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Objective: We evaluated the instructional design properties of interactive e-learning modules using a four-pronged approach. The elements assessed in this method included: 1) module objectives, 2) pedagogical strategies, 3) instructional design properties measured by the instructional design scale (IDS), and 4) level of interactivity. Methods: This descriptive study exemplifies the evaluation process of 18 previously developed e-learning Pediatric Nutrition Series (PNS) modules with the involvement of educators from six academic institutions. Using multiple tools, including Bloom’s taxonomy, IDS, and interactivity scale and templates, we examined and synthesized the four elements of the module properties as mentioned above. Data were analyzed using qualitative thematic and interpretive content analysis, descriptive statistics, and intraclass correlations. Results: All 18 PNS modules showed a consistent structure, including content with basic interactive components. Of 66 learning objectives, only three were vague/not measurable. A majority of the objectives were grouped in three cognitive levels: knowledge, comprehension, and evaluation. Six distinct pedagogical strategies were most frequently used in the PNS modules to support content and convey the message in a multisensory mode. Average evaluation scores for the modules across six instructional design domains ranged between 1.75 and 1.94 for the overall scale on the 50-item IDS. The results suggested that all modules were considered to be between “very good” with a score of 1.5 and “excellent” with a score of 2. All modules demonstrated either second- (limited interaction) or third-level interactivity (moderate interaction). Conclusion: Instructional design is a critical component of any e-learning developments. Applying the science of learning and theory-driven instructional design, principles may dramatically increase instructional effectiveness, engaging learners in purposeful learning practices. The four-pronged approach can provide a valuable road map to determine the instructional design qualities and has the potential to be an evaluation model for other e-learning applications in any field of the study.

Background Traditionally, quizzes have been applied as a tool for summative assessment, though literature suggests their use as a formative assessment can improve motivation and content retention. With this premise, we implemented a series of intermittent, online quizzes known as the Board Examination Simulation Exercise (BESE). We sought to demonstrate an association between BESE participation and scores and performance on the American Board of Pediatrics (ABP) Certifying Examination (CE). Methods Residents were assigned online quizzes on a single topic at 2 week intervals that consisted of 20 multiple choice questions written by the study authors. This analysis includes graduates of 3 Pediatric and Internal Medicine-Pediatrics residency programs. Results Data were available for 329 residents. The overall BESE score weakly correlated with ABP CE score (n = 287; r = 0.39, p

Background: Interventions to address burnout include mind-body skills training (MBST), but few studies have evaluated the feasibility of MBST for busy pediatric residents. Objective: In this pilot study, we tested the feasibility of a brief MBST intervention, using in-person peer-led training supported by online modules, to decrease stress and burnout in pediatric resident physicians. Methods: Of 99 (10%) residents, 10 residents at Nationwide Children’s Hospital in Ohio participated in up to four 90-minute MBST sessions more than 1 month, led by a co-resident with 5 years of informal training in mind-body skills. Participants were offered 8 assigned online modules through OSU Center for Integrative Health and Wellness. Measures including Maslach Burnout Inventory (MBI), Cohen’s Perceived Stress, Smith’s Brief Resilience, Cognitive and Affective Mindfulness Scale-Revised, and Neff’s Self-Compassion Scale (NSS) were administered before (T1) and after (T2) the course. Participants were offered optional monthly “maintenance” sessions for 6 months and completed a third set of measures at this follow-up (T3). Results: The residents completed an average of 4.3/8 online modules and attended an average of 2.8/4 in-person sessions. There was significant improvement in positive attitude, perceived stress, and resilience post intervention (T2). Follow-up evaluation (T3) also demonstrated significant improvement in burnout (depersonalization) and mindfulness. More than 75% of participants found the course worthwhile. Conclusions: A short mixed-method mindfulness-based skills course may be a practical way to offer resilience and stress management training to busy resident physicians.

There is scant literature describing the effect of glomerular disease on health-related quality of life (HRQOL). The Cure Glomerulonephropathy study (CureGN) is an international longitudinal cohort study of children and adults with four primary glomerular diseases (minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and IgA nephropathy). HRQOL is systematically assessed using items from the Patient-Reported Outcomes Measurement Informative System (PROMIS). We assessed the relationship between HRQOL and demographic and clinical variables in 478 children and 1115 adults at the time of enrollment into CureGN. Domains measured by PROMIS items included global assessments of health, mobility, anxiety, fatigue, and sleep impairment, as well as a derived composite measure incorporating all measured domains. Multivariable models were created that explained 7 to 32% of variance in HRQOL. Patient-reported edema consistently had the strongest and most robust association with each measured domain of HRQOL in multivariable analysis (adjusted β [95% CI] for composite PROMIS score in children, -5.2 [-7.1 to -3.4]; for composite PROMIS score in adults, -6.1 [-7.4 to -4.9]). Female sex, weight (particularly obesity), and estimated glomerular filtration rate were also associated with some, but not all, domains of HRQOL. Primary diagnosis, disease duration, and exposure to immunosuppression were not associated with HRQOL after adjustment. Sensitivity analyses and interaction testing demonstrated no significant association between disease duration or immunosuppression and any measured domain of HRQOL. Thus, patient-reported edema has a consistent negative association with HRQOL in patients with primary glomerular diseases, with substantially greater impact than other demographic and clinical variables.

