Clinical Assistant Professor, Pediatrics - General Pediatrics
Board Certification: American Board of Pediatrics, Pediatric Gastroenterology (2015)
Fellowship: Stanford Children's Hospital (2014) CA
Board Certification: American Board of Pediatrics, Pediatrics (2010)
Residency: Lucile Packard Children's Hospital (2010) CA
Medical Education: Stanford School of Medicine (2007) CA
Current Research and Scholarly Interests
Pediatric liver transplant, outcomes, adherence, transition, liver failure
Eliminating International Normalized Ratio Threshold for Transfusion in Pediatric Patients with Acute Liver Failure.
INTRODUCTION: Transfusion protocols are not well-studied for pediatric patients with acute liver failure (ALF). This study evaluates the utility of an international normalized ratio (INR)-based transfusion threshold for these patients.METHODS: Forty-four ALF pediatric patients from 2009 to 2018 were reviewed and divided into two groups: (1) a threshold group including patients between 2009-2015 who were transfused for an INR above 3.0, per institutional policy (n=30), and (2) a post-threshold group including patients after 2015 through 2018 who were transfused based on clinical judgment (n=14). Preoperative INRs, preoperative transfusions, intraoperative transfusions, early reoperation, renal function, graft function and deaths were compared.RESULTS: Liver failure severity was similar between threshold and post-threshold groups. Threshold patients had a lower average INR prior to transplantation, 2.8 (range 1.8-3.8) versus 4.4 (range 2.1-9.0), respectively (p=0.01). Twenty-six threshold patients (87%) received preoperative FFP compared to seven post-threshold patients (50%, p=0.0088). Two threshold patients (7%) received preoperative cryoprecipitate compared to five post-threshold patients (36%, p=0.014). The incidence of pre-transplant bleeding, operative transfusions and one-year patient and graft survival did not differ significantly.CONCLUSION: Clinical judgment versus an INR-based threshold for transfusions did not increase perioperative complications in children with ALF.
View details for DOI 10.1111/ctr.13819
View details for PubMedID 32037570
- Health Care System Factors Associated with Transition Preparation in Youth with Special Health Care Needs POPULATION HEALTH MANAGEMENT 2019; 22 (1): 63–73
Transitions in Pediatric Gastroenterology: Results of a National Provider Survey.
Journal of pediatric gastroenterology and nutrition
2016; 63 (5): 488-493
Transition and transfer to adult-oriented health care is an important yet challenging task for adolescents and young adults with chronic medical conditions. Transition practices vary widely, but a paucity of data makes determination of best practices difficult. We describe North American pediatric gastroenterologists' preferences and current transition practice patterns and explore whether experience affects providers' perspectives.An on-line survey was distributed via email to members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Participation was voluntary and answers were anonymous. Quantitative and qualitative analysis was performed.Almost three quarters of the 175 respondents describe providing transition or self-care management education, but only 23% use structured readiness assessments. Most respondents (88%) report having age cut-offs above which they no longer accept new referrals, with the most common age being 18 years (57%). One third report the ability to provide age-appropriate care to patients over age 21 years. Only 6% indicate that their practice or institution should provide care for individuals over age 25 years. Many (63%) indicate that their practice or institution has a policy regarding age of transfer, but most (79%) are flexible. Provider preferences for triggers to transfer to adult care diverge widely between age, milestones and comorbidities. Overall, parent (81%) and patient (74%) attachment to pediatric healthcare providers are cited as the most common barriers to transition.Preferences and practices surrounding transition preparation and transfer to adult care vary widely, reflecting continued uncertainty regarding optimal transition strategies.
View details for PubMedID 27027904
Text Messaging Improves Participation in Laboratory Testing in Adolescent Liver Transplant Patients.
