What is POTS Again?

Patient Presentation
A 14-year-old female came to clinic for a second opinion regarding headache, fatigue, dizziness and fainting spells. Three months previously she had laboratory-diagnosed influenza and three weeks after that she began to have syncope. Syncope episodes were described as occurring after 1-5 minutes of standing, she becomes dizzy and then falls to the floor. She loses consciousness but is not noted to be postictal nor to have any unusual movements or posturing before, during or after the events. Her headaches occur intermittently throughout the day and do not awaken her at night. She complains of general dizziness and fatigue that has increased over time and she is not able to attend school, interact with friends or do other things she enjoys doing. She is able to complete homework and talk with friends by telephone. She also complains of intermittent abdominal pain that occurs in the mid-epigastric area without radiation and without regards to food or drink. The past medical history is positive for intermittent migraine headaches that began about 2.5 years previously. She is treated with minocycline for acne. The family history is positive for cancer and diabetes. The social history shows her to be an average student who enjoys the arts and family activities. The review of systems is negative for weight changes, fever, night sweats, shortness of breath, numbness or tingling, photophobia or visual changes, tinnitus or rashes. She had no bowel changes.

The pertinent physical exam showed an alert female. Lying position vital signs were heart rate = 80 beats per minute (BPM) and blood pressure of 122/74, sitting heart rate = 83 bpm and blood pressure of 122/72 and standing heart rate = 97 bpm and blood pressure of 112/70. The rest of her vital signs were normal for age and showed no weight loss. Her examination was normal except that the pertinent physical examination showed her heart examination to be normal. Her neurological examination was normal originally, but she had a positive Romberg test and was unable to perform a tandem gait test after standing for 5 minutes. The work-up by her local physician included normal complete blood count, thyroid function tests, basic metabolic panel, electrocardiogram, echocardiogram, Holter monitor, brain magnetic resonance imaging, electroencephalogram and titers for Epstein-Barr virus and Cytomegalovirus. All tests were negative. A neurologist was consulted by telephone and felt that this was not a neurological problem because the abnormal neurological examination occurred after standing and she had brain head imaging. The neurologist felt that this was most likely a cardiac etiology, and more specifically autonomic nervous system related. The patient’s clinical course showed that she was referred to a pediatric cardiologist who after a careful history and physical examination also agreed that this was probably postural orthostatic tachycardia syndrome (POTS). In his clinic, she again had similar blood pressures but a difference in her heart rate of 22 bpm was found on tilt table testing. The cardiologist agreed that although she did not meet the adult criteria of a 30 bpm change in heart rate the diagnosis of POTS was most consistent. She was recommended to increase her fluid intake to 1.5-2 liters/day, increase her salt intake, begin conditioning and improved aerobic exercise under the supervision of a physical therapist, and was to followup in 4 weeks with the cardiologist.

Discussion
Orthostatic intolerance are problems experienced when moving from a supine to upright position that are relieved when moving back to a supine position. Orthostatic intolerance can be due to autonomic or other compensatory dysfunction. Acute orthostatic intolerance includes syncope, simple faints and initial orthostatic hypotension.

  • Syncope is a transient loss of consciousness and postural tone. It is caused by reduced cerebral blood flow with rapid recovery.
    Syncope may be caused by orthostasis or other causes such as cardiac arrhythmias, coronary artery disease or muscle diseases.

  • Simple faint is also referred to as vasovagal syncope or reflex syncope. It is a common problem and patients are well before and after the occurrence. Precipitators include standing for prolonged periods of time without moving, being overheated, and being in stressful situations.
    Patients almost immediately are alert and able to remember events before they fainted. Patients may feel nausea or sweating just before or after the episode which usually resolves quickly.

  • Initial orthostatic hypotension occurs when patients rapidly come to a upright position and feel dizzy. The dizziness improves with remaining in the upright position. Dizziness does not bother the patient at other times, and patients usually learn to move into upright positions more slowly.

