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OBJECTIVE: Pediatric residency programs prioritize clinical learning environment components depending on resource availability, institutional constraints and culture, and accreditation requirements. However, there is limited literature on the landscape of implementation and maturity of clinical learning environment components across programs nationally. METHODS: We used Nordquist's clinical learning environment conceptual framework to craft a survey around the implementation and maturity of learning environment components. We performed a cross-sectional survey of all pediatric program directors enrolled in the Pediatric Resident Burnout-Resiliency Study Consortium. RESULTS: Components with the highest implementation rates were resident retreats, in-person social events, and career development, while components least likely to be implemented were scribes, onsite childcare, and hidden curriculum topics. The most mature components were resident retreats, anonymous systems for reporting patient safety events, and faculty-resident mentoring programs, while the least mature components were use of scribes and formalized mentorship for trainees underrepresented in medicine. Learning environment components included in the Accreditation Council of Graduate Medical Education Program Requirements were significantly more likely to be implemented and mature than non-required components. CONCLUSIONS: To our knowledge, this is the first study to use an iterative and expert process to provide extensive and granular data about learning environment components for pediatric residencies. [ABSTRACT FROM AUTHOR]

Human subjects research protections have historically focused on mitigating risk of harm and promoting benefits for research participants. In many low-resource settings (LRS), complex and often severe challenges in daily living, poverty, geopolitical uprisings, sociopolitical, economic, and climate crises increase the burdens of even minimal risk research. While there has been important work to explore the scope of ethical responsibilities of researchers and research teams to respond to these wider challenges and hidden burdens in global health research, less attention has been given to the ethical dilemmas and risk experienced by frontline researcher staff as they perform research-related activities in LRS. Risks such as job insecurity, moral distress, infection, or physical harm can be exacerbated during public health crises, as recently highlighted by the COVID-19 pandemic. We highlight the layers of risk research staff face in LRS and present a conceptual model to characterize drivers of this risk, with particular attention to public health crises. A framework by which funders, institutions, principal investigators, and/or research team leaders can systematically consider these additional layers of risk to researchers and frontline staff is an important and needed addition to routine research proposals and protocol review. [ABSTRACT FROM AUTHOR]

The aim of this study was to characterize attitudes and practices among health care providers (HCPs) in Mongolia regarding parental involvement in neonatal resuscitation (NR)-related decisions. A voluntary, anonymous questionnaire was administered to 210 HCPs across 19 of 21 Mongolia provinces. Eligible HCPs included midwives, neonatologists, pediatricians, and obstetricians involved in neonatal-perinatal care in both rural and urban hospitals. A total of 210 pediatric HCPs were surveyed and 100% completed all questions (response rate 100%). Despite the absence of nation-wide guidelines, NR is uniformly performed at 32-weeks gestation across HCP professions and across rural/urban settings. Most HCPs (67%) indicate that parents should be counseled about resuscitation, but only 9% ask the parents if they want their extremely premature child resuscitated and only 17% counsel the parents prior to birth of an at-risk infant. Most HCPs (72%) prefer to unilaterally decide when to withdraw NR, and only 28% indicated that both parents should be involved in the decision. Following a newborn's death, 75% of all HCPs reported that they do explain the death to parents, although only 28% reported receiving any training in parental grief counseling. For HCPs in Mongolia, a discrepancy exists between the perceived value of parental involvement and the actual practice of NR-related counseling. This report is a necessary first step toward understanding the factors that influence NR-related practices in Mongolia, and may serve as model for collecting these types of data in other low and middle income countries. Keywords Neonatal resuscitation * High-risk pregnancy * Neonatal intensive care * Prematurity * Global health, Introduction Neonatal resuscitation (NR) has the potential to save lives and prevent morbidity [1]. Basic NR steps that can be performed in any setting include drying and positioning the infant, [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ydbio.2006.07.018 Byline: Michael S. Foulk, Chun Liang, Nan Wu, Hannah G. Blitzblau, Heidi Smith, Daniel Alam, Maneesh Batra, Susan A. Gerbi Keywords: DNA amplification; Ecdysone; Sciara coprophila; DNA puff; EcRE; Amplification factor Abstract: DNA replication is normally tightly regulated to ensure the production of only one copy of the genome per cell cycle. However, DNA puffs of the salivary gland giant polytene chromosomes of Sciara coprophila undergo DNA amplification during the normal course of development, overriding this control. This developmental strategy provides more template for the production of large amounts of protein needed for pupation. We have focused on DNA puff II/9A, which amplifies [approximately equal to]17-fold over the rest of the genome. Evidence presented here suggests that DNA amplification at this locus is controlled by the steroid hormone ecdysone, the master regulator of insect development. Explanted, pre-amplification stage salivary glands undergo premature amplification when incubated with ecdysone. Injection of ecdysone into pre-amplification stage larvae induces amplification. Ecdysone also induces transcription of the II/9A genes. We report the presence of a putative ecdysone response element directly adjacent to the origin recognition complex (ORC)-binding site in the II/9A origin and demonstrate that it is efficiently bound by the Sciara ecdysone receptor. These results implicate ecdysone in the regulation of DNA amplification in Sciara and suggest the ecdysone receptor may be the elusive amplification factor. This would be a new role for this transcription factor. Author Affiliation: Brown University, 69 Brown St.-J.W. Wilson Laboratory, Providence, RI 02912, USA Article History: Received 17 May 2006; Revised 13 July 2006; Accepted 14 July 2006

