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Background To define the incidence of acute kidney injury (AKI), chronic kidney disease (CKD), and hypertension (HTN) in pediatric patients diagnosed with acute lymphoblastic leukemia (ALL) over a recent 9-year period. Methods This study is a retrospective cohort study of all pediatric patients diagnosed with ALL at Nationwide Children's Hospital from January 1, 2008, to December 31, 2016. Patient demographic and clinical data including serum creatinine and blood pressure were collected at diagnosis up to 9 years post diagnosis. Results A total of 222 patients were identified for this study. The overall incidence of AKI in our cohort was high, with 101 subjects (45.5%, CI 38.8-52.3%) developing AKI at least once. CKD status could only be determined in 214 patients due to limited later GFR data. The incidence of CKD was low with only 5 of 214 patients developing CKD (2.3%, CI: 0.8-5.4%). The overall incidence of HTN at diagnosis was 45.6% (95% CI: 59.1-72%), and at 1 month post diagnosis was 65.8% (95% CI: 59.1-72.0%). Chronic HTN could only be determined in 216 patients due to limited blood pressure data. Chronic HTN was noted in 34.3% of patients (74/216, 95% CI: 28-41%). Conclusions Among children with ALL, the incidence of AKI is relatively high at the time of diagnosis. However, development of CKD is relatively rare, suggesting good mid-term kidney prognosis. There is a high incidence of HTN at the time of diagnosis, 1 month post diagnosis, and chronic HTN that often goes untreated. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information, Author(s): Reeti Kumar [sup.1] , Suzanne Reed [sup.2] , Joseph R. Stanek [sup.2] , John D. Mahan [sup.3] Author Affiliations: (1) grid.189509.c, 0000000100241216, Department of Pediatrics, Division Nephrology, Duke University [...]

Burnout in pediatric residents is widespread. Certain factors are associated with decreased burnout, such as empathy, self-compassion, mindfulness, and resilience, while perceived stress is associated with increased burnout. Narrative medicine may reduce burnout by its impact on protective and exacerbating factors and can be an active tool to promote wellness. The objective of this pilot study was to evaluate immediate and delayed benefits of a longitudinal narrative medicine intervention for pediatric residents using qualitative and quantitative measures. We designed a voluntary longitudinal narrative medicine intervention implemented via Zoom teleconferencing software over five months for pediatric residents at Nationwide Children's Hospital. It consisted of six one-hour long sessions where residents engaged with literature, responded to a writing prompt, and shared their reflections. It was evaluated using open-ended survey questions and established quantitative assessment tools of well-being with validity evidence. Results were compared before the intervention, immediately after, and six months later using one-way ANOVA and multiple linear regression. Qualitative data was analyzed using thematic analysis. Twenty-two (14% of eligible) residents participated in at least one session. After the intervention, the following themes emerged for benefits to resident well-being: the ability to Build Community, have an Outlet for Self-Expression, reap Emotional and Mental Health Benefits, and work on Personal Growth. Benefits were sustained even six months later, which has not been shown previously. While there were significant qualitative findings, between all three time points, there was no change in any quantitative well-being measures. Our longitudinal narrative medicine pilot study showed meaningful sustained qualitative benefits, though no quantitative changes, in measured well-being outcomes that have been previously associated with lower resident burnout. While not a panacea, narrative medicine can be a useful strategy for residency programs to improve pediatric resident well-being even after completion of planned interventions. We used a mixed-methods approach to assess the effects of a longitudinal narrative medicine intervention on well-being in pediatric residents. Open-ended responses indicated that residents found utility in and appreciated the intervention and experienced sustained improvements in their mental and emotional health, though the sample size was likely too small to show quantitative changes in well-being measures. Narrative medicine is not a panacea, but it can be a useful tool to provide to pediatric residents to promote sustained improvements in their well-being through the framework of relationship-centered care. [ABSTRACT FROM AUTHOR]