Background Burnout is highly prevalent among residents and associated with poor personal health and worse patient outcomes. Little is known about the factors which impact burnout longitudinally. Objectives 1) Define burnout prevalence (via Maslach Burnout Inventory) from 2016-2018 among pediatric residents; 2) Explore demographic factors and experiences related to burnout over time; and 3) Elucidate factors that predict future burnout, stress, and confidence in providing compassionate care (CPCC). Methods The Pediatric Residency Burnout-Resilience Consortium, a national sample of 34 programs in 2016, 43 programs in 2017, and 49 programs in 2018, conducted an annual anonymous survey of residents for 3 years via APPD LEARN. The survey included personal qualities (quality of life, sleepiness, mindfulness, self-compassion, empathy); experiences (current rotation, recent errors/patient deaths and time off, special learning tracks), satisfaction (career, work/life balance, support, learning environment) and measures of burnout, stress, and CPCC. Cross-sectional and longitudinal regression analyses for these measures was performed. Results >60% of eligible residents participated each year; burnout rates (54%-56%) were similar all 3 years and not associated with any specified demographic characteristic. In each year burnout was associated with stress, sleepiness, dissatisfaction with work/life balance, and reporting a recent medical error; burnout was inversely associated with higher levels of empathy, self-compassion, quality of life, and CPCC. Higher self-compassion in 2017 correlated with lower stress in 2018. Mindfulness and satisfaction with learning environment and pediatrics as career in 2017 correlated with higher CPCC in 2018. Conclusion Nationally, burnout prevalence in pediatric residents consistently exceeds 50%. We identified modifiable factors associated with lower burnout including empathy, mindfulness, self-compassion and stress and programmatic interventions which may mitigate burnout such as training in medical errors response, and healthy scheduling paradigms.

Cross-sectional studies of children with prevalent nephrotic syndrome (NS) have shown 25-vitamin D (25(OH)D) deficiency rates of 20–100 %. Information on 25(OH)D status in incident patients or following remission is limited. This study aimed to assess 25(OH)D status of incident idiopathic NS children at presentation and longitudinally with short-term observation. Multicenter longitudinal study of children (2–18 years old) from 14 centers across the Midwest Pediatric Nephrology Consortium with incident idiopathic NS. 25(OH)D levels were assessed at diagnosis and 3 months later. Sixty-one children, median age 5 (3, 11) years, completed baseline visit and 51 completed second visit labs. All 61 (100 %) had 25(OH)D

Introduction The Self-Management and Transition to Adulthood with Rx = Treatment (STARx) Questionnaire was developed to collect information on self-management and health care transition (HCT) skills, via self-report, in a broad population of adolescents and young adults (AYAs) with chronic conditions. Methods Over several iterations, the STARx questionnaire was created with AYA, family, and health provider input. The development and pilot testing of the STARx Questionnaire took place with the assistance of 1219 AYAs with different chronic health conditions, in multiple institutions and settings over three phases: item development, pilot testing, reliability and factor structuring. Results The three development phases resulted in a final version of the STARx Questionnaire. The exploratory factor analysis of the third version of the 18-item STARx identified six factors that accounted for about 65% of the variance: Medication management, Provider communication, Engagement during appointments, Disease knowledge, Adult health responsibilities, and Resource utilization. Reliability estimates revealed good internal consistency and temporal stability, with the alpha coefficient for the overall scale being .80. The STARx was developmentally sensitive, with older patients scoring significantly higher on nearly every factor than younger patients. Conclusion The STARx Questionnaire is a reliable, self-report tool with adequate internal consistency, temporal stability, and a strong, multidimensional factor structure. It provides another assessment strategy to measure self-management and transition skills in AYAs with chronic conditions.

Background : While both patients and physicians identify communication of bad news as an area of great challenge, the factors underlying this often complex task remain largely unknown. Emotional intelligence (EI) has been positively correlated with good general communication skills and successful leadership, but there is no literature relating EI to the delivery of bad news. Purpose : Our objectives were to determine: 1) performance of first-year pediatric residents in the delivery of bad news in a standardized patient (SP) setting; and 2) the role of EI in these assessments. Our hypothesis was that pediatric trainees with higher EI would demonstrate more advanced skills in this communication task. Methods : Forty first- year residents participated. Skill in bad news delivery was assessed via SP encounters using a previously published assessment tool (GRIEV_ING Death Notification Protocol). Residents completed the Emotional and Social Competency Inventory (ESCI) as a measure of EI. Results : Residents scored poorly on bad news delivery skills but scored well on EI. Intraclass correlation coefficients indicated moderate to substantial inter-rater reliability among raters using the delivering bad news assessment tool. However, no correlation was found between bad news delivery performance and EI. Conclusions : We concluded that first-year pediatric residents have inadequate skills in the delivery of bad news. In addition, our data suggest that higher EI alone is not sufficient to effectively deliver death news and more robust skill training is necessary for residents to gain competence and acquire mastery in this important communication domain. Keywords: breaking bad news; emotional intelligence; pediatrics (Published: 17 August 2015) Citation: Med Educ Online 2015, 20: 24245 - http://dx.doi.org/10.3402/meo.v20.24245

