Publications by authors named "Ann Thompson"

116 Publications

Lipid therapy: A new whiteboard video for patient education.

Can Pharm J (Ott) 2021 May-Jun;154(3):175-178. Epub 2021 Apr 23.

Department of Pharmacy, St. Boniface Hospital, Winnipeg, MB.

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http://dx.doi.org/10.1177/17151635211006166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165892PMC
April 2021

Riding the rapids: COVID-19, the three rivers curriculum, and the experiences of the university of pittsburgh school of medicine.

FASEB Bioadv 2021 Feb 24. Epub 2021 Feb 24.

University of Pittsburgh School of Medicine Pittsburgh PA USA.

When faced with the COVID-19 pandemic this past spring, the University of Pittsburgh's School of Medicine (UPSOM) took rapid steps to ensure the safety of students, staff, and the faculty as well as to maintain the educational process. Curriculum reform efforts, already underway, proved to be an advantage in the transformation. We quickly converted to a remote and then a hybrid curriculum. Research labs were reopened with appropriate safety measures. Clinical experiences for students restarted via a phased process that emphasized safety and graduation requirements. A variety of assessment mechanisms were restarted with appropriate modifications. New teaching models, such as flipped classrooms, have become the norm, and it seems hard to imagine our returning to our old pedagogy. The curriculum committee met continually to guide the process of change and reopening. The curricular adaptation process remains ongoing, and challenges remain. Nonetheless, we have learned from our experiences and hope to use this knowledge gained as we move forward.
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http://dx.doi.org/10.1096/fba.2020-00099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014164PMC
February 2021

Providing quality improvement training in an advanced pharmacy practice experience elective.

Curr Pharm Teach Learn 2021 04 13;13(4):397-402. Epub 2020 Dec 13.

University of Alberta, Department of Medicine, Clinical Department of Medicine, Alberta Health Services, 13-103 Clinical Science Building, 11350 - 83 Ave. NW, Edmonton, AB T6G 2V2, Canada. Electronic address:

Background And Purpose: Quality Improvement (QI) science is a burgeoning component of healthcare systems and the practice of pharmacy. There is limited published literature on the implementation of QI training in undergraduate pharmacy education. We describe the development and implementation of QI training in an experiential course.

Educational Activity And Setting: A QI curriculum was developed for an existing eight-week pharmacy practice elective experience for year four pharmacy students. The curriculum was divided into two, four-week blocks, combining didactic instruction and applied learning activities. A partnership between university departments and a local health organization provided a QI preceptor along with an interdisciplinary clinical team in an acute care setting to improve clinical services.

Findings: Six students have completed the elective along with completing three QI projects. The Kirkpatrick 4 level model guided course evaluation. A curriculum strength was no additional cost or educational burden on the faculty of pharmacy and pharmaceutical sciences. Students recognized benefit from (1) course flexibility and independence to learn, (2) clear expectations and weekly guidance from the preceptor, (3) alignment of weekly readings and real-time application of QI concepts, and (4) the Institute for Healthcare Improvement education modules. Reducing the number of assigned tasks per week and improving availability of the clinical QI team to support student learning were identified as areas for improvement.

Summary: This elective course demonstrated a starting point from which QI education can be formally included in pharmacy undergraduate education.
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http://dx.doi.org/10.1016/j.cptl.2020.11.013DOI Listing
April 2021

Co-Evolutions of Pediatric and Adult Critical Care.

Crit Care Med 2021 02;49(2):188-200

Department of Critical Care, MedStar Washington Hospital Center, Washington, DC.

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http://dx.doi.org/10.1097/CCM.0000000000004803DOI Listing
February 2021

Temperament influences the relationship between symptom severity and adaptive functioning in children with autism spectrum disorder.

Autism 2020 11 2;24(8):2057-2070. Epub 2020 Jul 2.

McMaster University, Canada.

Lay Abstract: Temperament is often thought of as behavioural traits that are relatively stable over time but can vary between individuals. Children diagnosed with autism spectrum disorder are often characterized as having 'reactive' and 'negative' temperaments when compared to same-aged peers with or without disabilities, which can negatively impact the development of adaptive functioning skills but little is known about variations of temperament between individual children diagnosed with autism spectrum disorder. This study aimed to (a) explore the variation of individual temperament traits within a sample of school-aged children with autism spectrum disorder to determine whether subgroups with similar trait profiles emerge and (b) examine whether temperament influences the relationship between autism symptoms and adaptive functioning outcomes. Results from our dataset suggest that children diagnosed with autism spectrum disorder fit under two profiles: 'even' and 'reactive'. Furthermore, our analysis shows that temperament can influence the impact of increasing symptom severity on adaptive functioning skills in children with autism spectrum disorder. Study findings highlight the importance of considering temperament when trying to understand the individual differences that influence the development of functioning and developmental outcomes in children with autism spectrum disorder.
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http://dx.doi.org/10.1177/1362361320933048DOI Listing
November 2020

Strategies to optimize implementation of novel preceptorship models: Peer-assisted learning and near-peer teaching.

