What Tests are Available for Celiac Disease?

Patient Presentation
A 14 year old male came to diagnostic clinic for a second opinion concerning loose stools and abdominal pain.
He had had several months of loose stools up to 5-7 times/day which were described as loose and pudding-like without undigested food or blood. He said that sometimes his stool seemed to float on top of the toilet water and smelled bad, but this was not consistent.
About 2-3 months ago he began having abdominal pain that occurred several times per week. Some episodes woke him at night. These could make him cry but he was consolable.
He had no recent travel, pet or antibiotic exposures and he had a chlorinated urban water supply. His family members had been healthy.
The past medical history revealed constipation around the time of toilet training.
The family history was positive for a father with Celiac disease and lactose intolerance.
The review of systems was negative for fevers, excessive fatigue, weight loss, sweats, skin changes, or joint involvement.
The pertinent physical exam showed a gregarious male in no acute distress. His weight was 75% and height 50%. His abdominal examination revealed normal bowel sounds, no hepatosplenomegaly or masses, and a soft abdomen without guarding.
Rectal examination revealed a small amount of liquid stool that was released after the examination. The stool was guiaic negative. He had no edema.
The previous work-up by the local physician included an endomysial, transglutaminase, and antigliadin antibodies, all of which were negative.
He also had a hemoglobin level of 13.2 g/L, platelet count of 210 x 1000/mm2, erythrocyte sedimentation rate that was slightly elevated at 24 mm/hour (normal up to 20 mm/hour). C-reactive protein, total protein, albumin, urinalysis, liver function tests and electrolytes were normal.
Abdominal radiographs showed a non-specific bowel gas pattern. Serial stool examinations were negative for blood, bacteria or parasites.
Repeated laboratory evaluation in the clinic was positive for IgA antigliadin antibody and the patient was referred to a pediatric gastroenterologist.
An upper endoscopy with a small bowel biopsy was performed and showed villous atrophy on 4 of 6 samples.
The diagnosis of Celiac disease was made and the patient was instructed on elimination of gluten from his diet. The parents were very supportive as the father had to follow the same diet restrictions already.
The patient’s clinical course over the next month showed clinical improvement with resolution of the abdominal pain, and the loose stools occurring only 1-2 times/day. He had gained ~1 pound of weight.
The patient was screened again for iron deficiency, Vitamin D, calcium, fasting glucose and thyroid function tests. All were normal.
The patient was to follow up again in 2 months.

Discussion
Celiac disease (also known as celiac sprue, nontropical sprue or gluten-sensitive enteropathy) is a chronic malabsorption disorder of the small bowel that is caused by exposure to dietary gluten in genetically predisposed individuals.
It is found in people from infancy to late adulthood and is genetically associated with HLA-DQ2 and DQ8. It is more common in Caucasian individuals of northern European descent.

Clinically it can present with many different symptoms including being asymptomatic, abdominal pain, diarrhea with/without hematochezia, constipation, steatorrhea, fatigue, irritability, vomiting, weight loss, failure to thrive (weight and height), muscle wasting, ascites (secondary to hypoproteinemia), and anemia.
Classic stools in children < 2 years are described as pale, water semi-formed, voluminous and foul-smelling.

Differential diagnosis includes:

  • Bacterial overgrowth
  • Crohn’s disease
  • Cow’s milk protein intolerance
  • Duodenitis
  • Eosinophilic gastroenteritis
  • Status-post viral gastroenteritis
  • Giardiasis
  • Lymphoma
  • Tropical sprue
  • Zollinger-Ellison syndrome

Treatment is elimination from the diet of gluten, prolamins (ethanol soluble protein) and glutenins (acid/alkali soluble protein). This includes all wheat, rye, barley, and possibly oats. Dairy products may also be a problem as patient may have lactose intolerance too.
They can eat soybean, tapioca, rice, corn, potatoes and buckwheat. Up to 70% of patients will have improvement of symptoms within 2 weeks of being on the diet.

Patients also need to be screened for micronutrient deficiencies including anemia, calcium/Vitamin D, folic acid and Vitamin B12.
Patients have a higher risk of gastrointestinal malignancies, skin disorders, and autoimmune diseases including Diabetes type 1, arthritis, Hashimoto’s thyroiditis and Grave’s disease.

Learning Point
Various laboratory tests are available to help confirm or exclude the diagnosis. Laboratory testing of blood may be normal even in people with symptoms and intestinal biopsy proven disease.
The sensitivity and specificity of a test itself cannot be used to estimate the probability of disease individual patients. Individual test results using likelihood ratios can be helpful though, especially if the results are not consistent between tests or over time. For a more extensive discussion of this please see the To Learn More articles below especially Akobeng’s article which uses Celiac disease as an example.