Abstract Introduction Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs). Methods Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria. Results Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs: • Two interventions prevent preterm births—smoking cessation and progesterone • Eight interventions prevent stillbirths—balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery • Eleven interventions improve survival of preterm newborns—prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome Conclusion The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions.

Background: During the early COVID-19 pandemic travel in Uganda was tightly restricted which affected demand for and access to care for pregnant women and small and sick newborns. In this study we describe changes to neonatal outcomes in one rural central Ugandan newborn unit before and during the early phase of the COVID-19 pandemic. Methods: We report outcomes from admissions captured in an electronic dataset of a well-established newborn unit before (September 2019 to March 2020) and during the early COVID-19 period (April–September 2020) as well as two seasonally matched periods one year prior. We report excess mortality as the percent change in mortality over what was expected based on seasonal trends. Findings: The study included 2,494 patients, 567 of whom were admitted during the early COVID-19 period. During the pandemic admissions decreased by 14%. Patients born outside the facility were older on admission than previously (median 1 day of age vs. admission on the day of birth). There was an increase in admissions with birth asphyxia (22% vs. 15% of patients). Mortality was higher during COVID-19 than previously [16% vs. 11%, p = 0.017]. Patients born outside the facility had a relative increase of 55% above seasonal expected mortality (21% vs. 14%, p = 0.028). During this period patients had decreased antenatal care, restricted transport and difficulty with expenses and support. The hospital had difficulty with maternity staffing and supplies. There was significant community and staff fear of COVID-19. Interpretation: Increased newborn mortality during the early COVID-19 pandemic at this facility was likely attributed to disruptions affecting maternal and newborn demand for, access to and quality of perinatal healthcare. Lockdown conditions and restrictions to public transit were significant barriers to maternal and newborn wellbeing, and require further focus by national and regional health officials. [ABSTRACT FROM AUTHOR]

The Board of the Association of Pediatric Program Directors (APPD) partnered with the APPD Global Health Learning Community (GHLC) to establish the APPD Global Pediatric Educator Scholarship. This award seeks to recognize pediatric educators who demonstrate leadership in improving pediatric education in low- and middle-income countries, and provide them with career development opportunities by attending the APPD Spring meeting. Two educators per year have been awarded the scholarship since 2017. The authors sent survey questions via email and obtained responses from 6 (100%) of the scholarship awardees, 8 (75%) APPD GHLC leadership individuals, and 4 (67%) APPD Board members. Three authors analyzed the responses with consensus achieved on themes. Awardees noted learning about educational strategies, academic opportunities through networking, and context for stronger bilateral exchange with partners. APPD leaders noted an expansion of the organization's mission to include global presence. Challenges included program visibility, sustainable funding, and logistics. Suggestions included better incorporation of awardees into APPD membership, longitudinal mentorship, targeted conference navigation, and visits to local academic institutions. The APPD Global Educator Scholarship is a replicable model of organizational global outreach that expands the concept of bidirectional exchange to include career sponsorship for global partners. [ABSTRACT FROM AUTHOR]

To examine the association of resident perception of colleague and faculty support with performance, as measured by milestones-based competency scores, exploring associations between race and gender and perception of support and milestone scoring. Resident satisfaction was measured using an annual survey of residents at 49 pediatric residency programs in 2016, 2017, and 2018. Satisfaction with colleague and faculty support was measured using Likert scale survey questions. Pediatric Milestone Competency scores were obtained from the Association of Pediatric Program Directors' Longitudinal Educational Assessment Research Network. Analysis included linear fixed-effects models to examine the relationship between support satisfaction, race, gender, and spring milestone scores. Over 60% of eligible residents responded to the survey. The majority of residents were satisfied with colleague and faculty support, with those identifying as Asian or underrepresented in medicine (URM) reporting lower rates of satisfaction than White peers. Residents satisfied with colleague support had higher milestone scores compared to those with a neutral degree of satisfaction. Residents reporting dissatisfaction with colleague and faculty support had lower milestone scores in most competency domains. Residents identifying as URM had lower milestone scores than White residents, which was partially mediated by lower rates of support satisfaction. Resident satisfaction with colleague and faculty support correlates with milestone performance. In particular, dissatisfied residents have lower scores than those who are neutral or satisfied. Racial inequities in resident milestone scores may be partially driven by lower rates of support satisfaction among underrepresented residents. [ABSTRACT FROM AUTHOR]