Curr Pharm Teach Learn 2020 Aug 1;12(8):945-955. Epub 2020 May 1.

Pharmacy Services, Alberta Health Services, 10030 107 St NW, Suite 500 North Tower, Edmonton, Alberta T5J 3E4, Canada. Electronic address:

Introduction: Hospital experiential placements have traditionally used a 1:1 (student to preceptor) ratio. Two models, peer-assisted learning (PAL) and near-peer teaching (NPT), have been described in the literature for education of health professions. This research explored the use of PAL and NPT, as well as advantages, challenges, and strategies to address challenges for implementation.

Methods: This study used an anonymous survey to solicit feedback from staff pharmacists and pharmacy leaders about their use of PAL and NPT models in hospital settings in Alberta, Canada. Using closed and open-ended questions, experience with each model and implementation considerations were explored.

Results: The survey was completed by 115 hospital pharmacists (11% response rate). PAL and NPT were utilized by 25% and 8% of respondents, respectively, and 10% had experience with both models. Advantages of these models include promoting teamwork and clinical independence, learners supporting each other, and fostering active learning. The highest ranked challenges were space/technology/computer access limitations and additional time to complete learner assessments. Many strategies were provided to address challenges, and facilitate implementation and utilization.

Conclusion: In the hospital setting, pharmacists used PAL more commonly than NPT. Feedback from pharmacists and leaders affirmed the advantages and challenges associated with use of these precepting models. Strategies to facilitate and optimize use were provided, which will guide faculty, pharmacy leaders, and preceptors in efforts to support implementation to increase capacity and expand the practice of precepting.
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http://dx.doi.org/10.1016/j.cptl.2020.04.001DOI Listing
August 2020

Use of low-dose acetylsalicylic acid for cardiovascular disease prevention: A practical, stepwise approach for pharmacists.

Can Pharm J (Ott) 2020 May-Jun;153(3):153-160. Epub 2020 Mar 19.

Chilliwack General Hospital (Barry), University of British Columbia, Vancouver, British Columbia.

Low-dose acetylsalicylic acid (ASA) is recommended in patients with established cardiovascular disease. However, the role of ASA in those without cardiovascular disease (i.e., primary prevention) is less clear, which has led to discordance among Canadian guidelines. In 2018, 3 double-blind, randomized controlled trials were published that evaluated ASA 100 mg daily versus placebo in patients without established cardiovascular disease. In the ASPREE trial, ASA did not reduce the risk of all-cause death, dementia, or persistent physical disability in patients ≥70 years of age but increased the risk of major bleeding. In the ARRIVE trial, ASA failed to lower the risk of a composite of cardiovascular events but increased any gastrointestinal bleeding in patients at intermediate risk of cardiovascular disease. In the ASCEND trial, ASA significantly reduced the primary composite cardiovascular outcome in patients with diabetes for a number needed to treat of 91 over approximately 7.4 years. Yet major bleeding was increased with ASA for a number needed to harm of 112. Therefore, in most situations, ASA should not be recommended for primary cardiovascular prevention. However, there are additional indications for ASA beyond cardiovascular disease. Thus, a sequential algorithm was developed based on contemporary evidence to help pharmacists determine the suitability of ASA in their patients and play an active role in educating their patients about the potential benefits (or lack thereof) and risks of ASA. 2020;153:xx-xx.
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http://dx.doi.org/10.1177/1715163520909137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265581PMC
March 2020

Facedown Positioning Following Surgery for Large Full-Thickness Macular Hole: A Multicenter Randomized Clinical Trial.

JAMA Ophthalmol 2020 07;138(7):725-730

National Institute of Health Research Biomedical Research Centre (BRC), Moorfields Eye Hospital National Health Service (NHS) Foundation Trust, UCL Institute of Ophthalmology, London, England.

Importance: The value of facedown positioning following surgery for large full-thickness macular holes is unknown.

Objective: To determine whether advice to position facedown postoperatively improves the outcome for large macular holes.

Design, Setting, And Participants: This randomized, parallel group superiority trial with 1:1 randomization stratified by site with 3 months' follow-up was conducted at 9 sites across the United Kingdom and included participants with an idiopathic full-thickness macular hole of at least 400 μm minimum linear diameter and a duration of fewer than 12 months. All participants had vitrectomy surgery with peeling of the internal limiting membrane and injection of perfluoropropane (14%) gas, with or without simultaneous surgery for cataract.

Interventions: Following surgery, participants were randomly advised to position either facedown or face forward for 8 hours daily for 5 days.

Main Outcomes And Measures: The primary outcome was closure of the macular hole determined 3 months following surgery by masked optical coherence tomography evaluation. Secondary outcome measures at 3 months were visual acuity, participant-reported experience of positioning, and quality of life measured by the National Eye Institute Visual Function Questionnaire 25.