IgG antibody tests are available but in various studies there is a great deal of heterogeneity in the sensitivity and specificity. IgG antibody tests have poor sensitivities of 40-90% but specificities are 98-100%. As IgA antibody tests are usually also available these are usually preferred.

IgA endomysial antibody

  • Direct immunofluorescence test where endomysial antibodies bind to connective tissue surrounding smooth muscle cells
  • Highest diagnostic accuracy: sensitivity is 96-98% and highly specific at 95-97%
  • In certain circumstances, a positive endomysial antibody is considered diagnostic and may obviate the need for confirmatory small bowel biopsy

IgA transglutaminase antibody

  • ELISA test – antibodies to tissue transglutminase enzymes are released by inflammatory cells, endothelial cells and fibroblasts because of the inflammation and irritation from the gluten
  • Test is fairly diagnostic: sensitivity of 93%, and 96-99% specificity
  • A positive test is fairly diagnostic

IgA antigliadin antibody

  • ELISA test – antibodies bind to gliadin which is a component of gluten
  • IgA has a sensitivity of 80% and specificity of 80-90%
  • A positive test is not specific enough to be diagnostic so generally requires a biopsy to confirm or exclude the diagnosis

Small bowel biopsy

  • Considered as the gold standard as histology will show vilous atrophy
  • Problem is that the atrophy may be patchy and therefore biopsy may miss involved areas
  • Villous atrophy can also be seen in many other diseases too therefore it is not specific for Celiac disease
  • Some recommend a repeat biopsy 3-4 months after beginning a gluten-free diet to show histologic improvement

Questions for Further Discussion
1. What skin disorders are more common with Celiac disease?
2. What gastrointestinal malignancies are more common with Celiac disease?
3. What histological changes are seen on intestinal biopsy with Crohn’s disease?
4. Explain sensitivity, specificity and likelihood ratios?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Celiac Disease and Laboratory Tests

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Rostom A, Dube C, Cranney A, et.al. The diagnostic accuracy of serologic tests for celiac disease: A systematic review.
Gastroenterology, 2005;128(4);S38-S46.

Busschots GV,
Vallee PA, Guandalini S. Sprue. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2146.htm (rev. 2/8/2006, cited 6/13/2007).

Mearin ML. Celiac disease among children and adolescents. Curr Probl Pediatr Adolesc Health Care. 2007 Mar;37(3):86-105.

Akobeng AK. Understanding diagnostic tests 2: likelihood ratios, pre- and post-test probabilities and their use in clinical practice. Acta Paediatrica. 2007;96(4);487-491.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    July 30, 2007

  • "How Will I Ever Remember the Dose for Tylenol®?"

    Patient Presentation
    An 18-month-old female came to clinic with upper respiratory tract symptoms and a fever to 101° F for two days. She was drinking well and playing but since she had a history of several ear infections her parents wanted her examined. She was otherwise well. The pertinent physical exam showed an alert female in no distress with normal vital signs and a temperature to 99.8° F temperature. She had rhinorrhea but her ears and the rest of her examination were normal. The diagnosis of an upper respiratory tract infection was made. As the new intern physician was counseling the family, the father asked what the proper dose of Tylenol® was. The intern consulted her pocket handbook and gave the parents the proper dosage for the acetaminophen. After the patient encounter, the intern was discussing how this dosing question was such a common parent question and that she felt she would never be able to remember the proper dosing especially with all the different forms of the medication available. Her attending physician said, “You need to learn the Rules of 10s – 80s and 100s and then you will always remember.” He then sat down and explained the general rule to her and the other interns and medical students in the room.

    Discussion
    Parents always have a number of common questions that any pediatric healthcare provider should be able to answer easily because they are so common. The proper dosing of antipyretics/analgesics is one of those questions. Parents often have this particular question because the labeling directions may tell the parent to contact a physician or they are concerned that they may be giving too much of the medication. Parents are often surprised to know that they are actually underdosing the medication because the child often has gained weight and therefore needs more medication for it to be effective.

    In an emergency room study, parents were asked to state the antipyretic dosage they would use for their child and then were asked to draw up the correct dosage using real medication and syringes/teaspoons etc. Overall, 40% of parents could accurately state the correct dosage, and only 30% could accurately state and then demonstrate drawing up the correct antipyretic dosage for their child. In another emergency room study, only 49% of children who received a known amount of antipyretic medication received a correct dosage. Infants less than 1 year of age were much more likely to receive an inaccurate dosage. This study also found that medication dosage based upon parental weight estimation was more likely to have an accurate dosage.

