- Pediatric Cardiology
- Palliative Care
- Adult Congenital Cardiology
- Adult Congenital Heart Disease
I have a background in internal medicine and pediatrics, and believe it is important to care for chronically ill patients across their entire life spectrum. In addition, I have always been interested in palliative care, provider communication, and patients' end of life experience. I would like to apply these interests to both pediatric cardiology and adult congenital cardiology. These patients often are critically or chronically ill, and they and their families would benefit from thoughtful communication, conversations about goals of care, and attention to quality of life. The adult congenital population is one that is growing exponentially due to the success of keeping pediatric cardiology patients healthy in their childhood. There is currently very little research at the intersection of palliative care, pediatric cardiology, and adult congenital cardiology, so I intend to add to this body of literature, and in so doing improve the lives of these patients.
Patient death is a formative and emotional experience for physicians. Medical trainees are particularly susceptible to the emotional impact of patient death. However, few studies have examined how trainees process patient death. This study describes annual patient memorials organized at a large multisite academic graduate medical education program. Peer-led, 1-hour patient memorial services were organized for internal medicine residents, including large and small group reflection, a moment of silence, and collective art projects. At the conclusion of each memorial, participants completed a 10-question survey regarding their experience during the memorial and their prior experiences with patient death. Ninety-nine surveys were analyzed over 2 years. Of resident respondents, 84% reported feeling comfortable or very comfortable participating in the memorials, and 93% rated reflection on patient death as important or very important. When asked how they reflect on patient death, 67% of residents reported processing patient death independently, while only 23% reported processing patient death with their medical teams. Patient memorials with small and large group discussions are easily adopted and replicated. Residents reflect on patient death frequently but often independently rather than with their medical teams. Patient memorials provide a venue for collective mourning and group reflection to support trainees.
View details for DOI 10.1080/08998280.2020.1818164
View details for PubMedID 33456146
View details for PubMedCentralID PMC7785196
To improve outpatient advanced care planning (ACP) for adults with congenital/pediatric heart disease followed in a pediatric heart failure (HF) and transplant clinic through quality improvement (QI) methodology.A one-year QI project was completed. We conducted quarterly chart reviews and incorporated feedback from the providers to direct subsequent interventions.Patients ?18 years of age seen in the HF and Transplant Clinic for follow-up visit were included in analysis.Interventions focused on five main areas: identifying and training providers to have ACP discussions, standardizing the ACP discussion, standardizing ACP and advance directive (AD) documentation in the electronic medical record, preparing providers to have ACP conversations, and preparing patients to engage in ACP and AD completion.The outcome measure was percent of adults seen in the HF and Transplant Clinic per month with documented AD (goal 50%). The process measure was percent of adults seen in the HF and Transplant Clinic per month with a documented ACP discussion (goal 100%).At baseline, no patients had a documented ACP discussion or AD. Fifty-eight adults (mean age 20.4?±?2.1 years) were seen from March 2016 to February 2017 for a total of 130 visits. In the final month of our study, 75% of adult encounters had a documented ACP discussion and 42% had a documented AD.The percentage of documented ADs in adults seen in the HF and Transplant Clinic at a quaternary children's hospital improved through a QI initiative. Over 50% of patients who were engaged in an ACP discussion completed an AD, suggesting this population is receptive to ACP and AD completion.
View details for DOI 10.1111/chd.12579
View details for DOI 10.1016/S0735-1097(17)33956-6
Solid organ transplant recipients (SOTRs) are 100 times more likely to develop cutaneous squamous cell carcinoma (SCC) with greater metastatic propensity compared with the general population, likely due to chronic immunosuppression and adverse drug effects on keratinocytes. Tumor-associated macrophages (TAMs) play critical roles in malignancies, either aiding in eradication of malignant cells or promoting tumor growth.The authors examined whether TAM density and polarization states differ between SOTRs and nontransplant individuals.The authors obtained normal skin, SCC in situ (SCCis), and SCC from SOTRs and nontransplant patients (N = 45) and stained with macrophage marker CD68, M1 marker CD40, and M2 marker arginase-1.The authors report a significantly higher density of TAMs in both SCCis and SCC. The intratumoral macrophage infiltration in SCCis from SOTR was significantly decreased compared with nontransplant patients. Tumor-associated macrophages in SCCis and SCC displayed both M1 and M2 polarization, and M2 activation levels were significantly lower in SCC from SOTR.Tumor-associated macrophages are present in early carcinogenesis and may play a critical role in the transition from SCCis to SCC, before invasion of the basement membrane by tumor cells. The intratumoral macrophage density in early stages of tumor development is significantly affected in SOTR.
View details for DOI 10.1097/DSS.0000000000000371
View details for Web of Science ID 000375432800004
View details for PubMedID 26035047