Introduction Training in integrative medicine aims to promote compassionate, patient-centered care, including non-pharmaceutical therapies to reduce common symptoms. Although specific competencies have been identified, few tools are available to assess clinician confidence in providing integrative care. We evaluated two instruments to address this gap. Methods We assessed face validity with focus groups. We assessed internal reliability (Cronbach's alpha) and convergent validity in a survey of 213 health professionals, correlating the new instruments to each other and to standard measures of mindfulness, compassion, empathy, training, and practice. Results The two measures each had 10 items with scores ranging from 0 to 100, and had good face validity. Cronbach's alpha was 0.87 for the calm, compassionate care scale (CCCS) and 0.95 for self-efficacy in providing non-drug therapies to relieve common symptoms (SEND). Scores for CCCS were significantly correlated with measures of mindfulness, compassion, empathic concern, and perspective-taking as well as training and practice (p Conclusion These two new tools, CCCS and SEND, have good psychometric properties and may be useful to educators and researchers evaluating clinicians’ confidence in providing calm, compassionate care and self-efficacy in using non-drug therapies to relieve common symptoms.

Objective. To test the hypothesis that small group concept mapping of 4 core neonatal topics as part of a fourth-year allopathic medical student elective would improve critical thinking (CT) as measured by the California Critical Thinking Skills Test (CCTST). To describe any correlations between scores on the CCTST and the step 1 and step 2 Clinical Knowledge parts of the United States Medical Licensing Exam. Methods. Twenty-seven students participated in this pilot study during a 1-month elective. A pretest CCTST, California Critical Thinking Disposition Inventory (CCTDI), and multiple choice knowledge test (MCKT) were completed immediately before the elective began. Four weekly group sessions were held with assigned reading on each of the 4 neonatal topics. Concept mapping was performed in small groups of 4 to 6 students with a group concept map collected at the end of the exercise. A posttest CCTST and MCKT was completed after the 4 group sessions. Results. Pre-CCTST overall score was 83.9 ± 6, and post-CCTST overall score was 85.6 ± 6.9 ( P = .57). Pearson correlation of USMLE step 1 and pre-CCTST showed r(25) = .276, P = .164. Pearson correlation of USMLE step 2 CK and pre-CCTST revealed r(25) = .214, P = .482. The precourse MCKT average was 35%, and the postcourse average 50% ( P ≤ .001). Conclusions. A recent meta-analysis confirms this is the first report of a comparison between the increasingly common CCTST and the USMLE. We confirmed that concept mapping is a valid mechanism to teach content knowledge. Although the difference in the CCTST scores was not significant, this study could serve as an important start toward development of a curriculum devoted to teaching content and improving CT. The small number of students may have prevented us from defining a significant impact.

The Federation of Pediatric Organizations engaged members of the pediatric community in an 18-month process to envision the future of the workforce in pediatrics, culminating in a Visioning Summit on the Future of the Workforce in Pediatrics. This article documents the planning process and methods used. Four working groups were based on the 4 domains that are likely to affect the future workforce: Child Health Research and Training, Diversity and Inclusion, Gender and Generations, and Pediatric Training Along the Continuum. These groups identified the issues and trends and prioritized their recommendations. Before the summit, 5 key megatrends cutting across all domains were identified: 1. Aligning Education to the Emerging Health Needs of Children and Families 2. Promoting Future Support for Research Training and for Child Health Research 3. Striving Toward Mastery Within the Profession 4. Aligning and Optimizing Pediatric Practice in a Changing Health Care Delivery System 5. Taking Advantage of the Changing Demographics and Expertise of the Pediatric Workforce At the Visioning Summit, we assembled members of each of the working groups, the Federation of Pediatric Organizations Board of Directors, and several invited guests to discuss the 5 megatrends and develop the vision, solutions, and actions for each megatrend. Based on this discussion, we offer 10 recommendations for the field of pediatrics and its leading organizations to consider taking action.

Objective Patients and physicians identify communication of bad news as a skill in need of improvement. Our objectives were to measure change in performance of first-year pediatric residents in the delivery of bad news after an educational intervention and to measure if changes in performance were sustained over time. Methods Communication skills of 29 residents were assessed via videotaped standardized patient (SP) encounters at 3 time points: baseline, immediately post-intervention, and 3 months post-intervention. Educational intervention used was the previously published “GRIEV_ING Death Notification Protocol.” Results The intraclass correlation coefficient demonstrated substantial inter-rater agreement with the assessment tool. Performance scores significantly improved from baseline to immediate post-intervention. Performance at 3 months post-intervention showed no change in two subscales and small improvement in one subscale. Conclusions We concluded that breaking bad news is a complex and teachable skill that can be developed in pediatric residents. Improvement was sustained over time, indicating the utility of this educational intervention. Practice implications This study brings attention to the need for improved communication training, and the feasibility of an education intervention in a large training program. Further work in development of comprehensive communication curricula is necessary in pediatric graduate medical education programs.

