Kevin Chi, MD

Abstract

Dismantling racism in health care demands that medical education promote racial justice throughout all stages of medical training. However, racial bias can be fostered unintentionally, influencing the way we make decisions as clinicians with downstream effects on patient health and health equity. The development of any anti-racism curriculum in medicine requires the ability to identify racial bias in practices we have not previously recognized as explicitly racist or unjust. This has limited the creation and delivery of effective antiracism education in healthcare.

View details for DOI 10.1016/j.amjmed.2022.12.014

View details for PubMedID 36566895

Abstract

OBJECTIVES: To increase the number of essential consult elements (ECEs) included in initial inpatient consultation requests between pediatric residents and fellows through implementation of a novel consult communication tool.METHODS: Literature review and previous needs assessment of pediatric residents and fellows were used to identify 4 specific ECEs. From February to June 2018, fellows audited verbal consult requests at a medium-sized, quaternary care children's hospital to determine the baseline percentage of ECE components within consults. A novel consult communication tool containing all ECEs was then developed by using a modified situation-background-assessment-recommendation (SBAR) format. The SBAR tool was implemented over 3 plan-do-study-act cycles. Adherence to SBAR, inclusion of ECEs, and consult question clarity were tracked via audits of consult requests. A pre- and postintervention survey of residents and fellows was used to examine perceived miscommunication and patient care errors and overall satisfaction.RESULTS: The median percentage of consults containing 3 ECEs increased from 50% preintervention to 100% postintervention with consult question clarity increasing from 52% to 92% (P < .001). Overall perception of consult miscommunication frequency decreased (52% vs 18%; P < .01), although there was no significant change in resident- or fellow-reported patient errors. SBAR maintained residents' already high consult satisfaction (96% vs 92%; P = .39) and increased fellows' consult satisfaction (51% vs 91%; P < .001).CONCLUSIONS: Implementation of a standardized consult communication tool resulted in increased inclusion of ECEs. Use of the tool led to greater consult question clarity, decreased perceived miscommunication, and improved overall consult satisfaction.

View details for DOI 10.1542/peds.2020-0681

View details for PubMedID 33858984

Abstract

BACKGROUND: Because of the impact of continuous pulse oximetry (CPOX) on the overdiagnosis of hypoxemia in bronchiolitis, the American Academy of Pediatrics and the Choosing Wisely campaign have issued recommendations for intermittent monitoring. Parental preferences for monitoring may impact adoption of these recommendations, but these perspectives are poorly understood.METHODS: Using this cross-sectional survey, we explored parental perspectives on CPOX monitoring before discharge and 1 week after bronchiolitis hospitalizations. During the 1-week call, half of the participants were randomly assigned to receive a verbal statement on the potential harms of CPOX to determine if conveying the concept of overdiagnosis can change parental preferences on monitoring frequency. An aggregate variable measuring favorable perceptions of CPOX was created to determine CPOX affinity predictors.RESULTS: In-hospital interviews were completed on 357 patients, of which 306 (86%) completed the 1-week follow-up. Although 25% of parents agreed or strongly agreed that hospital monitors made them feel anxious, 98% agreed that the monitors were helpful. Compared to other vital signs, respiratory rate (87%) and oxygen saturation (84%) were commonly rated as "extremely important." Providing an educational statement on CPOX comparatively decreased parental desire for continuous monitoring (40% vs 20%; P < .001). Although there were no significant predictors of CPOX affinity, the effect size of the educational intervention was higher in college-educated parents.CONCLUSIONS: Parents find security in CPOX. A brief statement on the potential harms of CPOX use had an impact on stated monitoring preferences. Parental perspectives are important to consider because they may influence the adoption of intermittent monitoring.

View details for DOI 10.1542/peds.2020-0130

View details for PubMedID 32675334

Abstract

ACC/AHA guidelines recommend a structured preparation for and transfer to adult-oriented cardiac care for adult survivors of pediatric onset heart disease (POHD). Given this, we sought to describe the transition and transfer practices for a cohort of young adults with POHD and to determine factors associated with successful transfer to adult-oriented cardiac care. We performed a single-center, retrospective chart review on patients 18years of age, with POHD likely to require lifelong cardiac care, who were seen in outpatient pediatric cardiology (PC) between 2008 and 2011. Successful transfer was defined as the subsequent attendance at adult cardiology (AC) within 2years of PC visit. We identified 118 patients who met study criteria. Mean age 22.42.0years, 59% male, 64% white and 40% Hispanic. Mean transition education topics noted was 3.31.8 out of 20 and covered the underlying cardiac disease (89%), follow-up and current medications (56%) and exercise limitations (34%). Recommendations for follow-up were AC (57%) and PC (33%). Of those told to transfer to AC, 79% successfully transferred. Characteristics of successful transfer included: prior cardiac surgery (p=0.008), cardiac medication use (p=0.006) and frequency of follow-up 1year (p=0.037). One-quarter of all subjects did not follow-up within at least 2years. Despite published guidelines, transition education appears lacking and the approach to transfer to adult cardiac care is not consistent. Given the increased risk of morbidity and mortality in this patient population, standardization of transition education and transfer processes appear warranted.

