly designed cross-sectional, Web-based survey of continuity clinic directors participating in a national network of pediatric continuity clinics (CORNET). Definitions of MH models included integrated or nonintegrated MH models or traditional care. The survey included questions regarding access, screening that was performed at sites, comfort with MH management as well as provider satisfaction and communication with referral sites. RESULTS: Seventy-eight percent (57 of 73) of CORNET site directors responded, representing input from 30% of US pediatric residency continuity programs. Thirty-five percent (n = 20) reported an integrated MH model while 65% (n = 37) reported a nonintegrated MH model. Seventy-nine percent screened for attention-deficit/hyperactivity disorder, 44% for behavioral-emotional issues, and 19% for pediatric depression. No differences were found in terms of screening or tools used on the basis of the level of MH integration. Those with integrated programs were more likely to have access to an on-site psychologist (P = .001) or psychiatrist (P = .006). CONCLUSIONS: Directors from one-third of training programs surveyed reported some level of MH integration in their primary care teaching clinics. Future studies are needed to compare patient and resident education outcomes between integrated and nonintegrated sites.


Assuntos
Serviços de Saúde Comunitária/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Pediatria/educação , Atenção Primária à Saúde/organização & administração , Serviços Comunitários de Saúde Mental/organização & administração , Pesquisas sobre Serviços de Saúde , Acesso aos Serviços de Saúde/organização & administração , Humanos , Internato e Residência
15.
Pediatrics ; 132(2): e502-11, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23858424

RESUMO

BACKGROUND AND OBJECTIVE: Although comprehensive smoking counseling to limit secondhand smoke (SHS) is widely endorsed, it is often not done. Published evaluations of brief and practical systems that improve screening and counseling to reduce SHS are limited. Our objective was to determine if a quality improvement activity around smoking counseling leads to changes in (1) medical assistant and pediatric provider assessment of smoking history and (2) smoking or other behaviors affecting children's SHS exposure. METHODS: In a large urban teaching clinic we assessed the ONE Step intervention, which included the following: (1) "Ask" (medical assistant asking whether caregivers smoke); (2) "Advise" (providers advising smoking outside and quitting if ready); (3) "Refer" (providers referring to the Colorado telephone QuitLine); and (4) electronic medical record prompts and required documentation regarding smoking. Medical assistant and provider assessments of smoking were evaluated with a chart review by using a pre-/posttest design. Caregiver behavior change was evaluated with a time-series survey that included assessment at baseline and follow-up via telephone at 6 and 12 months from study entry. RESULTS: ONE Step was associated with a statistically significant increase in Ask, Advise, and Refer documentation. Caregiver surveys showed that 97% found discussions of SHS with providers acceptable. Six- and 12-month follow-ups, respectively, showed that 14% and 13% of smokers reported quitting and that 63% and 70% of current smokers reported reduced SHS exposure. CONCLUSIONS: ONE Step was feasible to deliver in a busy outpatient setting, acceptable to families, and appears to have resulted in decreased exposure to SHS in our pediatric population.


Assuntos
Educação de Pacientes como Assunto/métodos , Melhoria de Qualidade , Abandono do Hábito de Fumar/métodos , Poluição por Fumaça de Tabaco/prevenção & controle , Adulto , Criança , Colorado , Comportamento Cooperativo , Documentação/normas , Registros Eletrônicos de Saúde , Feminino , Seguimentos , Hospitais de Ensino , Hospitais Urbanos , Humanos , Comunicação Interdisciplinar , Masculino , Ambulatório Hospitalar , Assistentes Médicos , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta
16.
Breastfeed Med ; 8(4): 349-53, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23886478

RESUMO

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.


Assuntos
Aleitamento Materno/métodos , Fenda Labial/fisiopatologia , Fissura Palatina/fisiopatologia , Feminino , Humanos , Lactente , Recém-Nascido , Leite Humano
17.
Pediatr Clin North Am ; 60(1): 115-45, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23178062

RESUMO

Although a large majority of US mothers now begin breastfeeding, exclusive breastfeeding rates fall far below national health objectives, with vulnerable populations being least likely to breastfeed exclusively. This article explores common personal and societal barriers to exclusive breastfeeding and offers evidence-based strategies to support mothers to breastfeed exclusively, such as ensuring prenatal education, supportive maternity practices, timely follow-up, and management of lactation challenges. The article also addresses common reasons nursing mothers discontinue exclusive breastfeeding, including the perception of insufficient milk, misinterpretation of infant crying, returning to work or school, early introduction of solid foods, and lack of support.