Chronic orthostatic intolerance patients generally are chronically ill and may also have intermittent syncope episodes. They also have a variety of symptoms including breathing and swallowing problems, exercise intolerance, fatigue, headache, nausea, palpitations, pallor, neurocognitive abnormalities, sweating, shaking and visual changes.

Learning Point
Postural orthostatic tachycardia syndrome (POTS) is an orthostatic intolerance that was first described in 1993 in adults and 1999 in adolescents. Adult patients must have an increase of >30 bpm when moving from a supine to upright position along with clinical signs such as headache, abdominal pain or discomfort, dizziness, nausea, fatigue and tachycardia. It is more common in females than males and in adolescents occurs usually within 3 years of the growth spurt. Patients usually have some preceding significant illness or trauma and then symptoms become worse because patients becoming more symptomatic and thereby decrease their activity, which then also increases their symptoms in a vicious cycle. Symptoms are worse after a period of being supine and then changing to an upright position. POTS has been associated with functional abdominal pain and chronic fatigue syndrome.

Treatment includes avoiding hypovolemia by increasing fluid and salt intake. Exercise is also beneficial as it increases venous return. Compression hose may be beneficial but often are not used by adolescents. First line medication is usually beta-blocks to blunt the heart rate acceleration. Appropriate mental health services to help the patients and families cope with the problems are also beneficial.

Questions for Further Discussion
1. What evaluation would you consider for a patient with a suspected orthostatic intolerance?
2. What consultants would you use and what are your indications for obtaining a consultation?

Related Cases

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

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Autonomic Nervous System Disorder

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

To view images related to this topic check Google Images.

Axelrod, FB, Chelimsky GG, Weese-Mayer DE.
Pediatric Autonomic Disorders. Pediatrics. 2006:18, 309-21.

Stewart JM, Medow MS. Orthostatic Intolerance. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/902155-overview (rev. 10/5/2009, cited 2/10/2010).

Johnson JN, Mack KJ, Kuntz NL, Brands CK, Porter CJ, Fischer PR. Postural orthostatic tachycardia syndrome: a clinical review.
Pediatr Neurol. 2010 Feb;42(2):77-85.

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.

  • Systems Based Practice
    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, University of Iowa Children’s Hospital

  • Why Do You Check the pH of the Eye after Chemical Exposure?

    Patient Presentation
    A 16-year-old female came to the emergency room after having a drop of cleaning fluid splashed into her right eye. She was using bleach and trisodium phosphate cleaners to wash walls prior to painting them. She was using gloves and eye protection, but had not put the eye protection back on after taking a break from the cleaning. She and her parents immediately flushed the eye for about 10 minutes and then brought her immediately to the emergency room as she still had pain and increasing redness. She denied photophobia or blurred vision. The past medical history was non-contributory.

    The pertinent physical exam showed a healthy appearing female with a reddened eye and moderate pain. The diagnosis of an alkali chemical exposure to the right eye was made. The patient’s clinical course included receiving 1 liter of normal saline flushed through a Morgan lens. Her examination showed increased pain from where the Morgan lens had been but decreased mild sclera injection. There was no photophobia and visual acuity by handheld card was 20/20. pH of the eye was ~7.0. She had tetracaine drops placed for pain relief and after irrigation with another liter of normal saline the pH was 7.3. Fluorescein testing showed no corneal abnormalities. An ophthalmologist briefly saw her and also concurred with the treatment. She was discharged with instructions to use oral analgesics for pain and to follow-up with ophthalmology if the pain increased or if she had any visual changes. She was also reminded to always use eye protection when using chemicals.

    Discussion
    About 30% of chemical eye injuries occur at home with 60% occurring in the workplace. Splashing is the most common cause and fortunately only about 20% of injuries have significant disability. About 35% of the eye injuries are in pediatric patients. In one study of hospitalized patients for eye injuries the most common problem was an open wound of ocular adnexa (26%), followed by an orbital floor fracture (25%). Chemical eye injuries accounted for only 1.5%.

    Patients with chemical eye injuries present with pain and foreign body sensation often, but they may also complain of increased tearing, photophobia and reddened eye.