Results: A total of 185 participants (45 men [24.3%]; 156 white [84.3%]; 9 black [4.9%]; 10 Asian [5.4%]; median age, 69 years [interquartile range, 64-73 years]) were randomized. Macular hole closure was observed in 90 (85.6%) who were advised to position face forward and 88 (95.5%) advised to position facedown (adjusted odds ratio, 3.15; 95% CI, 0.87-11.41; P = .08). The mean (SD) improvement in best-corrected visual acuity at 3 months was 0.34 (0.69) logMAR (equivalent to 1 Snellen line) in the face-forward group and 0.57 (0.42) logMAR (equivalent to 3 Snellen lines) in the facedown group (adjusted mean difference, 0.22 [95 % CI, 0.05-0.38]; equivalent to 2 Snellen lines); 95% CI, 0.05-0.38; P = .01). The median National Eye Institute Visual Function Questionnaire 25 score was 89 (interquartile range, 76-94) in the facedown group and 87 (interquartile range, 73-93) in the face-forward group (mean [SD] change on a logistic scale, 0.08 [0.26] face forward and 0.11 [0.25] facedown; adjusted mean [SD] difference on a logistic scale, 0.02; 95% CI, -0.03 to 0.07; P = .41).

Conclusions And Relevance: The results do not prove that facedown positioning following surgery is more likely to close large macular holes compared with facing forward but do support the possibility that visual acuity outcomes may be superior.

Trial Registration: Isrctn.org Identifier: 12410596.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.0987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206530PMC
July 2020

Segregating patterns of copy number variations in extended autism spectrum disorder (ASD) pedigrees.

Am J Med Genet B Neuropsychiatr Genet 2020 07 6;183(5):268-276. Epub 2020 May 6.

Centre for Addiction and Mental Health, The Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada.

Autism spectrum disorder (ASD) is a relatively common childhood onset neurodevelopmental disorder with a complex genetic etiology. While progress has been made in identifying the de novo mutational landscape of ASD, the genetic factors that underpin the ASD's tendency to run in families are not well understood. In this study, nine extended pedigrees each with three or more individuals with ASD, and others with a lesser autism phenotype, were phenotyped and genotyped in an attempt to identify heritable copy number variants (CNVs). Although these families have previously generated linkage signals, no rare CNV segregated with these signals in any family. A small number of clinically relevant CNVs were identified. Only one CNV was identified that segregated with ASD phenotype; namely, a duplication overlapping DLGAP2 in three male offspring each with an ASD diagnosis. This gene encodes a synaptic scaffolding protein, part of a group of proteins known to be pathologically implicated in ASD. On the whole, however, the heritable nature of ASD in the families studied remains poorly understood.
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http://dx.doi.org/10.1002/ajmg.b.32785DOI Listing
July 2020

Cost-effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery: Learning from 15,856 patients.

Int J Surg 2019 Dec 8;72:25-31. Epub 2019 Oct 8.

Barts & The London School of Medicine and Dentistry, Queen Mary University of London, UK.

Background: Patients undergoing emergency abdominal surgery are exposed to a high risk of death. A quality improvement (QI) programme to improve the survival for these patients was evaluated in the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. This study aims to assess its cost-effectiveness versus usual care from a UK health service perspective.

Methods: Data collected in a subsample of trial participants were employed to estimate costs and quality-adjusted life years (QALYs) for the QI programme and usual care within the 180-day trial period, with results also extrapolated to estimate lifetime costs and QALYs. Cost-effectiveness was estimated using incremental cost-effectiveness ratios (ICERs). The probability of being cost-effective was determined for different cost-effectiveness thresholds (£13,000 to £30,000 per QALY). Analyses were performed for lower-risk and higher-risk subgroups based on the number of surgical indications (single vs multiple).

Results: Within the trial period, QI was more costly (£467) but less effective (-0.002 QALYs). Over a lifetime, it was more costly (£1395) and more effective (0.018 QALYs), but did not appear to be cost-effective (ICER: £77,792 per QALY, higher than all cost-effectiveness thresholds; probability of being cost-effective: 28.7%-43.8% across the thresholds). For lower-risk patients, QI was more costly and less effective both within trial period and over a lifetime and it did not appear to be cost-effective. For higher-risk patients, it was more costly and more effective, and did not appear cost-effective within the trial period (ICER: £158,253 per QALY) but may be cost-effective over a lifetime (ICER: £14,293 per QALY).

Conclusion: The QI programme does not appear cost-effective at standard cost-effectiveness thresholds. For patients with multiple surgical indications, this programme is potentially cost-effective over a lifetime, but this is highly uncertain.
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http://dx.doi.org/10.1016/j.ijsu.2019.10.001DOI Listing
December 2019

Pharmacy student-led blood pressure clinic as part of a comprehensive approach to teaching blood pressure assessment.

Curr Pharm Teach Learn 2019 06 28;11(6):609-613. Epub 2019 Feb 28.

Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada. Electronic address:

Background And Purpose: Hypertension is highly prevalent and sub-optimally controlled in many patients. Strong evidence supports the role of pharmacists in assessing blood pressure (BP) and managing hypertension; however, there is limited literature on curricular activities to prepare pharmacy graduates for this role.