Background.Mind–body skills (MBS) training is popular, but in-person training can be inconvenient and costly. We assessed the impact of online MBS training on clinicians’ and trainees’ stress, mindfulness, and confidence in providing calm, compassionate care.Methods.This was a prospective cohort trial. Trainees entering medical school; graduate programs in nursing, social work, and dietetics; and residencies in family medicine and pediatrics at a large Midwestern academic health center were invited to complete online surveys before and 12 weeks after enrolling in online elective integrative health courses on MBS training or not. The elective offered no course credit and had no mandated deadlines for completion.Results.At baseline, the 60 who engaged in MBS training were similar to the 43 who did not in terms of profession, gender, perceived stress levels, mindfulness, resilience, and compassion. MBS participants engaged in a median of 3 of 12 available modules with a bimodal distribution peaking at 1 to 2 and 12 modules. Twelve weeks later, those who participated in MBS showed significantly greater improvements in measures of stress, mindfulness, and confidence in providing calm, compassionate care than those who did not.Conclusions.Online elective training offers a feasible strategy to improve mindfulness, stress, and confidence in providing calm, compassionate care. Additional studies are needed to determine the impact of required versus elective courses, the optimal dosage and content of training, and the costs and benefits of online versus in-person training.

Introduction Traditional normative Likert-type evaluations of faculty teaching have several drawbacks, including lack of granular feedback, potential for inflation, and the halo effect. To provide more meaningful data to faculty on their teaching skills and encourage educator self-reflection and skill development, we designed and implemented a milestone-based faculty clinical teaching evaluation tool. Methods The evaluation tool contains 10 questions that assess clinical teaching skills with descriptive milestone behavior anchors. Nine of these items are based on the Stanford Faculty Development Clinical Teaching Model and annual Accreditation Council for Graduate Medical Education (ACGME) resident survey questions; the tenth was developed to address professionalism at our institution. The tool was developed with input from residency program leaders, residents, and the faculty development committee and piloted with graduate medical education learners before implementation. Results More than 7,200 faculty evaluations by learners and 550 faculty self-evaluations have been collected. Learners found the form easy to use and preferred it to previous Likert-based evaluations. Over the 2 years that faculty self-evaluations have been collected, their scores have been similar to the learner evaluation scores. The feedback provided faculty with more meaningful data on teaching skills and opportunities for reflection and skill improvement and was used in constructing faculty teaching skills programs at the institutional level. Discussion This innovation provides an opportunity to give faculty members more meaningful teaching evaluations and feedback. It should be easy for other institutions and programs to implement. It leverages a familiar milestone construct and incorporates important ACGME annual resident survey information.

Obtain evidence-based information to make timely and accurate diagnoses and treatment decisions. Continuing with this volume, Succinct Pediatrics is an ongoing series covering the entire scope of pediatric medicine. Each volume includes concise chapters with key features and invaluable tables and algorithms--resources health care professionals can use to deliver the highest quality of care. This third volume features 41 topics with key points and detailed therapies in neonatology, genetics, neurology, and developmental and behavioral disorders. Evidence-based levels of decision support are also provided throughout the book to provide insight into diagnostic tests and treatment modalities. Topics include Apnea of Prematurity Birth Injuries Respiratory Distress Syndrome Down Syndrome and Turner Syndrome Ataxia and Movement Disorders Cerebral Palsy Febrile Seizures Hydrocephalus Autism Spectrum Disorders Behavior Patterns And more...

Despite increasing numbers of patients with neurodisability, residents lack training to develop physical examination skills. Following a blended educational intervention combining online and bedside teaching, residents demonstrated desired patient-care behaviors on standardized clinical exam assessment.

Background Nephrotic syndrome represents a condition in pediatric nephrology typified by a relapsing and remitting course, proteinuria and the presence of edema. The PROMIS measures have previously been studied and validated in cross-sectional studies of children with nephrotic syndrome. This study was designed to longitudinally validate the PROMIS measures in pediatric nephrotic syndrome. Methods One hundred twenty seven children with nephrotic syndrome between the ages of 8 and 17 years participated in this prospective cohort study. Patients completed a baseline assessment while their nephrotic syndrome was active, a follow-up assessment at the time of their first complete proteinuria remission or study month 3 if no remission occurred, and a final assessment at study month 12. Participants completed six PROMIS measures (Mobility, Fatigue, Pain Interference, Depressive Symptoms, Anxiety, and Peer Relationships), the PedsQL version 4.0, and two global assessment of change items. Results Disease status was classified at each assessment: nephrotic syndrome active in 100% at baseline, 33% at month 3, and 46% at month 12. The PROMIS domains of Mobility, Fatigue, Pain Interference, Depressive Symptoms, and Anxiety each showed a significant overall improvement over time (p

The aim of this study was to evaluate whether the current state of child neurology education during pediatric residency provides adequate preparation for pediatric practice. A survey was sent to recent graduates from 3 pediatric residency programs to assess graduate experience, perceived level of competence, and desire for further education in child neurology. Responses from generalists versus subspecialists were compared. The response rate was 32%, half in general pediatric practice. Only 22% feel very confident in approaching patients with neurologic problems. This may represent the best-case scenario as graduates from these programs had required neurology experiences, whereas review of Accreditation Council of Graduate Medical Education-accredited residency curricula revealed that the majority of residencies do not. Pediatric neurologic problems are common, and pediatric residency graduates do encounter such problems in practice. The majority of pediatricians report some degree of confidence; however, some clear areas for improvement are apparent.