Background: Teach Back (TB) is recommended to assess and ensure patient understanding, thereby promoting safety, quality, and equity. There are many TB trainings, typically lacking assessment tools with validity evidence. We used a pediatric resident competency-based communication curriculum to develop initial validity evidence and refinement recommendations for a Teach-back Observation Tool (T-BOT). Objective: This study aimed to develop initial validity evidence for a refined T-BOT and provide guidance for further enhancements to improve essential TB skills training among pediatric residents. Methods: After an interactive health literacy (HL) training, residents participated in recorded standardized patient (SP) encounters. Raters developed T-BOT scoring criteria, then scored a gold standard TB video and resident SP encounters. For agreement, Fleiss' Kappa was computed for >2 raters, and Cohen's Kappa for two raters. Percent agreement and intraclass correlation (ICC) were calculated. Statistics were calculated for gold standard (GS) and TB items overall for all six raters, and for five faculty raters. Agreement was based on Kappa: no agreement (≤0), none to slight (0.01–0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–0.80), almost perfect (0.81–1.00). Key Results: For six raters, Kappa for the GS was 0.554 (moderate agreement) with 71.4% agreement; ICC =.597; for SP encounters, it was 0.637 (substantial) with 65.4% agreement; ICC =.647. Individual item agreement for SP encounters average was 0.605 (moderate), ranging from 0.142 (slight) to 1 (perfect). For five faculty raters, Kappa for the GS was 0.779 (substantial) with 85.7% agreement; ICC =.824; for resident SP encounters, it was 0.751 (substantial), with 76.9% agreement; ICC =.759. Individual item agreement on SP encounters average was 0.718 (substantial), ranging from 0.156 (slight) to 1 (perfect). Conclusion: We provide initial validity evidence for a modified T-BOT and recommendations for improvement. With further refinements to increase validity evidence, accompanied by shared understanding of TB and rating criteria, the T-BOT may be useful in strengthening approaches to teaching and improving essential TB skills among health care team members, thereby increasing organizational HL and improving outcomes. [HLRP: Health Literacy Research and Practice. 2023;7(4):e187–e196.] Plain Language Summary: We provide initial validity evidence for a refined T-BOT and recommendations for further enhancements to improve essential TB skills among pediatric residents. With attention to a shared understanding of TB and rating criteria, this tool may be used to improve HL training, thereby increasing organizational HL and improving outcomes. [ABSTRACT FROM AUTHOR]

Pediatric residents and subspecialty fellows experience a significant number of stressors during training, but they have rarely been self-reported or compared between groups. This qualitative study aimed to identify and compare themes of stressors experienced by pediatric residents and subspecialty fellows at a single large children's hospital. Using an open-ended survey at single time point for each group, we asked residents and fellows to list the stressors they face in training. The survey data was iteratively analyzed using thematic analysis then quantified by its frequency in each group and compared using a chi-square distribution or a Fisher's exact test, as appropriate. Twenty-eight of 159 residents (18%) and 38 of 180 fellows (21%) answered the survey question, and an average of 2.8 stressors were identified by each resident and fellow. Two major themes and five major subthemes were shared between both groups. The theme Stressors at Home included the subthemes Difficulty Maintaining Overall Health and External Stressors. The theme Stressors at Work encompassed the subthemes Clinical Stressors Innate to Patient Care, Demanding Workload and Schedule, and Stressors Related to Culture of Work Environment. Within the subthemes, there were differences in categories of stressors between the groups. While there was no statistically significant difference in the distribution of themes, subthemes, or categories of stressors mentioned between groups, in general residents identified stressors associated with lack of autonomy and control whereas fellows focused on clinical uncertainty and complex situations. While residents and fellows shared similar themes and subthemes for stressors, there was variability between individual categories. This study identified individual self-reported stressors that can be used by programs to design interventions to improve trainee well-being, but it also implies that programmatic support at different levels of training should be tailored to the target group. At our hospital, we found that some self-reported stressors facing pediatric residents and fellows were common and some unique. Stressors included those that can be eliminated or diminished as well as those that cannot. With knowledge that these disparities exist, training programs should use unique strategies to provide support for the two groups and their stressors. [ABSTRACT FROM AUTHOR]