Educational Activity And Setting: This study describes the integration of a BP screening clinic at a tertiary-care cardiac centre as part of a second-year pharmacy curriculum and its impact on pharmacy students' perceived ability and confidence in BP measurement and patient education on hypertension.

Findings: We analyzed anonymized course feedback from students attending the BP clinic from 2014 to 2017. The response rate was 96.5% (498/516). Over 90% of students greatly/mostly agreed that participating in the BP screening clinic improved both their ability and confidence in manually measuring BP. Additionally, over 75% greatly/mostly agreed that participating in the clinic improved their ability and confidence in educating patients about hypertension prevention and management. In addition to technical aspects of BP measurement such as landmarking and correct positioning, students reported experiences from the clinic enriched several non-technical skills, including communication, information gathering, public engagement, and advocacy.

Summary: Implementing a BP screening clinic at a tertiary-care healthcare facility as part of a second-year pharmacy curriculum improved students' self-reported ability and confidence in manually measuring BP and educating members of the public.
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http://dx.doi.org/10.1016/j.cptl.2019.02.023DOI Listing
June 2019

Cost of operating room time for endovascular transcatheter aortic valve replacement.

J Med Econ 2019 Oct 25;22(10):1022-1024. Epub 2019 Jun 25.

Health Economics & Reimbursement, Edwards Lifesciences Corp , Irvine , CA , USA.

Procedural efficiencies can contribute to cost reductions in transcatheter aortic valve replacement procedures (TAVR). The objective of this study is to determine operating room (OR) variable cost per minute in endovascular TAVR procedures, in a real-world hospital setting. Using Premier data from January 2015-June 2016 for patients undergoing a primary endovascular TAVR (primary ICD-9 code of 35.05, ICD-10 code of 02RF37Z, 02RF38Z, 02RF3JZ, or 02RF3KZ) procedure, the OR cost per minute was calculated for each patient by dividing the total hospital OR variable cost by the OR time (minutes). Of the 4,573 patients in the cohort, the average age was 80 years, 77% were admitted electively, and the vast majority were discharged home with (30%) or without (45%) home care. Median OR time for endovascular TAVR procedures was 180 min. The trimmed mean OR cost per minute was $43.59 (SD = $28.68). When stratified by Elixhauser Risk score and Charlson comorbidity index, OR cost per minute increased with higher risk and comorbidity ( < 0.0001 and  < 0.041, respectively). This contemporary estimate of the real-world variable OR cost per minute provides researchers with a critical parameter to refine economic models of TAVR and aid clinical program directors in resource planning according to risk and comorbidity.
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http://dx.doi.org/10.1080/13696998.2019.1627364DOI Listing
October 2019

In Conclusion, Word Choice Matters: Female Physician Leadership and Cardiopulmonary Resuscitation Outcomes.

Crit Care Med 2019 04;47(4):e383

Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, and Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA.

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http://dx.doi.org/10.1097/CCM.0000000000003618DOI Listing
April 2019

Management of hypoadrenocorticism (Addison's disease) in dogs.

Vet Med (Auckl) 2018 9;9:1-10. Epub 2018 Feb 9.

School of Veterinary Science, The University of Queensland, Gatton, Queensland, Australia.

Hypoadrenocorticism (HOAC; Addison's disease) is an endocrine condition seen in small animal practice. Dogs with this disease can present in a variety of ways from acute hypovolemic collapse to vague, chronic, waxing, and waning clinical signs. In the most common form of this disease, animals have both mineralocorticoid and glucocorticoid deficiency, resulting in hyponatremia and hyperkalemia, and signs of cortisol deficiency. The etiology may be immune-mediated destruction of the adrenal cortex, drug-induced adrenocortical necrosis (mitotane), enzyme inhibition (trilostane), or infiltrative processes such as neoplastic or fungal disease. Much less commonly, dogs have signs of cortisol deficiency, but no electrolyte changes. This is referred to as atypical HOAC. The veterinarian needs to have a clinical suspicion for HOAC to make a diagnosis in a timely manner. Treatment of dogs with an acute presentation prioritizes correcting the hypovolemia, hyperkalemia, acidosis, and hypoglycemia. Fluid therapy addresses most of these issues, but other directed therapies may be required in the most severe cases. For chronic management, all patients with Addison's disease will require replacement of glucocorticoids (usually prednisone), and most patients require replacement of mineralocorticoids with either desoxycorticosterone pivalate or fludrocortisone. Atypical Addisonians do not require mineralocorticoid supplementation, but electrolytes should be monitored in case the need arises in the future. The prognosis for dogs treated for HOAC promptly and appropriately is excellent; most patients die from other diseases. However, if the diagnosis is missed, patients may die as a consequence of HOAC. Thus, knowledge of the hallmarks of Addison's disease is imperative.
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http://dx.doi.org/10.2147/VMRR.S125617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055912PMC
February 2018

A genome-wide linkage study of autism spectrum disorder and the broad autism phenotype in extended pedigrees.