A workforce crisis for many pediatric specialties, particularly nephrology, is due to growing retirement rates, attrition during training, and retention difficulties. To obtain specific information regarding pediatric nephrology trainee shortages, we administered two cross-sectional surveys to non-renal pediatric subspecialty fellows and pediatric nephrology program directors. We characterized the fellows' experiences with nephrology and the program directors' experiences with their fellows as well as their outcomes in the last 10 years. We analyzed responses from 531 non-renal fellows (14.4% response rate). Overall, 317 (60%) fellows rated nephrology as difficult, particularly women (65.4% vs. 49.5%, p 0.001), with American women medical graduates rating nephrology as more difficult compared to all others (p = 0.001). More men than women (24% vs. 8%, p 0.001) considered the monetary benefit as not adequate. Program directors (25; 64% response rate) represented 57% of all USA fellows in training, and 15 (60%) found it difficult to recruit qualified applicants. Of the 183 graduates in the past 10 years, 35 (19%) were reported as not in the USA pediatric nephrology workforce. These findings support our belief that a strong effort needs to be made by the academic community to teach nephrology in more interesting and understandable formats. While these are national samples, we were unable to contact non-nephrology fellows directly and program directors from larger programs were underrepresented. Difficulties in attracting/retaining trainees (particularly women) to nephrology must be addressed systematically, identifying incentives to practice in this field. Bold concerted efforts are required and we propose seven steps to achieve this goal.

It is important in teaching adults to recognize the essential characteristics of adult learners and how these characteristics define their learning priorities and activities. The seven key premises and practices for teaching adults provide a good guide for those interested in helping adults learn. The emerging science of the neurobiology of learning provides powerful new insights into how learning occurs in the complex integrated neural network that characterizes the adult. Differentiation of the two types of thinking: System 1 (fast, intuitive, and, often, emotional) and System 2 (slower, deliberate, and logical). System 1 thinking helps explain the basis for quick decisions and reliance of humans on heuristics (or rules of thumb) that leads to the type of convenient thinking associated with errors of thinking and judgment. We now know that the learning experience has an objective location—in the temporal and parietal lobes—as persistent dynamic networks of neurons and neuronal connections. Learning is initially stored in transient working memory (relatively limited capacity and time frame) and then moved under the right conditions to more long-lasting / stable memory (with larger capacity) that is stored for future access and development. It is clear that memories are not static and are not destined, once developed, to forever remain as stable constructs; rather, memories are dynamic, always available for modulation and alteration, and heavily invested with context, emotion, and other operant factors. The framework for such neural networks involves new neuronal connections, enhanced neuronal synaptic transmission, and neuron generation. Ten key teaching and learning concepts derived from recent neurobiology studies on learning and memory are presented. As the neurobiology of learning is better defined, the basis for how adults best learn, and even the preferences they display, can be employed as the physiological foundation for our best methods to effectively teach adults and facilitate their learning.

e-Learning has become a popular medium for delivering instruction in medical education. This innovative method of teaching offers unique learning opportunities for medical trainees. The purpose of this article is to define the present state of e-learning in pediatrics and how to best leverage e-learning for educational effectiveness and change in medical education. Through addressing under-examined and neglected areas in implementation strategies for e-learning, its usefulness in medical education can be expanded. This study used a systematic database review of published studies in the field of e-learning in pediatric training between 2003 and 2013. The search was conducted using educational and health databases: Scopus, ERIC, PubMed, and search engines Google and Hakia. A total of 72 reference articles were suitable for analysis. This review is supplemented by the use of "e-Learning Design Screening Questions" to define e-learning design and development in 10 randomly selected articles. Data analysis used template-based coding themes and counting of the categories using descriptive statistics.Our search for pediatric e-learning (using Google and Hakia) resulted in six well-defined resources designed to support the professional development of doctors, residents, and medical students. The majority of studies focused on instructional effectiveness and satisfaction. There were few studies about e-learning development, implementation, and needs assessments used to identify the institutional and learners' needs. Reviewed studies used various study designs, measurement tools, instructional time, and materials for e-learning interventions. e-Learning is a viable solution for medical educators faced with many challenges, including (1) promoting self-directed learning, (2) providing flexible learning opportunities that would offer continuous (24h/day/7 days a week) availability for learners, and (3) engaging learners through collaborative learning communities to gain significant learning and augment continuous professional development. Several important recommendations for faculty instructors interested in providing and/or improving e-learning activities for today's learners are detailed.