Prior work demonstrating that burnout is associated with decreased performance in medical trainees has relied on self-report and/or single-site studies. We explored the relationship between burnout status and Milestones-based scores in pediatric residents nationally. In April to June 2016, we confidentially surveyed residents using the Maslach Burnout Inventory. Separately, programs submitted resident Milestones scores in June 2016. We examined the relationship between burnout and performance as assessed by Milestones scores for each domain of competence. We performed multivariate analysis to determine which components of burnout (depersonalization [DP], emotional exhaustion, and lack of personal accomplishment [PA]) were most impactful. About 1494 of 2368 (63%) residents at 32 programs completed the Maslach Burnout Inventory and had Milestones scores submitted. Residents who scored positive for burnout scored lower in all Milestones domains. Subgroup analysis demonstrated that this association was only significant (P <.05) in the post-graduate year 1 (PGY1) categorical pediatric cohort. In the PGY1 residents (n = 442), those positive for burnout had lower Milestones scores in patient care (PC) (2.78 vs 2.98), systems-based practice (2.69 vs 2.87), practice-based learning and improvement (2.77 vs 2.93), professionalism (3.09 vs 3.24), and interpersonal and communication skills (2.95 vs 3.12), but not medical knowledge. Multivariate analysis demonstrated that, in PGY1 residents, lower PC score was associated with lower PA and higher DP. Burnout is associated with decreased Milestones performance for pediatric PGY1 residents. DP and low PA were associated with lower PC scores in PGY1 residents. Future research should address whether strategies to mitigate burnout improve PGY1 performance. [ABSTRACT FROM AUTHOR]

Describe the demographics of pediatric and internal medicine/pediatric residents participating in global health (GH) experiences and examine relationships between GH involvement and self-perceived burnout, resilience, mindfulness, empathy, and spirituality. The Pediatric Resident Burnout and Resilience Study Consortium developed a national longitudinal study through collaboration with the Association of Pediatric Program Directors' Longitudinal Educational Assessment Research Network. Electronic surveys were administered to pediatric trainees annually (2016–2018). GH and well-being data were extracted. Descriptive statistics were calculated. Of 9653 eligible pediatric and medicine/pediatric residents from 55 institutions, 6150 responded to the survey in 1 or more years, with average completion rate of 63.7% over a 3-year period. Controlling for repeat survey-takers, 12.7% (536/4213) of residents reported involvement in a GH-specific pathway, curricula, or track. GH participants were significantly more likely to be unmarried (P <.001), childless (P =.003), and medicine/pediatric trainees (P <.001). Controlling for repeated measures and demographic factors, GH participants demonstrated higher levels of empathic concern (P <.001) and higher spirituality scores in 2 of 3 domains (P <.01/<.05). GH involvement was not associated with lower reports of burnout or improved resilience/mindfulness. Although GH involvement is associated with increased levels of empathy and spirituality, it was not protective against burnout in this study. This highlights the need to study and promote the well-being of all residents, and perhaps especially those experiencing the challenges of working in low-resource settings. Future efforts should determine the impact of predeparture training, programmatic support, and post-trip debriefing on resident well-being. [ABSTRACT FROM AUTHOR]

Measuring burnout symptoms is important, but the Maslach Burnout Inventory (MBI) has 22 items. This project compared 3 single-item measures with the MBI and other factors related to burnout. Data were analyzed from the 2016 and 2017 Pediatric Resident Burnout-Resilience Study Consortium surveys, which included standard measures of perceived stress, mindfulness, resilience, and self-compassion; the MBI; and the 1- and 2-item screening questions. In 2016 and 2017, data were collected from 1785/2723 (65%) and 2148/3273 (66%) eligible pediatric residents, respectively. Burnout rates on the MBI were 56% in 2016 and 54% in 2017. The Physician Work Life Study item generated estimates of burnout prevalence of 43% to 49% and, compared with the MBI for 2016 and 2017, had sensitivities of 69% to 72%, specificities of 79% to 82%, positive likelihood ratios of 3.4 to 3.8, and negative likelihood ratios of 0.35 to 0.38. The combination of an emotional exhaustion item and a depersonalization item generated burnout estimates of 53% in both years and, compared with the full MBI, had sensitivities of 85% to 87%, specificities of 84% to 85%, positive likelihood ratios of 5.7 to 6.4, and negative likelihood ratios of 0.18 for both years. Both items were significantly correlated with their parent subscales. The single items were significantly correlated with stress, mindfulness, resilience, and self-compassion. The 1- and 2-item screens generated prevalence estimates similar to the MBI and were correlated with variables associated with burnout. The 1- and 2-item screens may be useful for pediatric residency training programs tracking burnout symptoms and response to interventions. [ABSTRACT FROM AUTHOR]