J Neurodev Disord 2018 06 11;10(1):20. Epub 2018 Jun 11.

Centre for Addiction and Mental Health, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Background: Although several genetic variants for autism spectrum disorder (ASD) have now been identified, these largely occur sporadically or are de novo. Much less progress has been made in identifying inherited variants, even though the disorder itself is familial in the majority of cases. The objective of this study was to identify chromosomal regions that harbor inherited variants increasing the risk for ASD using an approach that examined both ASD and the broad autism phenotype (BAP) among a unique sample of extended pedigrees.

Methods: ASD and BAP were assessed using standardized tools in 28 pedigrees from Canada and the USA, each with at least three ASD-diagnosed individuals from two nuclear families. Genome-wide linkage analysis was performed using the posterior probability of linkage (PPL) statistic, a quasi-Bayesian method that provides strength of evidence for or against linkage in an essentially model-free manner, with outcomes on the probability scale.

Results: The results confirm appreciable interfamilial heterogeneity as well as a high level of intrafamilial heterogeneity. Both ASD and combined ASD/BAP specific loci are apparent.

Conclusions: Inclusion of subclinical phenotypes such as BAP should be more widely employed in genetic studies of ASD as a way of identifying inherited genetic variants for the disorder. Moreover, the results underscore the need for approaches to identifying genetic risk factors in extended pedigrees that are robust to high levels of inter/intrafamilial locus and allelic heterogeneity.
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http://dx.doi.org/10.1186/s11689-018-9238-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5996536PMC
June 2018

Mutations in in individuals with intellectual disability, autism spectrum disorder, and macrocephaly.

Mol Autism 2017 9;8:59. Epub 2017 Nov 9.

Program in Genetics and Genome Biology, The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON Canada.

Background: Autism spectrum disorder (ASD), a developmental disorder of early childhood onset, affects males four times more frequently than females, suggesting a role for the sex chromosomes. In this study, we describe a family with ASD in which a predicted pathogenic nonsense mutation in the X-chromosome gene segregates with ASD phenotype.

Methods: Clinical phenotyping, microarray, and whole genome sequencing (WGS) were performed on the five members of this family. Maternal and female sibling X inactivation ratio was calculated, and phase was investigated. Mutant-induced pluripotent stem cells engineered for an exon 2 nonsense mutation were generated and differentiated into cortical neurons for expression and pathway analyses.

Results: Two males with an inherited mutation both presented with macrocephaly, intellectual disability (ID), and ASD. Their female sibling with the same mutation presented with ID and a broad autism phenotype. In contrast, their transmitting mother has no neurodevelopmental diagnosis. Our investigation of phase indicated maternal preferential inactivation of the mutated allele, with no such bias observed in the female sibling. We offer the explanation that this bias in X inactivation may explain the absence of a neurocognitive phenotype in the mother. Our cellular knockout model of revealed an impact on expression in differentiated neurons for several genes implicated in brain development and function, supported by our pathway enrichment analysis.

Conclusions: Penetrance for ASD is high among males but more variable among females with mutations. A critical role for this gene in brain development and function is demonstrated.
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http://dx.doi.org/10.1186/s13229-017-0175-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679329PMC
February 2018

An Intensive, Simulation-Based Communication Course for Pediatric Critical Care Medicine Fellows.

Pediatr Crit Care Med 2017 Aug;18(8):e348-e355

1Department of Critical Care Medicine, The Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA. 2Peter M. Winter Institute for Simulation, Education, and Research (WISER), Pittsburgh, PA. 3Department of Pediatrics, University of Washington, Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA. 4Division of General Internal Medicine, The University of Pittsburgh Medical Center, Pittsburgh, PA. 5University of Alabama at Birmingham, Birmingham, AL.

Objective: Effective communication among providers, families, and patients is essential in critical care but is often inadequate in the PICU. To address the lack of communication education pediatric critical care medicine fellows receive, the Children's Hospital of Pittsburgh PICU developed a simulation-based communication course, Pediatric Critical Care Communication course. Pediatric critical care medicine trainees have limited prior training in communication and will have increased confidence in their communication skills after participating in the Pediatric Critical Care Communication course.

Design: Pediatric Critical Care Communication is a 3-day course taken once during fellowship featuring simulation with actors portraying family members.

Setting: Off-site conference space as part of a pediatric critical care medicine educational curriculum.

Subjects: Pediatric Critical Care Medicine Fellows.

Interventions: Didactic sessions and interactive simulation scenarios.