    Injuries appear different if the chemical is acid or alkali.

    • Acids break apart into hydrogen ions and anions. The hydrogen alters the pH and the anion causes protein precipitation and coagulation. The protein coagulation often prevents penetration deeper into the tissues and the cornea may look like ground glass.
    • Alkalis break apart into a hydroxyl ion and a cation. The hydroxyl ion saponifies of cell membranes and the cation interacts with the collagen and glycosaminoglycans.
      Stromal haze can be seen. Unfortunately these interactions can allow deeper penetration into underlying tissues. Intraocular pressure can be increased because of several mechanisms.

    Learning Point
    Chemical exposure to the eye is an emergency and complete history and physical examination can be deferred until initial irrigation is completed. The pH of the eye is normally neutral (7.0 to 7.3). It is important to neutralize the chemical and return the pH to neutral to avoid further eye injury. The pH is tested to help determine if the eye has been irrigated enough to remove the chemical. The irrigation must contact the corneal surface usually through a special eye irrigation system such as Morgan lenses or by opening the eye with an eye speculum. Even running water across the eye immediately after exposure begins to neutralize the chemical. One-two liters of Ringer’s lactate or normal saline solution usually is effective in neutralizing the chemicals but pH testing should be done to confirm this, and if not neutral, then continued irrigation is necessary.

    Next steps in treatment include:

    • Assisting ocular surface healing – using artificial tears as burned eyes don’t adequately make tears, use of ascorbate, bandaging the eye including use of special contact lenses
    • Decreasing inflammation – using steroids, acetylcystine or other eye drops
    • Preventing infection – prophylactic antibiotic eye drops
    • Controlling intraocular pressure – using aqueous suppressant eye drops as needed
    • Pain control – ciliary spasm may cause pain and cycloplegics may assist. Often oral analgesics are enough to control the pain.

    Pictures and instructions for Morgan lens use can be found here

    Questions for Further Discussion
    1. What are the indications for an ophthalmology consultation?
    2. When do chemical exposures to the eye require surgical debridement?
    3. What causes an eye injury to be serious?

    Related Cases

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Injuries.

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

    To view images related to this topic check Google Images.

    Brophy M, Sinclair SA, Hstetler SG, Xiang H. Pediatric Eye Injury – Related Hospitalizations in the United States. Pediatrics. 2006:117;e1263–e1271.

    Randleman JB, Bansal AS, Loft ES, Broocker G. Burns, Chemical. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/1215950-overview (rev. 4/7/2009, cited 2/3/2010).

    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.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

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

  • What Causes Pharyngitis?

    Patient Presentation
    A 7-year-old male came to clinic with a 4 day history of a sore throat. His mother reports that he also had some voice changes like laryngitis and some mild croupy sounding cough. That morning he came to the kitchen for breakfast crying almost inconsolably because he was in so much pain. He had been going to school and there was strep throat circulating in the community. He also had been taking ibuprofen with some relief. The past medical history was non-contributory and his immunizations were current. The review of systems revealed no fever, chills, rhinorrhea, ear pain, headache, muscle ache, abdominal pain or rash.

    The pertinent physical exam showed a slightly tired appearing male who was afebrile and had normal growth parameters. He had a laryngitic sounding voice. HEENT examination revealed erythematous tonsils without exudates. There was no palatal petechiae, but pinpoint vesicles on the soft palate were seen. There was no deviation of the tonsillar pillars. His ears and nose were normal. He had shoddy anterior cervical adenopathy. The rest of his examination was negative. The laboratory evaluation included a rapid streptococcal antigen test that was negative. The throat culture eventually was negative. The diagnosis of viral pharyngitis/laryngitis was made and appropriate instructions were given to the family.