To assess and compare the risk of venous thromboembolism (VTE) and arterial thromboembolism (ATE) in NOMAC-E2 users with levonorgestrel-containing combined oral contraceptive (COCLNG) users. This large, prospective, observational active surveillance study used a non-inferiority design. New users of NOMAC-E2 and COCLNG were recruited in 12 countries in Australia, Europe, and Latin America. Women were followed up directly and self-reported outcomes of interest were validated via treating physicians. The main outcome of interest was VTE, specifically deep venous thrombosis of the lower extremities (DVT) and pulmonary embolism (PE). Secondary outcomes included all VTE and ATE. Data on confounders were captured and independent blinded adjudication assessed the classification of events. Incidence rates, crude (HRcrude), and adjusted (HRadj) hazard ratios were calculated. A total of 101,498 women (49,598 NOMAC-E2 users and 51,900 COCLNG users) were enrolled and followed for up to 2 years (144,901 WY of observation). NOMAC-E2 users had a higher mean age (31.0 ± 8.63 years) than COCLNG users (29.3 ± 8.53 years) but other baseline characteristics were similar between the cohorts. The main analysis comparing the risk of DVT of the lower extremities and PE in NOMAC-E2 users versus COCLNG users yielded an HRadj of 0.59 (95% CI, 0.25–1.35) (adjusted for age, BMI, family history of VTE, and current duration of use). The risk of all VTE and ATE was not higher in NOMAC-E2 users compared with COCLNG users. NOMAC-E2 use was not associated with a higher risk of VTE or ATE compared with COCLNG. [ABSTRACT FROM AUTHOR]

To assess and compare the risk of unintended pregnancy in NOMAC-E2 users with levonorgestrel-containing COC (COCLNG) users in clinical practice. In this observational study, new users1 of NOMAC-E2 and COCLNG were recruited in Europe, Australia, and Latin America and followed for up to 2 years. Unintended pregnancy was expressed by the Pearl Index (contraceptive failures per 100 women-years [WY]), crude hazard ratios (HRcrude) and adjusted hazard ratios (HRadj). Overall, 44,559 and 46,754 users were recruited to the NOMAC-E2 and COCLNG user cohorts, respectively. There were 64 unintended pregnancies in NOMAC-E2 users (0.15 per 100 WY; 95% CI, 0.11–0.19) and 200 in COCLNG users (0.41 per 100 WY; 95% CI, 0.35–0.47). The unintended pregnancy risk was statistically significantly lower in the NOMAC-E2 cohort (p<.0001) compared to the COCLNG user cohort. The HRadj of NOMAC-E2 vs COCLNG was 0.45 (95% CI, 0.34–0.60; adjusted for age, body mass index, gravidity, COC user status, education level). NOMAC-E2 demonstrated superior contraceptive effectiveness compared to COCLNG, likely due to the comparatively short hormone-free interval and possibly reinforced by the long half-life of NOMAC. [ABSTRACT FROM AUTHOR]

Background: Medical educators juggle competing demands as they seek to integrate medical advancements and new technology with the call for earlier introduction to clinical experiences. Newer models of medical education place even greater emphasis on the importance of deliberate training of providers who can deliver compassionate patient-centered care. The need for adaptable, effective communication skills training has never been more relevant than now, in our high-tech and ever-evolving learning climate. Methods: At a large pediatric academic center, we used Kern's six-step approach to complete a needs assessment, identify goals and learning preferences of trainees, and ultimately develop and evaluate a multimodal communication curriculum. This curriculum was rooted in the Accreditation Council for Graduate Medical Education's Pediatric Milestones, with the goal of enhancing knowledge, skills, and competency. Pediatric interns were randomized to either the new curriculum (n = 19) or the existing didactic-based communication training (n = 17) from 2019 to 2020. We evaluated the impact of the new and traditional curriculum through evaluations by expert facilitators, learner surveys, and faculty-assigned resident milestones. Results: Many trainees self-identified performance gaps in communication skills at baseline. Eighteen residents attended 1 to 6 in-person deliberate practice workshops. Workshop participation by the residents varied over time due to a variety of factors. All residents, regardless of curricular exposure, showed statistically significant improvement in communication milestones from first to second year and those enrolled in the deliberate practice curriculum highly valued the workshops and coaching. Discussion: Our curriculum demonstrates the value of deliberate practice opportunities for residents to gain skills in advanced communication. Residents appreciated this type of training and the time devoted to expand these skills. Lessons learned and barriers to implementation from this curriculum can be helpful for educators interested in integrating active, deliberate practice, simulation-based communication training into their current educational model. [ABSTRACT FROM AUTHOR]