PIK3CA‐related overgrowth spectrum (PROS) refers to a group of disorders of segmental overgrowth of a wide variety of tissues as well as venous and lymphatic malformations. Clinical and molecular diagnosis can be challenging due to phenotypic heterogeneity and difficulties detecting low‐level mosaicism using standard methods. Here, we report a patient with a severe presentation of PIK3CA‐related overgrowth with analysis of 27 posthumously collected tissues by droplet digital polymerase chain reaction (PCR) at autopsy. This patient had a complicated medical course, with coagulopathy, ischemic brain injury, and sepsis resulting in multi‐organ failure and death at age 2 months despite sirolimus therapy. Five of the 27 tissues analyzed possessed a mosaic PIK3CA mutation (p.E545K), with mutation levels ranging from 3 to 20% across affected tissues. We found no correlation between tissue‐specific disease severity and mutation levels, likely reflecting sampling limitations. We also tested a series of 22 individuals with somatic overgrowth and/or vascular‐lymphatic malformations using a targeted next generation sequencing panel and found PIK3CA mutations in nine individuals, identifying three novel PIK3CA variants. This report expands the clinical and molecular spectrum of PROS, emphasizes that different molecular methods can be complimentary in the diagnosis of these disorders, and highlights the risk of coagulopathy in a subset of patients with PIK3CA‐related overgrowth. [ABSTRACT FROM AUTHOR]

The medical care team was blinded to this score, and treatment decisions were made by provider discretion. Given a scoring system always best predicts outcomes in the patient sample from which it was derived, an ideal future study will include validation of the simplified score against the full RSS in a new population. [Extracted from the article]

Purpose: Early warning scores (EWS) identify high-risk hospitalized patients prior to clinical deterioration; however, their ability to identify high-risk pediatric patients in the emergency department (ED) has not been adequately evaluated. We sought to determine the association between modified pediatric EWS (MPEWS) in the ED and inpatient ward-to-pediatric intensive care unit (PICU) transfer within 24 hours of admission. Methods: This is a case–control study of 597 pediatric ED patients admitted to the inpatient ward at Seattle Children’s Hospital between July 1, 2010, and December 31, 2011. Cases were children subsequently transferred to the PICU within 24 hours, whereas controls remained hospitalized on the inpatient ward. The association between MPEWS in the ED and ward-to-PICU transfer was determined by chi-square analysis. Results: Fifty children experienced ward-to-PICU transfer within 24 hours of admission. The area under the receiver–operator characteristic curve was 0.691. Children with MPEWS > 7 in the ED were more likely to experience ward-to-PICU transfer (odds ratio 8.36, 95% confidence interval 2.98-22.08); however, the sensitivity was only 18.0% with a specificity of 97.4%. Using MPEWS >7 for direct PICU admission would have led to 167 unnecessary PICU admissions and identified only 9 of 50 patients who required PICU care. Conclusions: Elevated MPEWS in the ED is associated with increased risk of ward-to-PICU transfer within 24 hours of admission; however, an MPEWS threshold of 7 is not sufficient to identify more than a small proportion of ward-admitted children with subsequent clinical deterioration. [ABSTRACT FROM AUTHOR]