Measurements And Main Results: Prior to and after the course, fellows complete an anonymous survey asking about 1) prior instruction in communication, 2) preparedness for difficult conversations, 3) attitudes about end-of-life care, and 4) course satisfaction. We compared pre- and postcourse surveys using paired Student t test. Most of the 38 fellows who participated over 4 years had no prior communication training in conducting a care conference (70%), providing bad news (57%), or discussing end-of-life options (75%). Across all four iterations of the course, fellows after the course reported increased confidence across many topics of communication, including giving bad news, conducting a family conference, eliciting both a family's emotional reaction to their child's illness and their concerns at the end of a child's life, discussing a child's code status, and discussing religious issues. Specifically, fellows in 2014 reported significant increases in self-perceived preparedness to provide empathic communication to families regarding many aspects of discussing critical care, end-of-life care, and religious issues with patients' families (p < 0.05). The majority of fellows (90%) recommended that the course be required in pediatric critical care medicine fellowship.

Conclusions: The Pediatric Critical Care Communication course increased fellow confidence in having difficult discussions common in the PICU. Fellows highly recommend it as part of PICU education. Further work should focus on the course's impact on family satisfaction with fellow communication.
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http://dx.doi.org/10.1097/PCC.0000000000001241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5648007PMC
August 2017

Variable phenotype expression in a family segregating microdeletions of the and autism spectrum disorder susceptibility genes.

NPJ Genom Med 2017 May;2

Program in Genetics and Genome Biology, The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada.

Autism Spectrum Disorder (ASD) is a developmental condition of early childhood onset, which impacts socio-communicative functioning and is principally genetic in etiology. Currently, more than 50 genomic loci are deemed to be associated with susceptibility to ASD, showing and inherited unbalanced copy number variants (CNVs) and smaller insertions and deletions (indels), more complex structural variants (SVs), as well as single nucleotide variants (SNVs) deemed of pathological significance. However, the phenotypes associated with many of these genes are variable, and penetrance is largely unelaborated in clinical descriptions. This case report describes a family harboring two CNV microdeletions, which affect regions of and - each well-established in association with risk of ASD and other neurodevelopmental disorders. Although each CNV would likely be categorized as pathologically significant, both genomic alterations are transmitted in this family from an unaffected father to the proband, and shared by an unaffected sibling. This family case illustrates the importance of recognizing that phenotype can vary among exon overlapping variants of the same gene, and the need to evaluate penetrance of such variants in order to properly inform on risks.
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http://dx.doi.org/10.1038/s41525-017-0020-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482711PMC
May 2017

Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department.

Acad Emerg Med 2017 08 6;24(8):948-956. Epub 2017 Jun 6.

The Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA.

Objectives: Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea.

Methods: We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders.

Results: There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods.

Conclusions: Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.
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http://dx.doi.org/10.1111/acem.13211DOI Listing
August 2017

An Assessment of the Accuracy of Home Blood Pressure Monitors When Used in Device Owners.

Am J Hypertens 2017 Jul;30(7):683-689

Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.

Objective: To examine the accuracy of home blood pressure (BP) devices, on their owners, compared to auscultatory reference standard BP measurements.

Methods: Eighty-five consecutive consenting subjects ≥18 years of age, who owned an oscillometric home BP device (wrist or upper-arm device), with BP levels between 80-220/50-120 mm Hg, and with arm circumferences between 25-43 cm were studied. Pregnancy and atrial fibrillation were exclusion criteria. Device measurements from each subject's home BP device were compared to simultaneous 2-observer auscultation using a mercury sphygmomanometer. Between-group mean comparisons were conducted using paired t-tests. The proportion of patients with device-to-auscultatory differences of ≥5, 10, and 15 mm Hg were tabulated and predictors of systolic and diastolic BP differences were identified using linear regression.

Results: Mean age was 66.4 ± 11.0 years, mean arm circumference was 32.7 ± 3.7 cm, 54% were female and 78% had hypertension. Mean BPs were 125.7 ± 14.0/73.9 ± 10.4 mm Hg for home BP devices vs. 129.0 ± 14.7/72.9 ± 9.3 for auscultation (difference of -3.3 ± 7.3/0.9 ± 6.1; P values <0.0001 for systolic and 0.17 for diastolic). The proportion of devices with systolic or diastolic BP differences from auscultation of ≥5, 10, and 15 mm Hg was 69%, 29%, and 7%, respectively. Increasing arm circumference was a statistically significant predictor of higher systolic (parameter estimate 0.61 per cm increase; P value 0.004) and diastolic (0.38; 0.03) BP.

Conclusions: Although mean differences from 2-observer auscultation were acceptable, when tested on their owners, most home BP devices were not accurate to within 5 mm Hg. Ensuring acceptable accuracy of the device-owner pairing should be prioritized.
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http://dx.doi.org/10.1093/ajh/hpx041DOI Listing
July 2017

Use of computerized interview scheduling program for pediatric surgery match applicants.

J Pediatr Surg 2017 Jun 18;52(6):1056-1059. Epub 2017 Mar 18.

Oregon Health & Science University, Department of Surgery, Division of Pediatric Surgery, Doernbecher Children's Hospital, Portland, OR, USA.

Background: Pediatric surgery fellowship applicants and programs coordinate over 20 interviews per cycle. We hypothesized that replacing e-mail and phone communication with a computerized-scheduling program (CSP) could benefit both parties.