Assuntos
Aleitamento Materno , Cuidado do Lactente , Lactação , Atitude Frente a Saúde , Aleitamento Materno/métodos , Aleitamento Materno/psicologia , Aleitamento Materno/estatística & dados numéricos , Emprego , Feminino , Hospitais , Humanos , Lactente , Cuidado do Lactente/métodos , Cuidado do Lactente/psicologia , Fórmulas Infantis , Recém-Nascido , Lactação/fisiologia , Lactação/psicologia , Serviços de Saúde Materna , Política Organizacional , Papel do Médico , Gravidez , Cuidado Pré-Natal , Meio Social , Fatores Socioeconômicos , Estados Unidos
18.
J Mammary Gland Biol Neoplasia ; 17(2): 167-88, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22752723

RESUMO

This paper resulted from a conference entitled "Lactation and Milk: Defining and refining the critical questions" held at the University of Colorado School of Medicine from January 18-20, 2012. The mission of the conference was to identify unresolved questions and set future goals for research into human milk composition, mammary development and lactation. We first outline the unanswered questions regarding the composition of human milk (Section I) and the mechanisms by which milk components affect neonatal development, growth and health and recommend models for future research. Emerging questions about how milk components affect cognitive development and behavioral phenotype of the offspring are presented in Section II. In Section III we outline the important unanswered questions about regulation of mammary gland development, the heritability of defects, the effects of maternal nutrition, disease, metabolic status, and therapeutic drugs upon the subsequent lactation. Questions surrounding breastfeeding practice are also highlighted. In Section IV we describe the specific nutritional challenges faced by three different populations, namely preterm infants, infants born to obese mothers who may or may not have gestational diabetes, and infants born to undernourished mothers. The recognition that multidisciplinary training is critical to advancing the field led us to formulate specific training recommendations in Section V. Our recommendations for research emphasis are summarized in Section VI. In sum, we present a roadmap for multidisciplinary research into all aspects of human lactation, milk and its role in infant nutrition for the next decade and beyond.


Assuntos
Aleitamento Materno , Desenvolvimento Infantil , Lactação , Glândulas Mamárias Humanas/crescimento & desenvolvimento , Glândulas Mamárias Humanas/metabolismo , Leite Humano/metabolismo , Morfogênese , Adulto , Animais , Animais Recém-Nascidos , Pesquisa Biomédica/tendências , Suscetibilidade a Doenças , Feminino , Humanos , Lactente , Recém-Nascido , Intestinos/crescimento & desenvolvimento , Intestinos/microbiologia , Glândulas Mamárias Animais , Doenças Metabólicas/etiologia , Doenças Metabólicas/prevenção & controle , Leite/metabolismo
19.
Acad Pediatr ; 11(1): 58-65, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21272825

RESUMO

OBJECTIVE: The aim of this study was to determine if a quality improvement intervention in a teaching clinic was associated with the following: 1) improved asthma action plan creation and distribution, 2)increased classification of asthma patients as intermittent or persistent, 3) increased prescriptions of asthma controller medications, 4) decreased emergency department visits and hospitalizations, and 5) sustainable changes in outcomes after the intervention year. METHODS: A retrospective analysis was conducted of a quality improvement project involving children aged >2 years who were diagnosed with asthma, evaluated in a large hospital-based teaching clinic. Outcomes were assessed for 1 year before and 3 years after quality improvement intervention. RESULTS: Data from children with asthma seen in the clinic over the 4 years of the study (N = 1797) were analyzed. Mixed effects model regressions showed that children after the intervention were over twofold more likely to receive an asthma action plan (using 2006 as referent, adjusted risk ratio [ARR] 2.29, 95% confidence interval [CI] 2.03-2.56 in 2007; ARR 2.40, 95% CI 2.15-2.66 in 2008; ARR 2.86, 95% CI 2.60-3.20 in 2009). Recorded assessment of asthma severity was 31% to 47% more likely post-intervention (ARR 1.31, 95% CI 1.26-1.36 in 2007, ARR 1.44 95% CI 1.38-1.50 in 2008, ARR 1.47 95% 1.41-1.54 in 2009). Controller medication prescribing increased postintervention ARR 1.08, 95% CI, 1.02-1.14 in 2007; ARR 1.11, 95% CI, 1.04-1.17 in 2008; ARR 1.11, 95% CI, 1.05-1.19 in 2009. Emergency department visits and hospitalizations trended lower postintervention (not significant). CONCLUSIONS: A quality improvement intervention in a hospital-based teaching clinic was associated with increased use of asthma action plans, classification of asthma severity, and controller medications, and possibly a trend toward fewer emergency visits and hospitalizations.


Assuntos
Albuterol/uso terapêutico , Asma/tratamento farmacológico , Broncodilatadores/uso terapêutico , Assistência Centrada no Paciente/métodos , Adolescente , Asma/diagnóstico , Criança , Pré-Escolar , Colorado , Uso de Medicamentos , Feminino , Hospitais de Ensino , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Ambulatório Hospitalar , Pobreza , Melhoria de Qualidade , Análise de Regressão , Estudos Retrospectivos , Índice de Gravidade de Doença , Inquéritos e Questionários
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