Objective: Cardiac dysfunction may contribute to high mortality in severely malnourished children. Our objective was to assess the effect of malnutrition on cardiac function in hospitalised African children.Design: Prospective cross-sectional study.Setting: Public referral hospital in Blantyre, Malawi.Patients: We enrolled 272 stable, hospitalised children ages 6-59 months, with and without WHO-defined severe acute malnutrition.Main Outcome Measures: Cardiac index, heart rate, mean arterial pressure, stroke volume index and systemic vascular resistance index were measured by the ultrasound cardiac output monitor (USCOM, New South Wales, Australia). We used linear regression with generalised estimating equations controlling for age, sex and anaemia.Results: Our primary outcome, cardiac index, was similar between those with and without severe malnutrition: difference=0.22 L/min/m(2) (95% CI -0.08 to 0.51). No difference was found in heart rate or stroke volume index. However, mean arterial pressure and systemic vascular resistance index were lower in children with severe malnutrition: difference=-8.6 mm Hg (95% CI -12.7 to -4.6) and difference=-200 dyne s/cm(5)/m(2) (95% CI -320 to -80), respectively.Conclusions: In this largest study to date, we found no significant difference in cardiac function between hospitalised children with and without severe acute malnutrition. Further study is needed to determine if cardiac function is diminished in unstable malnourished children. [ABSTRACT FROM AUTHOR]

BACKGROUND: Respiratory distress is a leading cause of neonatal death in low-income and middle-income countries. CPAP is a simple and effective respiratory support modality used to support neonates with respiratory failure and can be used in low-income and middle-income countries. The goal of this study was to describe implementation of the Silverman-Andersen respiratory severity score (RSS) and bubble CPAP in a rural Ugandan neonatal NICU. We sought to determine whether physicians and nurses in a low-income/middle-income setting would assign similar RSS in neonates after an initial training period and over time. METHODS: We describe the process of training NICU staff to use the RSS to assist in decision making regarding initiation, titration, and termination of bubble CPAP for neonates with respiratory distress. Characteristics of all neonates with respiratory failure treated with bubble CPAP in a rural Ugandan NICU from January to June 2012 are provided. RESULTS: Nineteen NICU staff members (4 doctors and 15 nurses) received RSS training. After this, the Spearman correlation coefficient for respiratory severity scoring between doctor and nurse was 0.73. Twenty-one infants, all < 3 d of age, were treated with CPAP, with 17 infants starting on the day of birth. The majority of infants (16/21, 76%) were preterm, 10 (48%) were <1,500 g (birthweight), and 13 (62%) were outborn. The most common diagnoses were respiratory distress syndrome (16/21, 76%) and birth asphyxia (5/21, 24%). The average RSS was 7.4 ± 1.3 before starting CPAP, 5.2 ± 2.3 after 2– 4 h of CPAP, 4.9 ± 2.7 after 12–24 h of CPAP, and 3.5 ± 1.9 before CPAP was discontinued. Duration of treatment with CPAP averaged 79 ± 43 h. Approximately half (11/21, 52%) of infants treated with CPAP survived to discharge. CONCLUSIONS: Implementing bubble CPAP in a low-income/middle-income setting is feasible. The RSS may be a simple and useful tool for monitoring a neonate’s respiratory status and for guiding CPAP management. [ABSTRACT FROM AUTHOR]

The ROC curve for 10 min RSS and intubation by 24 h is shown in Figure 1A. A RSS cut-off of > = 7 at 10 min and 1 h had the highest proportion correctly classified for intubation by 24 and 72 h. Keywords: neonate; endotracheal intubation; respiratory failure; surfactant treatment EN neonate endotracheal intubation respiratory failure surfactant treatment 1450 1451 2 04/19/21 20210501 NES 210501 Background: Treatment with mechanical ventilation is associated with chronic lung disease and poor neurologic outcomes in very premature neonates. [Extracted from the article]

Background Innovative online technology can enhance the practice of medicine, yet it also may be a forum for unprofessional behavior. Objective We surveyed program directors regarding their perceptions and experiences with residents' use of social networking sites (SNS). Methods In September 2011, we sent an online survey to program directors and associate program directors of pediatrics residency programs within the United States who are members of the Association of Pediatric Program Directors. Results A total of 162 program directors or associate program directors (representing 50% of residency programs) responded to the survey. One-third of respondents are ''very familiar'' with SNS and 23% use them ''daily or often.'' Most respondents (70%) rated ''friending'' peers as ''completely appropriate,'' whereas only 1% of respondents rated ''friending'' current or past patients as ''completely appropriate.'' More than one half of respondents believe inappropriate behavior on SNS is ''somewhat'' or ''very'' prevalent, and 91% are ''somewhat'' or ''very'' concerned that the prevalence of inappropriate behavior on SNS may increase. The most commonly reported problematic online activity was posting inappropriate comments about the workplace. Posting of inappropriate comments about self, patients, and staff also was observed. Residency programs commonly educate trainees about SNS during intern orientation (45%), or using written guidelines (29%) and ad hoc remediation (16%). Conclusions As educators teach trainees principles of online professionalism, appropriate use of SNS needs to be included in the training process. Curricular efforts may be hindered by some program directors' lack of familiarity with SNS. [ABSTRACT FROM AUTHOR]