Journal of participatory medicine
In solid organ transplant patients, non-participation in all aspects of the medical regimen is a prevalent problem associated with adverse consequences particularly in the adolescent and young adult (AYA) age group. This study is the first to evaluate the feasibility, utility and impact of a text messaging (TM) intervention to improve participation in laboratory testing in adolescent liver transplant patients.AYA patients, aged 12 to 21 years, were recruited for a prospective pilot trial evaluating a TM intervention delivered over a 1-year period. The intervention involved automated TM reminders with feedback administered according to a prescribed laboratory testing frequency. Participation rate in laboratory testing after the intervention was compared to the year prior. Patient responses and feedback by text and survey were used to assess feasibility, acceptability and use of the intervention.Forty-two patients were recruited and 33 patients remained enrolled for the study duration. Recipients of the TM intervention demonstrated a significant improvement in participation rate in laboratory testing from 58% to 78% (P<.001). This rate was also significantly higher than in non-intervention controls (P=.003). There was a high acceptability, response rate and a significant correlation with reported versus actual completion of laboratory tests by TM.TM reminders significantly improved participation in laboratory testing in AYA liver transplant patients. The intervention demonstrated feasibility, acceptability, and use with a high proportion of patients who engaged in and perceived a benefit from using this technology.
View details for PubMedID 26213633
View details for PubMedCentralID PMC4511378
Novel protocol including liver biopsy to identify and treat CD8+ T-cell predominant acute hepatitis and liver failure.
2014; 18 (5): 503-509
In the majority of children with ALF, the etiology is unknown and liver transplantation is often needed for survival. A patient case prompted us to consider that immune dysregulation may be the cause of indeterminate acute hepatitis and liver failure in children. Our study includes nine pediatric patients treated under a multidisciplinary clinical protocol to identify and treat immune-mediated acute liver injury. Patients with evidence of inflammation and no active infection on biopsy received treatment with intravenous immune globulin and methylprednisolone. Seven patients had at least one positive immune marker before or after treatment. All patients had a CD8+ T-cell predominant liver injury that completely or partially responded to immune therapy. Five of the nine patients recovered liver function and did not require liver transplantation. Three of these patients subsequently developed bone marrow failure and were treated with either immunosuppression or stem cell transplant. This series highlights the importance of this tissue-based approach to diagnosis and treatment that may improve transplant-free survival. Further research is necessary to better characterize the immune injury and to predict the subset of patients at risk for bone marrow failure who may benefit from earlier and stronger immunosuppressive therapy.
View details for DOI 10.1111/petr.12296
View details for PubMedID 24930635
IMPACT OF AN ADOLESCENT LIVER TRANSPLANT CLINIC ON CLINICAL OUTCOMES
WILEY-BLACKWELL. 2013: 67
View details for Web of Science ID 000321439600101
Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital
APPLIED CLINICAL INFORMATICS
2012; 3 (2): 175-185
Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children's Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process. When given the choice between electronic versus dictated report creation, the vast majority of users preferred the electronic method. In addition to increasing the legibility and accessibility of clinical notes, we also decreased the volume of dictated notes and scanning of handwritten notes, which provides the opportunity for cost savings to the institution.
View details for DOI 10.4338/ACI-2012-02-CR-0003
View details for Web of Science ID 000317183500003
View details for PubMedID 23620718
Non-adherence to post-transplant care: Prevalence, risk factors and outcomes in adolescent liver transplant recipients
2008; 12 (2): 194-200
This study examined the prevalence, demographic variables and adverse outcomes associated with non-adherence to post-transplant care in adolescent liver transplant recipients. We conducted a retrospective chart review of 111 adolescent patients (age 12-21 yr) greater than six months post-transplantation and defined non-adherence as not taking the immunosuppressive(s) or not attending any clinic visit in 2005. Fifty subjects (45.0%) were non-adherent and 61 (55.0%) were adherent. Twenty percent of the subjects did not attend clinic and 10.9% did not complete laboratory tests. Non-adherence was significantly associated with fewer completed laboratory tests (p < 0.0001), single parent status (p < 0.0186), and older age and greater years post-transplantation by both univariate and multivariate analyses (p < 0.008, p < 0.0141 and p < 0.0012, p < 0.0174, respectively). Non-adherence to medication was significantly associated with a rejection episode in 31 patients (p < 0.0069) but not in the subgroup of seven patients who stopped their immunosuppression completely. Non-adherence to post-transplant care is a prevalent problem in adolescents particularly of an older age and greater years post-transplantation. Rejection was a significant consequence of medication non-adherence except in a subgroup with presumed graft tolerance who discontinued their immunosuppression. These results emphasize the need for strict monitoring of adherence to post-transplant care to improve long-term survival and quality of life in adolescent transplant patients.