    Pediatric health care providers often cannot show a parent how to draw up the correct dosage in the office or emergency room setting. However, they can be familiar with common forms of the medication and common ways they are dispensed. Questioning the parents about what form of medication they have, and how they give it gives the health care provider the chance determine an accurate dosage and then verbally tell and write down how much the parent should give using what is available in the home. This also models for the parent using weight to obtain an accurate dose.

    Learning Point
    One method to remember common forms of antipyretic medication is the Rule of 10s, 80s and 100s.
    Abbreviations used below are: mg = milligrams, ml = milliliters, and kg = kilogram

    Dosing – The Rule of 10s

    Multiply the weight of the child in kilograms x 10 to give an estimated dose in milligrams (kg x 10 = dose in mg). Then adjust the dose up or down to a convenient amount of the medication for the parent to give the child based upon what form of medication and method to deliver it is available such as a syringe, cup, medication spoon, etc.

    		Acetaminophen		Ibuprofen
    Dosing 		10-15 mg/kg/dose	5-10 mg/kg/dose
    Dosing interval	every 4-6 hours		every 6-8 hours
    

    For example, a child weighs 15 kilograms and the parent has infant drop acetaminophen at home.
    15 kg x 10 = 150 mg/dose
    Because the dosing range for acetaminophen is 10-15 mg/kg/dose. The 150 mg/dose can be rounded up to 160 mg/dose which is 1.6 ml or 2 droppers of acetaminophen.
    If on the other hand the parent had chewable ibuprofen tablets available at home, the dose would be 150 mg which is 1.5 tablets/dose.

    Whole amounts are easier to accurately give than 1/2 amounts. Quarter and 3/4 amounts are often difficult to give. For example, give a whole or 1/2 tablet if possible as giving 1/4 or 3/4 of a tablet is more difficult.

    Acetaminophen – the Rule of 80s

    Acetaminophen concentrations are usually in some variant of 80 milligrams, the exceptions are dosages of 325 mg (close to 4 x 80 mg), 500 mg and 650 mg (close to 8 x 80 mg) in the tablet forms. Maximum dose is 4 grams/24 hours or 5 doses/24 hours.

    Drug form	Common Parent Names	Concentration
    
    Suspension/syrup/elixir "syringe-kind" 	160 mg/5 mls
    		"cup-kind"
    		"teaspoon-kind"
    		"syrup"
    		"suspension"
    		"elixir"
    Chewable tablets"chewables" 		80 or 160 mg/tablet
    		"chew-tabs"
    		"meltaways"
    Tablets/capsules			160, 325, 500, or 650 mg/tablet
    /caplets/geltabs "tablet"
    		"capsule"
    		"caplet"
    		"geltab"
    Suppositories	"rectal"	 	80, 160, 325, or 650 mg/suppository
    

    *Note bene: In the fall of 2011 all liquid brands of acetaminophen changed to a single concentration of 160 mg/5 ml. Previously there were two different concentrations.

    Ibuprofen – the Rule of 100s

    Ibuprofen concentrations are usually in some variant of 100 milligrams. Droppers for the administration of ibuprofen are usually marked .625 mls (= 25 mg), 1.25 mls (= 50 mg) and 1.875 ml (= 150 mg) to assist in dosing. Common parent names are the same and so are omitted here. Maximum dose is 40 mg/kg/24 hours.

    Drug form		Concentration
    Infant drops		50 mg/1.25 mls
    Suspension/syrup/ 	100 mg/5 mls
    elixir
    Chewable tablets 	50 or 100 mg/tablet
    Tablets/capsules	100, 200, 400, 600, or 800 mg/tablet
    /caplets/geltabs
    

    Questions for Further Discussion
    1. What other names do parents have for the different forms of acetaminophen and ibuprofen?
    2. What are other common medication questions that parents have?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Pain Relievers and Over-the-Counter Medicines
    and at Pediatric Common Questions, Quick Answers for this topic: Pain Management

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Simon HK, Weinkle DA. Over-the-counter medications. Do parents give what they intend to give? Arch Pediatr Adolesc Med. 1997 Jul;151(7):654-6.

    Li SF, Lacher B, Crain EF.
    Acetaminophen and ibuprofen dosing by parents. Pediatr Emerg Care. 2000 Dec;16(6):394-7.