    Discussion
    Sore throat caused by group A, beta-hemolytic streptococcus (GAS) is classically characterized as a patient with a constellation of various symptoms including fever, headache, emesis, sore throat, palatal petechiae, abdominal pain, sand-papery skin rash and often with a history of close contact. The rapidity of onset is relatively short but generally not characterized as rapid. Patients with upper respiratory tract symptoms or allergic symptoms including rhinitis, conjunctivitis, voice changes (e.g. raspy, croupy, laryngitic) tend to have viral etiologies for their sore throat. Differentiating between viral pharyngitis and GAS is a common conundrum. Rapid antigen testing and throat cultures assist in making the proper diagnosis, so that nonsupprative complications such as acute rheumatic fever or acute glomerulonephritis can be avoided. Serotypes 1,6, and 12 of GAS are associated with these sequelae. Rapid onset of fever, difficulty swallowing, drooling, voice change (particularly muffled or hot-potato), respiratory distress and toxicity may indicate retropharyngeal abscess, peritonsillar abscess, tonsillar hypertrophy caused by Epstein-Barr virus, or epiglottitis. An immunization history should help determine if a patient is at risk for Diphtheria or Haemophilus influenza type b. A careful sexual history of oral-genital contact should be obtained in tweens, teens and young adults looking for the possibility of a sexually transmitted infection.

    Learning Point
    The differential diagnosis of sore throat includes:

  • Infectious
    • Viral
      • Adenovirus
      • Coxsackie virus
      • Echovirus
      • Epstein-Barr virus
      • Herpes simplex
    • Bacterial
      • Streptococcus, group A, beta-hemolytic
      • Streptococcus, groups B, C and G, beta-hemolytic
      • Streptococcal pneumoniae
      • Staphylococcus aureus
      • Arcanobacterium haemolyticum
      • Chlamydia trachomatis
      • Corynebacterium diphheriae
      • Haemophilus influenza type b
      • Mycoplasma pneumoniae
      • Neisseria gonorrhea
      • Tularemia
    • Fungal
      • Candida albicans
  • Miscellaneous
    • Epiglottitis
    • Kawasaki disease
    • Peritonsillar abscess
    • Retropharyngeal abscess
    • Post-nasal drip (allergic, upper respiratory infection)
    • Tobacco
    • Trauma
    • Referred pain (lymphadenitis, otitis media)

    Questions for Further Discussion
    1. List clinical presentations of group A, beta-hemolytic streptococcus.
    2. List the phylogeny of streptoccus species.
    3. What are indications for surgical consultation for pharyngitis?

    Related Cases

      Symptom/Presentation: Pain

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Sore Throat and Viral Infections and at Pediatric Common Questions, Quick Answers for this topic: Strep Throat

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

    To view images related to this topic check Google Images.

    Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:306-08.

    Inkelis, SH. Sore Throat. in Pediatrics a Primary Care Approach. Berkowitz CD, ed. W.B. Saunders company, Philadelphia, PA. 1996;186-191.

    American Academy of Pediatrics. Group A Streptococcal Infections, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;616-628.

    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.
    4. Patient management plans are developed and carried out.
    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.

  • 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.

    Author

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

  • Learning From the Past. What is Chlorosis?

    Patient Presentation
    A pediatrician was reading for pleasure and came across this passage describing Mary Queen of Scots, just before her ascension as Queen of France when she was 17 years old in 1559: “{England’s ambassdor to France} Throckmorton also noticed that Mary was unwell and she soon had to retire from court in a state of nervous collapse. He found Mary and Henri’s daughter, Marguerite, ‘somewhat sickly’ and on 24 May, visitors said she was ‘very ill, pale and green and withal short-breathed and it is whispered amont them [in the French court] that she cannot live long’. By 18 June, one of Mary’s attendants felt that she ‘was very evil at ease and to keep her from fainting were fain to bring her wine from the altar…I never saw her look {so} ill…she cannot long continue’. ”

    The diagnosis of Queen Mary’s illness was chlorosis, which the pediatrician had never heard of. She decided to use a literature and Internet search to try to learn more about this adolescent malady.