Phenomenon: The phenomenon of individualized education, an essential component of competency-based medical education, addresses individual learner needs while working toward standardized learning outcomes. One challenge with broadly implementing individualized education is the lack of a pragmatic operational definition. To formalize expectations for individualized education, the Accreditation Council of Graduate Medical Education in 2013 began requiring six months of individualized curriculum (IC) during pediatric residency; however, there is not a national standard of formal curricular goals for the IC as an educational entity. Examining and describing the overarching curricular goals of IC could provide a framework for discourse about and further study of individualized education in medicine across disciplines and the continuum of medical education. Thus, we aimed to describe the phenomenon of individualized education through the lens of the goals of the IC in pediatric residency in the United States. Approach: In 2017, a purposeful sample of Pediatric Residency leaders were recruited to represent a diverse sample of program sizes, regions of the country, and importance of the IC to the program leadership. They completed an online survey with open-ended questions describing formal and implicit goals of their program's IC. The authors analyzed responses initially using conventional content analysis, then investigated whether the themes for program goals aligned with any existing educational theory. The concepts and language aligned with the principles of self-determination theory (SDT); therefore, the IC goals were subsequently grouped using the SDT domains of relatedness, autonomy, and competence. A focus group with a subset of survey respondents was conducted for member checking and elaboration of concepts. Findings: Program leaders from a diverse sample of 36 programs participated in the survey and a subset of 11 programs participated in the focus group. The common goals across all programs are listed in parentheses and organized by domains of SDT: 1)Relatedness goals (engage in mentorship, select a career) cultivate resident's professional identity based on their desired future career path; 2)autonomy goals (create a learning plan, practice accountability) help residents plan their path; and fulfillment of their plans lead to 3)competence goals (develop targeted clinical skills and knowledge, ensure comprehensive exposure, address learning gaps), ensuring they have a comprehensive skill set for their chosen identity. Insights: This study provides a framework to describe the phenomenon of individualized education through the lens of IC curricular goals in pediatric residency. The goals for IC that emerged from this study serve as a pragmatic framework for implementation of individualized education. They provide a common language and structure to promote more rigorous and collaborative study of individualized education across programs, disciplines, and settings in medicine. They may function as a roadmap for learners to navigate educational activities and for programs to help shape the experiences of their learners and examine outcomes of individualized education in their programs. The framework can also help individual pediatric residency programs structure improvements to their IC. Disciplines beyond pediatrics may also use this framework to better structure elective experiences to capitalize on the benefits of individual education. [ABSTRACT FROM AUTHOR]

