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Establishing and achieving learning goals (LGs) are important lifelong learning skills for residents. Faculty are critical in facilitation and achievement of residents' LGs, yet many have difficulty with this role in the busy inpatient setting.Our primary aim was to improve faculty engagement in resident LGs, targeting ≥80% of faculty achieving a mean score ≥goal, over a period of 1 year by setting prerotation expectations and stressing team-based faculty accountability during the rotation in the current inpatient learning environment.We identified key barriers to addressing LGs on an inpatient subspecialty service. Key interventions included 1) introducing LGs to faculty, 2) establishing a communication/handover process among faculty, 3) LGs development, and 4) tracking accountability. Baseline mean faculty milestone scores were determined from the prior year. Over 1 year, we developed and refined a system for residents to create and document LGs with faculty oversight and review. We reviewed faculty evaluations quarterly to measure progress and reviewed rotation evaluations.Faculty engagement with LGs improved through the course of the academic year. All but one faculty member had improved LGs scores during the intervention year. Most residents were very satisfied with the intervention and gave unprompted favorable feedback on rotation evaluations. The majority of submitted LGs were either partially or completely addressed.We demonstrated that a quality improvement approach to a faculty educational skill is feasible and effective. Our intervention related to LGs may be modified for any medical learner in any inpatient or outpatient setting.

Sedation is often used to reduce pain and anxiety in pediatric patients with acute lymphoblastic leukemia (ALL) undergoing lumbar punctures (LPs). There is a potential for long-term effects on neurocognition with repeat sedative exposures in young children. The purpose of this study is to determine the practice habits regarding sedation for LPs in pediatric patients with ALL among multiple institutions.This is a retrospective study of 48 hospitals in the Pediatric Health Information Systems (PHIS) between October 2015 and December 2019. Children 1 to 18 years old with ALL who received intrathecal chemotherapy in an outpatient setting were included. We analyzed the prevalence of anesthesia usage and the types of anesthetics used.Of the 16,785 encounters with documented use of anesthetic medications, intravenous and inhaled anesthetics were used in 16,486 (98.2%) and local anesthetics alone in 299 (1.8%). The most commonly used medications used for sedation were propofol (n=13,279; 79.1%), midazolam (n=4228; 25.2%), inhaled fluranes (n=3169; 18.9%), and ketamine (n=2100; 12.5%).The majority of children's hospitals in the United States use intravenous and inhaled anesthetics for routine therapeutic LPs in pediatric patients with ALL. Propofol is one of the most common medications used for sedation.

Objective 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. Study design 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. Results 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. Conclusion(s) NOMAC-E2 use was not associated with a higher risk of VTE or ATE compared with COCLNG.

To monitor pregnancy occurrence and outcomes among Nexplanon users in the United States during standard clinical practice.The Nexplanon Observational Risk Assessment (NORA) study was a large prospective cohort study conducted in the United States (US). Study participants with a newly inserted Nexplanon implant were recruited by health care professionals (HCPs) who had completed the Nexplanon clinical training. Via a survey, study participants were followed up at 6-month intervals for 36 months and 6 months after implant removal. Reported unintended pregnancies were validated and classified as noninsertion, preinsertion, during-use, or postremoval.Four hundred and twenty-eight HCPs in 47 states recruited 7364 Nexplanon users. Pregnancies included one noninsertion, eight preinsertion, three during-use, and 14 postremoval pregnancies; of these 26 pregnancies, 22 resulted in the birth of a healthy child, two resulted in an induced abortion, one resulted in a spontaneous abortion, and one resulted in an ectopic pregnancy. Six pregnancies occurred during-use (n = 3) or within 7 days following implant removal (n = 3), yielding a Pearl Index of 0.04 (95% CI, 0.02-0.09).Nexplanon is an effective contraceptive in real-world users; the Pearl Index was 0.02 (95% CI, 0.00-0.06) for during-use pregnancies, and 0.04 when including pregnancies that occurred within 7 days following implant removal.This large real-world-use study indicates that Nexplanon is as effective as shown in the preapproval clinical trials.

Objective 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. Methods 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. Results 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. Conclusions 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.

The Accreditation Council for Graduate Medical Education requires Milestone-based assessments of residents and fellows. In pediatrics, 11 subcompetencies are common to both residency and subspecialty fellowship training. It is unknown whether Milestone scores achieved during residency are related to Milestone scores achieved in early fellowship.To assess the relationship between final residency Milestones scores and first-year fellowship Milestones scores in the 11 common subcompetencies (CSCs) across pediatric subspecialties.This was a retrospective single-institution cohort study of pediatric fellows beginning fellowship training between July 2016 and July 2019. De-identified Milestone score sets for final residency scores (R), mid-year first-year fellowship scores (F1), and final first-year fellowship scores (F2) were collected. Spearman correlation and regression analyses were used to assess score relationships.Data for 85 of 98 eligible fellows were collected. Consistently, the F1 scores were lowest, and the R scores were highest. There was a weak positive correlation between the composite R scores and the composite F1 scores. There was a weak positive correlation between residency and fellowship scores for 6 CSCs and no significant correlation for the remaining 5.For the 11 pediatric CSCs, the final residency Milestone scores are consistently higher than and only weakly associated with early fellowship Milestone scores. There may be limitations to the use of residency scores for fellowship program directors in guiding individualized education for early fellows. This study provides groundwork for additional study of Milestone relationships and may help inform the next iteration of pediatric subspecialty Milestones.