View details for DOI 10.1111/j.1399-3046.2007.00809.x
View details for Web of Science ID 000253637400013
View details for PubMedID 18307668
High prevalence of non-adherence in adolescent liver transplant recipients: Associated with demographic risk factors and significant adverse outcomes.
BLACKWELL PUBLISHING. 2007: 73
View details for Web of Science ID 000246659800163
Transition from pediatric to adult care in liver transplant recipients.
BLACKWELL PUBLISHING. 2007: 63
View details for Web of Science ID 000246659800124
Adolescent non-adherence: Prevalence and consequences in liver transplant recipients
2006; 10 (3): 304-310
Few studies have examined the prevalence, demographic variables and adverse consequences associated with non-adherence to immunosuppressive therapy in the adolescent liver transplant population. Our hypothesis is that a significant proportion of adolescent liver transplant recipients exhibit non-adherence to medical regimens and that certain demographic and medical condition-related characteristics can be identified as potential predictors of non-adherent behavior. Furthermore, non-adherence leads to a greater incidence of morbidity and mortality in this population as compared with the adherent subset of adolescent patients. We reviewed the charts of 97 patients from 1987 to 2002 who by December of 2002 had survived at least 1 yr post-transplant and were followed by the Pediatric Liver Transplant Service at any point during their adolescent period (ages of 12-21). Non-adherence was defined as documentation of a report of non-adherence by a patient, parent or healthcare provider that was recorded in the patient's legal medical record. Descriptive statistics were used to determine the prevalence, demographic variables and adverse outcomes associated with non-adherence to immunosuppressive therapy. Categorical variables were analyzed using the chi-square test or the Fisher exact probability test. The unpaired Student's t-test was used to analyze the continuous variable of age at transplant. Using the inclusion criteria, a total of 97 patients represented the study sample of whom 37 subjects (38.1%) were defined as non-adherent and 60 (61.8%) were adherent. Non-adherent subjects were more likely to be female, older (>18 yr) and from a single-parent household. There was no significant difference in immunosuppressive regimen between non-adherent and adherent patients. Non-adherence was significantly (p<0.025) associated with lower socioeconomic status (SES), older age at transplant (p<0.005, 95% CI: -5.5 to -.99, Student's t-test) and episodes of late acute rejection (p<.001). Non-adherence was also significantly associated with re-transplantation and death secondary to chronic rejection by the Fisher exact test (p<0.006 and p<0.05, respectively). Non-adherence to immunosuppressive therapy is a prevalent problem that is correlated with certain demographic and medical condition-related risk factors and more frequent adverse consequences in the adolescent liver transplant population. The greater incidence of late acute rejection, death and re-transplantation owing to chronic rejection in non-adherent patients suggests that non-adherence is significantly associated with an increased risk of morbidity and mortality. Further investigation to identify patients at greatest risk for non-adherence is necessary to design the most effective intervention to increase patient survival and well being.
View details for DOI 10.1111/j.1399-3046.2005.00451.x
View details for Web of Science ID 000237096700007
View details for PubMedID 16677353
- Thirteen years' experience in pediatric liver transplantation: Differences between tacrolimus and cyclosporine 2nd International Congress on Immunosuppression ELSEVIER SCIENCE INC. 2002: 1976–78