Chronic kidney disease is a persistent chronic health condition commonly seen in pediatric nephrology programs. Our study aims to evaluate the sensitivity of the Patient Reported Outcomes Measurement Information System (PROMIS) pediatric instrument to indicators of disease severity and activity in pediatric chronic kidney disease. This cross sectional study included 233 children 8–17 years old, with chronic kidney disease from 16 participating institutions in North America. Disease activity indicators, including hospitalization in the previous 6 months, edema, and number of medications consumed daily, as well as disease severity indicators of kidney function and coexisting medical conditions were captured. PROMIS domains, including depression, anxiety, social-peer relationships, pain interference, fatigue, mobility, and upper extremity function, were administered via web-based questionnaires. Absolute effect sizes (AES) were generated to demonstrate the impact of disease on domain scores. Four children were excluded because of missing glomerular filtration rate (GFR) estimations. Of the 229 children included in the final analysis, 221 completed the entire PROMIS questionnaire. Unadjusted PROMIS domains were responsive to chronic kidney disease activity indicators and number of coexisting conditions. PROMIS domain scores were worse in the presence of recent hospitalizations (depression AES 0.33, anxiety AES 0.42, pain interference AES 0.46, fatigue AES 0.50, mobility AES 0.49), edema (depression AES 0.50, anxiety AES 0.60, pain interference AES 0.77, mobility AES 0.54) and coexisting medical conditions (social peer-relationships AES 0.66, fatigue AES 0.83, mobility AES 0.60, upper extremity function AES 0.48). The PROMIS pediatric domains of depression, anxiety, social-peer relationships, pain interference, and mobility were sensitive to the clinical status of children with chronic kidney disease in this multi-center cross sectional study. We demonstrated that a number of important clinical characteristics including recent history of hospitalization and edema, affected patient perceptions of depression, anxiety, pain interference, fatigue and mobility. The PROMIS instruments provide a potentially valuable tool to study the impact of chronic kidney disease. Additional studies will be required to assess responsiveness in PROMIS score with changes in disease status over time.

Background In 2013, the Accreditation Council for Graduate Medical Education (ACGME) began requiring program directors (PDs) to report Milestone levels for every resident semiannually. Our prior 2015 survey found that few PDs had minimum Milestone level expectations before residents are ready to supervise (20%) or ready to graduate (20%). Objective Characterize present day model for pediatric PD minimum Milestone expectations for residents before being ready to supervise and graduate. Methods Cross-sectional survey in Spring 2018 of pediatric PDs on their program Milestone expectations before residents are ready to supervise and graduate. At programs with no established Milestone expectations, PDs indicated expectations they considered for use in their program. Descriptive analyses were used to explore PD minimum expectations by level of training. Results Response rate was 46.2% (93/201). Few programs have minimum Milestone levels before residents are ready to supervise (22.6%; 21/93) or graduate (36.6%; 34/93). Minimum expectations before a resident was ready to supervise were highest for trustworthiness (Prof5), professional conduct (Prof3), professionalization (Prof2), transfer of care (PC3), organize and prioritize (PC2), humanism (Prof1), and help-seeking (Prof4), where most PDs felt that Level 2.5 was the minimum expectation. PD expectations for supervising residents were lowest for learning activities (PBLI2) and advocacy (SBP2), where the majority of PDs felt that there was no minimum or that Level 1 was sufficient. Minimum expectations for graduates were highest for diagnostic/therapeutic decisions (PC4), develop management plans (PC5), gather information (PC1), organize and prioritize (PC2), professionalization (Prof2), and trustworthiness (Prof5), where >70% of PDs felt that Level 3.0 was the minimum (Figure). PD expectations for graduating residents were lowest for quality improvement (PBLI3), advocacy, learning activities, and evidence-based medicine (MK), where >40% of PDs felt that Level 2.5 was the minimum. Conclusions Five years after the ACGME required Milestone reporting, only a minority of PDs have established minimum Milestones before residents are ready to supervise or ready to graduate. However, more PDs have minimum Milestone levels before residents are ready to graduate than in 2015 (36.6% vs 20%) and PDs recognize the relative importance of different competencies in establishing readiness to supervise and readiness to graduate.

Background The ACGME requires residency programs to monitor & address burnout. Previous studies of prevalence and interventions to address burnout are limited by small number of participants and cross-sectional designs. Objective Develop a national consortium of pediatric residency programs to characterize, monitor, and address resident burnout and well-being through research and advocacy. Methods The Pediatric Residency Burnout-Resilience Study Consortium (PRBRSC) was founded in 2015 by 8 members from 6 institutions, who continue to serve as a steering committee (SC). Activities have included assessing residency efforts to monitor/improve well-being, and assessing the prevalence, natural history, and protective/risk factors for burnout longitudinally. Membership was solicited through discussions at APPD meetings and email invitation to programs. In collaboration with APPD LEARN, the SC developed an anonymous annual online resident survey including standard measures of burnout and attributes of well-being based on literature review and consensus. A subcommittee developed a program report template so that aggregate results could be provided annually for each participating program to monitor their well-being. Proposed sub-analyses of the dataset can be submitted by any site investigator, requires involvement of investigators from >1 program and a SC member. Results The PRBRSC has grown from 34 residency programs (2723 residents) in 2016, to 43 (3273 residents) in 2017, and 49 (3657 residents) in 2018. Annual survey response rates were >60% in all 3 years. Program reports were distributed annually to each participating program. The PRBRSC has had 7 presentations at national meetings, 5 published manuscripts and 4 proposals for additional studies. Additional manuscripts are in preparation or have been submitted. Conclusion After 3 years, the PRBSC has established a nationally representative sample of programs to characterize prevalence and associated risk/protective factors and is poised to develop and study interventions to promote well-being and reduce burnout among residents.