    Robertson J, Shilkofski N. The Harriet Lane Handbook. 17th. Edit. Mosby Publications: St. Louis. 2005:688-689,839-840.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

  • How Can I Help One of My Moms Develop a Safety Plan?

    Patient Presentation
    An 8 month-old male came to clinic with upper respiratory tract infection symptoms for 2 days.
    The physician had seen the mother, infant and 2 other siblings for health supervision visits and several acute care visits for this infant and 2 other siblings who also came along.
    The children appeared well taken care of, but the mother seemed more disheveled in appearance than normal and withdrawn during the interview. When the physician asked her about how things were going at home, the mother burst into tears.
    Once she was calmer, the mother said she wanted to talk but not with the children around.
    While the children were watched by the nursing and office staff the mother revealed that her husband was becoming more and more angry with her especially since the birth of the third child.
    The “explosions” as she called them, came after the children went to bed and he would start to scream at her. The reasons for the episodes were various including money, household cleanliness, children’s behavior, etc. The episodes were worse if he had been drinking and occurred several times per week.
    He showed little remorse per the mother, and said that otherwise he spoke very little to her.
    She said that he never touched or hit her physically, nor would force her to perform sexual acts but that he would not allow her to go out of the house without him unless it was to the doctor’s office, the grocery store or her part-time job as a cashier at a gas station.
    She wasn’t allowed to have visitors over including her family that lived in the same town and she wasn’t allowed to talk with friends or family by the telephone.
    She was given money by him for groceries and for the doctor’s visits but only at the time of those errands.
    She gave him her paycheck as soon as she arrived home from work and he did not allow her any other money.
    She said that she never felt like he was going to hurt her physically so that she had never called the police but that the explosions were occurring more and he was drinking more.
    Overall she said he did help to take care of children physically, but that he preferred to work around the house or watch TV, and didn’t spend much time with the children.
    She said he talked “roughly” to them and occasionally would yell at them, but that he never had “exploded” at them or hurt them physically.
    The past medical history for the child was unremarkable.
    The social history revealed that the father worked in a manufacturing plant. Both parents were high school graduates.
    Both extended families lived in the area. The mother denied any domestic violence in the extended families or any problems with alcohol, drugs or law enforcement.
    The pertinent physical exam showed an infant with normal growth parameters and development. He had no obvious bruising, scratches or other skin changes. He had clear rhinorrhea and the rest of his examination was negative.
    The diagnosis of an infant with an upper respiratory infection and a mother who is being emotionally abused was made.
    The mother was afraid and unwilling to talk with a social worker or a counselor.
    She was very afraid of what her husband may do if he found out that she had told the physician about the episodes.
    The physician tried to talk about developing a safety plan for her and the children if the problems became worse and she needed to leave the home quickly, but the mother did not want to discuss it. She was willing to come back to have the child re-checked later in the week though.
    The patient’s clinical course showed that the infection was improving. There had been 1 explosive episode since the previous visit, and the mother said she had thought about the safety plan.
    She said that she was willing to take a paper with the local domestic violence intervention program telephone number on it as she knew a safe place that she could hide the paper. However she was unwilling to try to gather other items such as clothing and documents because she was afraid of her husband.
    Over the next few weeks, she brought the children to the clinic for rashes, upper respiratory infections and other minor illnesses. Each time she confided that she was slowly gathering items and had surreptitiously gotten some help from her family.
    She said that she was going to call the domestic violence intervention program soon. Unfortunately, she did not come back to the clinic after this visit.

    Discussion
    According to the National Domestic Violence Hotline, “Domestic violence can be defined as a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner.
    Abuse is physical, sexual, emotional, economic or psychological actions or threats of actions that influence another person. This includes any behaviors that frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure or wound someone.”

    It is a national and international problem mainly for women but men can also be abused. It affects the entire family including the children even if they are not directly abused as they may be a witness to the violence or suffer from neglect because of it.
    About half of men who abuse their female partners abuse their children also.

    Many professional organizations recommend screening for domestic violence. The American College of Obstetrics and Gynecology recommends asking all women the following 3 questions:

    • Within the past year — or since you have been pregnant — have you been hit, slapped, kicked or otherwise physically hurt by someone?

    • Are you in a relationship with a person who threatens or physically hurts you?
    • Has anyone forced you to have sexual activities that made you feel uncomfortable?

    The National Domestic Violence Hotline has a more extensive but short list of self-asked questions (see To Learn More below).