View details for DOI 10.1007/s00246-015-1267-5

View details for PubMedID 26385471

Abstract

With the increasing availability of integrated PET/MR scanners, the utility and need for MR contrast agents for combined scans is questioned. The purpose of our study was to evaluate whether administration of gadolinium chelates is necessary for evaluation of pediatric tumors on (18)F-FDG PET/MR images.First, in 119 pediatric patients with primary and secondary tumors, we used 14 diagnostic criteria to compare the accuracy of several MR sequences: unenhanced T2-weighted fast spin-echo imaging; unenhanced diffusion-weighted imaging; and-before and after gadolinium chelate contrast enhancement-T1-weighted 3-dimensional spoiled gradient echo LAVA (liver acquisition with volume acquisition) imaging. Next, in a subset of 36 patients who had undergone (18)F-FDG PET within 3 wk of MRI, we fused the PET images with the unenhanced T2-weighted MR images (unenhanced (18)F-FDG PET/MRI) and the enhanced T1-weighted MR images (enhanced (18)F-FDG PET/MRI). Using the McNemar test, we compared the accuracy of the two types of fused images using the 14 diagnostic criteria. We also evaluated the concordance between (18)F-FDG avidity and gadolinium chelate enhancement. The standard of reference was histopathologic results, surgical notes, and follow-up imaging.There was no significant difference in diagnostic accuracy between the unenhanced and enhanced MR images. Accordingly, there was no significant difference in diagnostic accuracy between the unenhanced and enhanced (18)F-FDG PET/MR images. (18)F-FDG avidity and gadolinium chelate enhancement were concordant in 30 of the 36 patients and 106 of their 123 tumors.Gadolinium chelate administration is not necessary for accurate diagnostic characterization of most solid pediatric malignancies on (18)F-FDG PET/MR images, with the possible exception of focal liver lesions.

View details for DOI 10.2967/jnumed.115.161646

View details for Web of Science ID 000367862700014

View details for PubMedCentralID PMC4703553

View details for DOI 10.1016/S0735-1097(15)60546-0

View details for Web of Science ID 000375328800547

Abstract

Newborns have frequent infections and manifest impaired vaccine responses, motivating a search for neonatal vaccine adjuvants. Alum is a neonatal adjuvant but might confer a T(H)2 bias. Toll-like receptor (TLR) agonists are candidate adjuvants, but human neonatal cord blood monocytes demonstrate impaired T(H)1-polarizing responses to many TLR agonists caused by plasma adenosine acting through cyclic AMP. TLR8 agonists, including imidazoquinolines (IMQs), such as the small synthetic 3M-002, induce adult-level TNF from neonatal monocytes, but the scope and mechanisms of IMQ-induced activation of neonatal monocytes and monocyte-derived dendritic cells (MoDCs) have not been reported.We sought to characterize IMQ-induced activation of neonatal monocytes and MoDCs.Neonatal cord and adult peripheral blood monocytes and MoDCs were cultured in autologous plasma; levels of alum- and TLR agonist-induced cytokines and costimulatory molecules were measured. TLR8 and inflammasome function were assayed by using small interfering RNA and Western blotting/caspase-1 inhibitory peptide, respectively. The ontogeny of TLR8 agonist-induced cytokine responses was defined in rhesus macaque whole blood exvivo.IMQs were more potent and effective than alum at inducing TNF and IL-1 from monocytes. 3M-002 induced robust TLR pathway transcriptome activation and T(H)1-polarizing cytokine production in neonatal and adult monocytes and MoDCs, signaling through TLR8 in an adenosine/cyclic AMP-refractory manner. Newborn MoDCs displayed impaired LPS/ATP-induced caspase-1-mediated IL-1 production but robust 3M-002-induced caspase-1-mediated inflammasome activation independent of exogenous ATP. TLR8 IMQs induced robust TNF and IL-1 in whole blood of rhesus macaques at birth and infancy.IMQ TLR8 agonists engage adenosine-refractory TLR8 and inflammasome pathways to induce robust monocyte and MoDC activation and represent promising neonatal adjuvants.

View details for DOI 10.1016/j.jaci.2012.02.042

View details for PubMedID 22521247

View details for PubMedCentralID PMC3387351