The evidence is growing that burnout in trainees, as well as in practicing physicians, comes at a cost to the physicians, those they interact with at home and work, and their patients.1 In their article in this issue entitled “Pediatric Resident Burnout and Attitudes Toward Patients,” Baer et al2 surveyed pediatric residents at 11 programs in New England to better understand the pathogenesis of burnout in these trainees; the goal was to assist in efforts to develop effective measures to prevent and/or address these maladaptive responses. It is unsurprising to those who work with trainees that 101 of 258 pediatric residents reported being “burned-out.”3–5 In fact, many studies show higher rates of burnout in pediatric trainees (40%–75%) depending on site and year of training.6,7 In the study by Baer et al,2 there were no significant differences in burnout rates according to sex, race/ethnicity, and relationship or parental status; younger residents (

Confidently evaluate evidence-based information to make timely and accurate diagnoses and treatment decisions! Continuing with this volume, Succinct Pediatrics will be an ongoing series covering the entire scope of pediatric medicine. Each volume will include short chapters with key features and invaluable tables and algorithms, allowing health care professionals the opportunity to deliver the highest quality of care. The second volume features 58 topics with key points and detailed therapies in Infectious Diseases and Dermatological Disorders. The book starts with an overview of the core knowledge needed for medical decision-making. Evidence-based levels of decision support are also provided throughout the book to provide insight into diagnostic tests and treatment modalities.

Our objective was to evaluate the utility of an educational program consisting of a workshop based on the Take the HEAT communication strategy, designed specifically for addressing patients who are angry, using a novel tool to evaluate residents' skills in employing this method.33 first-year pediatric and internal medicine-pediatrics residents participated in the study. The workshop presented the Take the HEAT (Hear, Empathize, Apologize, Take action) strategy of communication. Communication skills were assessed through standardized patient encounters at baseline and post-workshop. Encounters were scored using a novel assessment tool.After the workshop, residents' Take the HEAT communication improved from baseline total average score 23.15 to total average score 25.36 (Z=-3.428, p0.001). At baseline, empathy skills were the lowest. Intraclass Correlation Coefficient demonstrated substantial agreement (0.60 and 0.61) among raters using the tool.First-year pediatric trainees' communication with angry families improved with education focused on the Take the HEAT strategy. Poor performance by residents in demonstrating empathy should be explored further.This study demonstrates the utility of a brief communications curriculum aimed at improving pediatric residents' ability to communicate with angry families.

To evaluate the preparedness of pediatric residents entering accredited neonatal-perinatal medicine (NPM) fellowships in the United States.A multi-domain, validated survey was distributed to Program Directors (PDs) of US NPM fellowship programs. The 47-item survey explored 5 domains: professionalism, independent practice, psychomotor ability, clinical evaluation, and academia. A systematic, qualitative analysis on free-text comments was also performed.Sixty-one PDs completed the survey, for a response rate of 62% (61/98). For entering fellows, PDs assessed performance in professionalism positively, including 76% as communicating effectively with parents and 90% treating residents/house-staff with respect. In contrast, most PDs rated performance in psychomotor abilities negatively, including 59% and 79% as deficient in bag-and-mask ventilation and neonatal endotracheal intubation, respectively. Although 62% of PDs assessed entering fellows positively for genuine interest in academic projects, fewer than 10% responded positively that entering fellows understood research protocol design, basic statistics, or were capable of writing a cohesive manuscript well. Thematic clustering of qualitative data revealed deficits in psychomotor ability and academia/scholarship.On the basis of the perspective of front line educators, graduating pediatric residents are underprepared for subspecialty fellowship training in NPM. To provide the best preparation for pediatric graduates who pursue advanced training, changes to residency education to address deficiencies in these important competencies are warranted.

The role of biochemical bone turnover markers (BTMs) in assessing low bone mass and monitoring bisphosphonate treatment in pediatric patients with clinical bone fragility is not well established. The aim of the study was to examine the correlations of BTMs and the bone mineral density (BMD), and evaluate the effects of bisphosphonates therapy on BTMs in children with clinical bone fragility.Clinical data of 115 patients with clinical bone fragility (mean age 9.7±5.8 years), 102 of whom received bisphosphonates, were studied. Serum alkaline phosphatase (ALP), osteocalcin (OC), urine pyridinoline (PD) and deoxypyridinoline (DPD), BMD at baseline and subsequent years were analyzed.There was a significant negative correlation between urine PD and lumbar BMD (slope=–0.29, pIn children with clinical bone fragility, BTMs correlated with each other, but not with lumbar BMD Z-score. While they were not reliable predictors of degree of low BMD, the bone markers showed suppression during bisphosphonate therapy and may be helpful in monitoring the response to therapy.

Prospective data regarding the de novo use of everolimus following kidney transplantation in children are sparse. In a prospective, 12-month, single-arm, open-label study, pediatric kidney transplant patients received everolimus (target trough concentration ≥3 ng/mL) with reduced-exposure CsA and corticosteroids, with or without basiliximab induction. Sixteen of the 18 patients completed the study on-treatment. Age range was 2-16 yr (mean 10.9 yr); eight patients received a living donor graft. Mean (s.d.) everolimus level was 7.4 (3.1) ng/mL during the first 12 months post-transplant. There were no cases of BPAR, graft loss, or death during the study. Protocol biopsies were performed at month 12 in seven patients, with subclinical (untreated) acute rejection diagnosed in one case. Mean (s.d.) estimated GFR (Schwartz formula) was 98 (34) mL/min/1.73 m(2) at month 12. Three patients experienced one or more serious adverse events with a suspected relation to study medication. One patient discontinued study medication due to post-transplant lymphoproliferative disease (5.6%). Everolimus with reduced-dose CsA and corticosteroids achieved good efficacy and renal function and was well tolerated in this small cohort of pediatric kidney transplant patients. Controlled trials are required to answer remaining questions about the optimal use of everolimus in this setting.