    Physical abuse that may trigger the healthcare provider to consider domestic violence as a cause. There are also behavioral and emotional symptoms can also represent domestic violence.

    • Anxiety
    • Aggression towards self or others
    • Apathy
    • Attention seeking, often for minor problems
    • Depression
    • Eating disorders
    • Emotional lability
    • Withdrawing from social interactions
    • Learning problems and declining school or work performance, especially in children
    • Malnutrition
    • Neglect of self or others
    • Sexual dysfunction including early initiation of sexual activity and compulsive sexual behaviors
    • Sleep disturbance
    • Somatization disorders
    • Substance abuse including alcohol, drugs and tobacco
    • Suicide attempt
    • Poor adherence to medical recommendations
    • Problems with authorities including lying, stealing, truancy and running away, particularly in children

    Resources are available to healthcare providers to assist their patients and families.
    The National Domestic Violence Hotline is available 24 hours per day at: 1-800-799-SAFE (7233), 1-800-787-3224 (TTY).

    Guidelines are also available from the Victorian Government Department of Justice in Australia, which are applicable internationally (see To Learn More below).

    Learning Point
    Victims of domestic violence should be offered help to develop a safety plan to get out of a violent situation quickly, even if they are not willing or able to leave their current environment. The plan needs to be thought out with the idea that the victim and/or children may never be able to return to that location again.
    The plan should include:

    • Try to avoid fighting in a kitchen or bathroom where the abuser may have access to weapons or where there is no escape.
    • Know exactly where you will go. Regardless of the time of day or night, know a friend’s or a relative’s home or a shelter for battered women where you can go. Also think of another alternative if for some reason you couldn’t go to this place. Remember that you may not be able to return ever!
    • Pack a suitcase and keep it in a safe place. Keep a change of clothing for you and your children, bathroom items, and an extra set of keys to the house and car with a friend or neighbor.
    • Keep special items in a safe place. Keep important items handy so you can take them with you on short notice, or pack duplicates. These may include prescription medicines, identification, extra cash, checkbook, credit cards, and address book and telephone numbers. Also include medical and financial records, such as mortgage or rent receipts. Consider taking a special toy or book for each child.
    • Talk to your children. Let them know that it is not their job to try to stop the fighting. Tell them to call the police or get help from a family member, friend, or neighbor if they need to.
    • If you are hurt call your doctor or go to the emergency room. Give your doctor complete information about how you were injured. Ask for a social worker or a domestic violence intervention worker to help you and the children with finding safe housing, medical treatment and filing charges with police officers if you wish
    • Call the police. Domestic violence is a crime. Give the police complete information about what happened. Be sure to get the officer’s badge number and a copy of the report in case you want to file charges later.

    Questions for Further Discussion
    1. What is PTSD and how does it relate to domestic violence?
    2. What days of the week or year are especially high risk for domestic violence?
    3. What is the telephone number to the local domestic violence intervention program?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Domestic Violence and Child Abuse
    and at Pediatric Common Questions, Quick Answers for this topic: Child Abuse

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Committee on Child Abuse and Neglect.
    The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women.
    Pediatrics 1998 101: 1091-1092. Available from the Internet at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;101/6/1091 (rev. 10/2004, cited 5/23/07).

    American College of Emergency Physicians. Policy Statement. Guidelines for the Role of EMS Personnel in Domestic Violence. Available from the Internet at http://www.acep.org/webportal/PracticeResources/issues/pubhlth/violence/GuidelinesRoleEMSPersonnelDomesticViolence.htm (rev. 2000, cited 5/23/07).

    American College of Obstetrics and Gynecology. Domestic Violence. Available from the Internet at http://www.acog.org/publications/patient_education/bp083.cfm (rev. 2002, cited 5/23/07)

    American Academy of Family Physicians. Policy Statement. Family and Intimate Partner Violence and Abuse. Available from the Internet at http://www.aafp.org/online/en/home/policy/policies/f/familyandintimatepartner-violenceandabuse.html (rev. 2004, cited 5/23/07).

    Victorian Government Department of Justice. Management of the whole family when intimate partner violence is present: guidelines for primary care physicians. Melbourne, Australia, 2006. Available from the Internet at http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/
    Familywomenviolence/Intimatepartnerabuse/20060507intimatepartnerviolence.pdf
    (rev. 10/2006, cited 5/23/2007).

    American Bar Association. Safety Tips for You and Your Family.Available from the Internet at http://www.abanet.org/domviol/safety_tips.html (cited 5/31/2007).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    July 16, 2007