    Discussion
    In practicing medicine, clinicians try to provide the best care for the patients and families they serve. They usually try to use the most current information available and apply it to the specific patient situation, yet medicine is an ever-changing science and art. Disease theories change. For example, mental illness was once thought to be caused by the lunar cycles thus the name “lunacy” or “lunatic.” Overtime it became known that neurochemical and genetic factors play a role. Scientific information is re-analyzed or classified. For example, the organism that causes cat-scratch disease has had 3 names since 1991 – Afipis felis, Rochlimacae henselae, and currently Bartonella henselae. Disease treatments are often changing as new information becomes available. For example, up until the early 1990s, intravenous theophylline was widely used for asthma treatment as it was thought to be better than aerosolized albuterol, and oral steroids were not used at all. Likewise “new” diseases are described. Some continue to be a distinct entity because the causative agent is accepted as distinct, such as HIV. Other diseases also continue to be viewed as distinct entities but a causative agent has not been defined or may be multifactorial, i.e. Kawasaki disease. It is only the test of time that allows clinicians to know with more or less certainty if their present information is correct.

    Learning Point
    Chlorosis was considered a blood dyscrasia that was ill-understood, but feared by people. Clinical descriptions were of teenage and young women with menstrual irregularities who were generally well-nourished but would have a pale coloring of their skin. The skin color was described as greenish and hence the name, but this actually occurred very rarely. The young ladies were always described as having extreme fatigue, to the point that many were felt to be dying. Other descriptions include being a brunette, blond or redhead (depending on the source), and having a bluish cast to the eyes. Possible causes included overwork or underwork, poor hygiene, tight corsets or clothing, spurned love, or sudden shocks or frights. Other names for the disease were norbus virgineus (virgin disease) or greensickness. Many different treatments were promulgated, but the most common one was to marry and begin sexual intercourse. If a woman continued to have episodes after marriage, then increased frequency of intercourse was recommended.

    Contemporary accounts of chlorosis go back to ancient history. William Shakespeare described greensickness in 4 plays including 1 where he describes a “male greensickness.” Even in the early 20th century, Henry James’s novel The Wings of the Dove describes a woman who is mortally ill with an ill-defined disease which is often taken for tuberculosis, but which describes chlorosis. Many young girls and women were felt to be dying when they would have these episodes including Mary Queen of Scots, presented above. With newer science, the true cause of chlorosis was determined to be iron deficency anemia and thus over time, chlorosis has had its demise including its own obituary written in 1936.

    It is intriguing to think about how history might have changed if the then “modern” understanding of chlorosis was true. In real history, Mary Queen of Scots was truly felt to be dying while she was married to King Francois II. He later died before producing an heir with her. Queen Mary remarried and later had one child, James VI of Scotland who eventually became James I of England and Ireland, effectively unifying the current Great Britain. How would the histories of France, Scotland, England and Europe itself have changed if the prevailing understanding of chlorosis was actually true and Mary had died? How will our understanding of disease today, change the future of the world?

    Questions for Further Discussion
    1. What changes in medicine have you experienced over your professional lifetime?
    2. What other extinct diseases can you name?
    3. What is the effect of disease on war?
    4. List other histories that were or may have been changed because of disease?

    Related Cases

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

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Anemia and at Pediatric Common Questions, Quick Answers for this topic: Iron Defiency Anemia

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

    To view images related to this topic check Google Images.

    Shakespeare W. Romeo and Julie Act 3 Scene 5.

    Shakespeare W. Antony and Cleopatra Act 3 Scene II.

    Shakespeare W. King Henry IV Part 2 Act 4. Scene III.

    Shakespeare W. Pericles, Prince of Tyre Act 4, Scene VI.

    Fowler WM. Chlorosis – An Obituary. Annals of Medical History. 1936:8,168-177.

    Time Magazine. Medicine: Chlorosis. April 6, 1936.

    Mercer CG, Wangensteen SD. Chlorosis, A Heroine’s Illness in The Wings of the Dove. Journal of the History of Medicine and Allied Sciences. 1985;259-285.

    Graham, R. The Life of Mary Queen of Scots, An Accidental Tragedy. Pegasus Books, NY. 2009 page 83.

    ACGME Competencies Highlighted by Case

  • 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
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    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, University of Iowa Children’s Hospital