Background Self-assessment and self-directed learning are essential to becoming an effective physician. Objective To identify factors associated with resident self-assessment on the competencies, and to determine whether residents chose areas of self-assessed relative weakness as areas for improvement in their Individualized Learning Plan (ILP). Methods We performed a cross-sectional analysis of the American Academy of Pediatrics' PediaLink ILP database. Pediatrics residents self-assessed their competency in the 6 Accreditation Council for Graduate Medical Education competencies using a color-coded slider scale with end anchors “novice” and “proficient” (0–100), and then chose at least 1 competency to improve. Multivariate regression explored the relationship between overall confidence in core competencies, sex, level of training, and degree (MD or DO) status. Correlation examined whether residents chose to improve competencies in which they rated themselves as lower. Results A total of 4167 residents completed an ILP in academic year 2009–2010, with residents' ratings improving from advanced beginner (48 on a 0–100 scale) in postgraduate year-1 residents (PGY-1s) to competent (75) in PGY-3s. Residents rated themselves as most competent in professionalism (mean, 75.3) and least competent in medical knowledge (mean, 55.8) and systems-based practice (mean, 55.2). In the adjusted regression model, residents' competency ratings increased by level of training and whether they were men. In PGY-3s, there was no difference between men and women. Residents selected areas for improvement that correlated to competencies where they had rated themselves lower (P Conclusion Residents' self-assessment of their competencies increased by level of training, although residents rated themselves as least competent in medical knowledge and systems-based practice, even as PGY-3s. Residents tended to choose subcompetencies, which they rated as lower to focus on improving.

Calcium nephrolithiasis in children is increasing in prevalence and tends to be recurrent. Although children have a lower incidence of nephrolithiasis than adults, its etiology in children is less well understood; hence treatments targeted for adults may not be optimal in children. To better understand metabolic abnormalities in stone forming children, we compared chemical measurements and the crystallization properties of 24-hour urine collections from 129 stone formers matched to 105 non-stone forming siblings and 183 normal, healthy children with no family history of stones; all aged 6 to 17 years. The principal risk factor for calcium stone formation was hypercalciuria. Stone formers have strikingly higher calcium excretion along with high supersaturation for calcium oxalate and calcium phosphate, and a reduced distance between the upper limit of metastability and supersaturation for calcium phosphate, indicating increased risk of calcium phosphate crystallization. Other differences in urine chemistry that exist between adult stone formers and normal individuals such as hyperoxaluria, hypocitraturia, abnormal urine pH and low urine volume were not found in these children. Hence, hypercalciuria and a reduction in the gap between calcium phosphate upper limit of metastability and supersaturation are crucial determinants of stone risk. This highlights the importance of managing hypercalciuria in children with calcium stones.

The transfer of young patients from pediatric to adult renal care takes place after a transition process which involves both sides. It is important that it is individualized for each young person, focusing on self-management skills as well as assessing support structures. The consensus statement has been developed by the panel of adult and pediatric nephrologists and endorsed by the councils of both ISN and IPNA. It is hoped that the statement will provide a basis for the development of locally appropriate recommendations for clinical practice.

Poor growth is a common sequela of CKD in childhood. It not only affects the psychosocial development of a child but also has significant effects even in the adult life. The multifactorial etiology and severe consequences of growth failure in CKD warrant evaluation of all the modifiable and nonmodifiable causes. Treatment strategies must be directed toward the specific factors for each child with CKD. Among the various metabolic, nutritional, and hormonal disturbances complicating CKD, disordered growth hormone (GH) and insulin-like growth factor-1 axis are important contributors toward poor growth in children with CKD. CKD is recognized as a state of GH resistance rather than GH deficiency, with multiple mechanisms contributing to this GH resistance. Recombinant GH (rGH) therapy can be used in this population to accelerate growth velocity. Although its use has been shown to be effective and safe in children with CKD, there continues to be some uncertainty and reluctance among practitioners and families regarding its usage, thereby resulting in a surprisingly low use in children with CKD. This review focuses on the pathogenesis of growth failure, its effect, and management strategies in children with CKD.

Chronic kidney disease can severely impair linear growth in children. For many children, growth improves after renal transplantation, but for some, growth velocity remains low and for others, catch-up growth is insufficient to compensate for the deficit imparted by renal disease in the preceding years. Inadequate final adult height after renal transplant is multifactorial and can adversely affect the quality of life (QOL), psychosocial development and long term prospects for these children as they grow into adulthood. Growth failure after renal transplant requires thorough evaluation and its management in renal transplant recipients can involve improved nutritional intake, correction of metabolic acidosis, treatment of secondary hyperparathyroidism, steroid-sparing immunosuppression and/or use of recombinant human growth hormone (rGH). Treatment with rGH after renal transplant has been evaluated by a limited number of clinical trials suggesting efficacy and safety for this treatment strategy. Several important clinical questions regarding rGH use in children post-renal transplant remain unanswered.