The Accreditation Council for Graduate Medical Education recently made available final residency Milestones for first-year fellows to fellowship program directors (FPDs). Usefulness of residency Milestones for fellows is unknown. Our objective was to determine how many pediatric FPDs downloaded final residency Milestones for their first-year fellows and FPD perspectives about usefulness of residency Milestones. Mixed methods survey of pediatric FPDs, assessing FPD use of residency Milestones for first-year fellows, and FPD opinions about utility of residency Milestones for fellowship, including during fellow recruitment. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using content analysis. The response rate was 67.8% (544 of 802). Only 39.3% (209 of 532) of FPDs downloaded final residency Milestones for their first-year fellows. Twenty-four percent (129 of 532) of all FPDs thought residency Milestones were useful. Forty-one percent (218 of 532) thought residency Milestones would be useful during recruitment; others believed this may harm applicants. Of FPDs that downloaded and reviewed residency Milestones, 27% (50 of 185) used them for individualized education. FPDs felt residency Milestones might allow for identification of trainee needs and baseline assessments, but thought that residency Milestones had limited usefulness during fellowship due to concerns about lack of validity evidence, relevance, and how Milestones are assessed and reported. Most FPDs find residency Milestones to be of limited utility for their fellows and do not use residency Milestones to tailor education for their first-year fellows. Improving relevance of residency Milestones to fellowship training, validity, and how Milestones are assessed and reported may improve their usefulness for fellow training. [ABSTRACT FROM AUTHOR]

To determine current practices for communication skills curriculum and assessment in pediatric residency programs and to identify programs' greatest needs regarding communication curricula and assessment. We surveyed pediatric residency program directors about their programs' approach to teaching and assessing residents' communication skills and how satisfied they were with their curricula and assessment of competence. Respondents were asked about their programs' greatest needs for teaching and assessing communication skills. Response rate was 41% (82/202). Most programs did teach communication skills to residents; only 14% provided no formal training. Programs identified various 1) educational formats for teaching communication skills, 2) curricular content, and 3) assessment methods for determining competence. Many programs were less than satisfied with their curriculum and the accuracy of their assessments. The greatest programmatic need regarding curricula was time, while the greatest need for assessment was a tool. While teaching and assessment of communication skills is common in pediatric residency programs, it is inconsistent and variable, and many programs are not satisfied with their current communication training. There is need for development of and access to appropriate and useful curricula as well as a practical tool for assessment which has been evaluated for validity evidence. [ABSTRACT FROM AUTHOR]

The RAM immunophenotype has been recently described as a subtype of acute myelogenous leukemia (AML) that is characterized clinically by extremely poor prognosis. We present a case of AML with RAM immunophenotype in a 5-year-old patient that resulted in poor outcome despite early hematopoietic cell transplant. We describe the unusual morphologic features that, along with the distinct immunophenotype, may provide initial diagnostic clues and further justify the classification of this AML variant as a rather distinct subtype. [ABSTRACT FROM AUTHOR]

OBJECTIVE To compare serum concentrations of biomarkers of cartilage and bone metabolism between racehorses with a carpal or metacarpophalangeal or metatarsophalangeal (ie, fetlock) joint injury and matched uninjured control horses, determine changes in biomarker concentrations following joint injury, and establish the biomarkers' diagnostic test performance. ANIMALS 50 Thoroughbred racehorses with a carpal or fetlock joint injury and 50 matched uninjured horses (control horses). PROCEDURES Serum concentrations of 2 cartilage synthesis biomarkers (carboxy-terminal propeptide of type II collagen [CPU] and chondroitin sulfate epitope 846 [CS846]), 2 cartilage degradation biomarkers (neoepitope generated by collagenase cleavage of type II collagen [C2C] and cross-linked carboxy-terminal telopeptide fragments of type II collagen [CTX-ll]),and serum activity of a bone formation marker (bone-specific alkaline phosphatase [BAP]) were measured around the time of injury diagnosis and monthly thereafter for as long as possible. RESULTS Injured horses as a group and horses specifically with fetlock joint injuries had significantly lower serum CPU concentrations and significantly higher serum BAP activities than matched control horses. Concentrations of CTX-II were decreased between 2 and 4 months following joint injury. Measurement of CPU concentration at baseline could distinguish between injured horses and control horses with a sensitivity of 82% and specificity of 50%. CONCLUSIONS AND CLINICAL RELEVANCE Although significant differences in specific biomarker concentrations between horses with carpal and fetlock joint injuries and matched control horses were identified, there was no convincing evidence of the suitability of these biomarkers as diagnostic or prognostic tools in a clinical setting. [ABSTRACT FROM AUTHOR]