Methods: We used a CSP to schedule 2016 interviews. Time to schedule and e-mail communication per applicant was compared to 2015, when traditional scheduling was used. Additionally, 2016 interviewees were surveyed about their experience with the CSP vs. traditional means. Analysis was performed using descriptive statistics and a Student's T-test.

Results: We found a significant decrease in mean scheduling time from 14.4 to 1.7h (p<0.001) and in e-mails exchanged from 3.4 to 1.0 (p<0.0001). Survey respondents reported 92% satisfaction with the CSP, and 87% found it easier to schedule interviews. Applicants also reported quicker finalization of interview dates (96%), improved access to interview slots (71%), and easier coordination of additional services and time off (63%). Notably, the mean longest time reported to schedule interviews using traditional methods was 7days (range 1-30). Overall, 84% supported widespread adoption of CSPs.

Conclusions: Using CSPs improved the scheduling process for the significant majority of interviewees, and our program. If widely adopted, this could greatly improve the efficiency of pediatric surgery interview scheduling.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.03.033DOI Listing
June 2017

The intensive care medicine clinical research agenda in paediatrics.

Intensive Care Med 2017 Sep 17;43(9):1210-1224. Epub 2017 Mar 17.

Division of Pediatric Intensive Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Sainte-Justine Hospital, Room 3431, 3175 Côte Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.

Background: Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care.

Methods: Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years?

Results: (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings.

Conclusion: Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.
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http://dx.doi.org/10.1007/s00134-017-4729-9DOI Listing
September 2017

Whole genome sequencing resource identifies 18 new candidate genes for autism spectrum disorder.

Nat Neurosci 2017 Apr 6;20(4):602-611. Epub 2017 Mar 6.

The Centre for Applied Genomics, Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada.

We are performing whole-genome sequencing of families with autism spectrum disorder (ASD) to build a resource (MSSNG) for subcategorizing the phenotypes and underlying genetic factors involved. Here we report sequencing of 5,205 samples from families with ASD, accompanied by clinical information, creating a database accessible on a cloud platform and through a controlled-access internet portal. We found an average of 73.8 de novo single nucleotide variants and 12.6 de novo insertions and deletions or copy number variations per ASD subject. We identified 18 new candidate ASD-risk genes and found that participants bearing mutations in susceptibility genes had significantly lower adaptive ability (P = 6 × 10). In 294 of 2,620 (11.2%) of ASD cases, a molecular basis could be determined and 7.2% of these carried copy number variations and/or chromosomal abnormalities, emphasizing the importance of detecting all forms of genetic variation as diagnostic and therapeutic targets in ASD.
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http://dx.doi.org/10.1038/nn.4524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5501701PMC
April 2017

The Impact of Preoperative Magnetic Resonance Imaging in Detecting Additional Disease in Breast Cancer Patients.

J Registry Manag 2016 ;43(2):87-9

In newly diagnosed breast cancer patients, it has been shown that magnetic resonance imaging (MRI) detects additional cancer not found on mammography and thus is useful to map out the extent of disease in the affected breast.1 Others have shown MRI valuable in detecting occult disease in the contralateral breast.2 More recently, it has been reported that MRI is suitable for guiding surgical decisions, especially in younger women with lobular cancer and/ or increased breast density.3 Consequently, MRI is increasingly being used for clinical staging of breast cancer and is currently supported by the National Comprehensive Cancer Network (NCCN) to define the extent and/or multifocality of cancer in the ipsilateral breast, and to screen the contralateral breast at the time of initial diagnosis.4.
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April 2018

A Quality Assessment of a Collaborative Model of a Pediatric Antimicrobial Stewardship Program.

Pediatrics 2016 05 6;137(5). Epub 2016 Apr 6.

Surgery, and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Background: Infectious Diseases Society of America guidelines recommend that key antimicrobial stewardship program (ASP) personnel include an infectious disease (ID) physician leader and dedicated ID-trained clinical pharmacist. Limited resources prompted development of an alternative model by using ID physicians and service-based clinical pharmacists at a pediatric hospital. The aim of this study was to analyze the effectiveness and impact of this alternative ASP model.

Methods: The collaborative ASP model incorporated key strategies of education, antimicrobial restriction, day 3 audits, and practice guidelines. High-use and/or high-cost antimicrobial agents were chosen with audits targeting vancomycin, caspofungin, and meropenem. The electronic medical record was used to identify patients requiring day 3 audits and to communicate ASP recommendations. Segmented regression analyses were used to analyze quarterly antimicrobial agent prescription data for the institution and selected services over time.

Results: Initiation of ASP and day 3 auditing was associated with blunting of a preexisting increasing trend for caspofungin drug starts and use and a significant downward trend for vancomycin drug starts (relative change -12%) and use (-25%), with the largest reduction in critical care areas. Although meropenem use was already low due to preexisting requirements for preauthorization, a decline in drug use (-31%, P = .021) and a nonsignificant decline in drug starts (-21%, P = .067) were noted. A 3-month review of acceptance of ASP recommendations found rates of 90%, 93%, and 100% for vancomycin, caspofungin, and meropenem, respectively.

Conclusions: This nontraditional ASP model significantly reduced targeted drug usage demonstrating acceptance of integration of service-based clinical pharmacists and ID consultants.
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http://dx.doi.org/10.1542/peds.2015-0316DOI Listing
May 2016

Cutaneous manifestations and management of hematologic neoplasms.

Semin Oncol 2016 06 23;43(3):370-83. Epub 2016 Feb 23.

Hematology Oncology Division, Department of Medicine, Vanderbilt University Medical Center, Nashville TN.

Many malignant hematologic neoplasms can directly and indirectly involve the skin with lesions that are disfiguring, painful, and compromise integumentary function. The majority of lymphomas that directly infiltrate the skin are of T-cell origin but B-cell lymphomas, and other hematologic neoplasms, including acute myeloid and lymphoblastic leukemias, can also have cutaneous involvement, whereas some have an indolent course, eg, mycosis fungoides and marginal zone lymphoma, and easily respond to localized therapy with overall survival (OS) measured in years to decades. Others have a more clinically aggressive course, eg, natural killer (NK)/T-cell lymphoma and diffuse large B-cell lymphoma, leg type, that require high-dose multimodality therapy, and have an OS measured in months to a few years. Lymphoma can also lead to secondary cutaneous alterations, including a variety of paraneoplastic phenomena. We present an overview of direct and indirect skin involvement by malignant lymphocytes and other hematologic neoplasms. We also describe molecular and immunophenotypic aspects of these diseases and how they are treated.
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http://dx.doi.org/10.1053/j.seminoncol.2016.02.021DOI Listing
June 2016

Molecular evidence of undescribed Ceratonova sp. (Cnidaria: Myxosporea) in the freshwater polychaete, Manayunkia speciosa, from western Lake Erie.

J Invertebr Pathol 2016 06 3;137:49-53. Epub 2016 May 3.

U.S. Geological Survey, Great Lakes Science Center, 1451 Green Road, Ann Arbor, MI 48105, USA. Electronic address:

We used PCR to screen pooled individuals of Manayunkia speciosa from western Lake Erie, Michigan, USA for myxosporean parasites. Amplicons from positive PCRs were sequenced and showed a Ceratonova species in an estimated 1.1% (95% CI=0.46%, 1.8%) of M. speciosa individuals. We sequenced 18S, ITS1, 5.8S, ITS2 and most of the 28S rDNA regions of this Ceratonova sp., and part of the protein-coding EF2 gene. Phylogenetic analyses of ribosomal and EF2 sequences showed the Lake Erie Ceratonova sp. is most similar to, but genetically distinct from, Ceratonova shasta. Marked interspecific polymorphism in all genes examined, including the ITS barcoding genes, along with geographic location suggests this is an undescribed Ceratonova species. COI sequences showed M. speciosa individuals in Michigan and California are the same species. These findings represent a third parasite in the genus Ceratonova potentially hosted by M. speciosa.
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http://dx.doi.org/10.1016/j.jip.2016.05.001DOI Listing
June 2016

Impact of personal and social resources on parenting stress in mothers of children with autism spectrum disorder.

Autism 2017 Feb 9;21(2):155-166. Epub 2016 Jul 9.

3 McMaster University, Canada.

This study examined the longitudinal associations between child behavior problems, coping strategies, social resources, and parenting stress in mothers of young children with autism spectrum disorder. Participants were 283 mothers who completed self- and child-report measures at the time of diagnosis and 2 years later. Hierarchical multiple regression was conducted to predict overall parenting stress. At diagnosis, the final model indicated that high levels of social support and mothers' use of active engaged coping strategies were associated with lower levels of parenting stress. Conversely, high levels of child externalizing behavior problems, family dysfunction, and mothers' use of disengaged coping strategies were associated with higher parenting stress. Two years later, high levels of parenting stress at diagnosis predicted increased parenting stress. In addition, high or increasing levels of social support predicted a decrease in parenting stress, while high or increasing levels of family dysfunction predicted increased stress. Finally, increased use of disengaged coping strategies and decreased use of active coping strategies over time predicted higher levels of parenting stress. Results are discussed in terms of their implications for the provision of targeted supports that are designed to enhance the personal and social resources available to mothers of children with autism spectrum disorder.
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http://dx.doi.org/10.1177/1362361316633033DOI Listing
February 2017

Family Presence During Pediatric Tracheal Intubations.

JAMA Pediatr 2016 Mar 7;170(3):e154627. Epub 2016 Mar 7.

Critical Care Medicine, Rhode Island/Hasbro Children's Hospital, Providence.

Importance: Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated.

Objective: To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs.

Design, Setting, And Participants: Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs.

Exposures: Family presence and no FP during TI in the PICU.

Main Outcomes And Measures: The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level.

Results: A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥ 3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders.

Conclusions And Relevance: Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.
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http://dx.doi.org/10.1001/jamapediatrics.2015.4627DOI Listing
March 2016
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