Childhood acute lymphoblastic leukemia (ALL) fortunately has high survival rates, and understanding longer term implications of therapy is critical. In this study, we aimed to investigate kidney health outcomes by assessing the prevalence of renal dysfunction and hypertension (HTN) in children with ALL at 1-5 years after ALL diagnosis.This was a single-center, cross-sectional study of children with ALL who were 1-5 years post diagnosis. Glomerular filtration rate (GFR) measurements were calculated, and urine samples were collected to assess for protein/creatinine and albumin/creatinine. Blood pressure (BP) was determined by standard oscillometric technique, and children ≥6 years of age were eligible for ambulatory blood pressure monitoring (ABPM).Forty-five patients enrolled in the study, and 21 completed ABPMs. Fifteen patients (33%, 95% CI: 20%-49%) developed acute kidney injury (AKI) at least once. Thirteen (29%, 95% CI: 16%-44%) had hyperfiltration, and 11 (24%) had abnormal proteinuria and/or albuminuria. Prevalence of HTN based on clinic measurements was 42%. In the 21 ABPM patients, 14 had abnormal results (67%, 95% CI: 43%-85%), with the majority (11/21) demonstrating abnormal nocturnal dipping pattern.Among children with ALL, there is a high prevalence of past AKI. The presence of hyperfiltration, proteinuria, and/or albuminuria at 1-5 years after ALL diagnosis suggests real risk of developing chronic kidney disease (CKD) over time. There is a high prevalence of HTN on casual BP readings and even higher prevalence of abnormal ABPM in this group. The high prevalence of impaired nocturnal dipping by ABPM indicates an increased risk for future cardiovascular or cerebral ischemic events.

Background: Childhood acute lymphoblastic leukemia (ALL) fortunately has high survival rates, and understanding longer-term implications of therapy is critical. In this study, we aimed to investigate kidney health outcomes by assessing the prevalence of renal dysfunction and hypertension (HTN) in children with ALL at one to five years after ALL diagnosis. Methods: This was a single center, cross-sectional study of children with ALL who were 1-5 years post diagnosis. GFR measurements were calculated, and urine samples were collected to assess for protein/creatinine and albumin/creatinine. Blood pressure (BP) was determined by standard oscillometric technique, and children >6 years of age were eligible for ambulatory blood pressure monitoring (ABPM). Results: Forty-five patients enrolled in the study, 21 completed ABPMs. Fifteen patients (33%, 95% CI: 20-49%) developed AKI at least once. Thirteen (29%, 95% CI: 16-44%) had hyperfiltration, and 11 (24%) had abnormal proteinuria and/or albuminuria. Prevalence of HTN based on clinic measurements was 42%. In the 21 ABPM patients, 14 had abnormal results (67%, 95% CI: 43-85%) with the majority (11/21) demonstrating abnormal nocturnal dipping pattern. . Conclusions: Among children with ALL, there is a high prevalence of past AKI. The presence of hyperfiltration, proteinuria and/or albuminuria at 1-5 years after ALL diagnosis suggest real risk of developing CKD over time. There is a high prevalence of HTN on casual BP readings and even higher prevalence of abnormal ABPM in this group. The high prevalence of impaired nocturnal dipping by ABPM indicates an increased risk for future cardiovascular or cerebral ischemic events.

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.

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.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.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%).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. A higher resolution version of the Graphical abstract is available as Supplementary information.

Objective There are few opportunities in medical education dedicated to learning skills for effective communication in life altering patient scenarios. We therefore aimed to develop and assess a longitudinal advanced communication curriculum for pediatric residents using patient feedback and deliberate practice. Methods Pediatric residents at a large academic center were randomized into 2 groups. The intervention group received 6 educational sessions from 2019 to 2020, parent feedback of performance via the Communication Assessment Tool (CAT), and monthly communication tips. Communication skills of both groups were assessed at the end of the intervention. Results We collected 937 CAT assessments on 36 first-year residents. The intervention group demonstrated statistically significant improvement in communication skills from pre to post assessment (p = 0.0063, (odds ratio (OR) 1.76, 95 % confidence interval (CI) [1.17, 2.63]) compared to the control group (p = 0.080, OR 1.41, 95 % CI [0.96, 2.05]). Conclusions There are patient and self-identified performance gaps in communication skills for pediatric residents, underscoring the need for formalized curricula dedicated to these skills. Practice implications Our study highlights the value of deliberate practice and the integration of family feedback as an educational tool in communication skills development.

Objective The American Board of Pediatrics Certifying Exam (ABP CE) is a high stakes exam and is important for employment and fellowship opportunities in pediatrics. Although research has suggested interventions which may improve scores, little research has focused on resident perception of preparation for the ABP CE. In this study, we aimed to better define pediatric residents' attitudes and preferences regarding preparation for the ABP CE. Methods Pediatric residents from one residency program were invited to participate in focus groups to discuss their attitudes and preferences on board exam preparation for the ABP CE. Focus groups were audio recorded and transcribed. Conventional content analysis was used to analyze qualitative data. From the transcripts, authors developed codes through an iterative process, which were then organized into categories. These categories were then grouped into themes. Results Nineteen residents participated in three focus groups. Focus group transcription analysis resulted in 49 codes, which were sorted into 26 categories. The categories were then grouped into four key themes: 1) the ABP CE is not immediately important early in residency; 2) more personalized guidance is preferred; 3) consistent board preparation focus from the residency program is valued; 4) learning format is important. Conclusions Residents believe preparation for the ABP CE increases in importance as they progress through residency, and they desire more personalized, consistent, and structured focus from their training program related to ABP CE preparation. Attention to these perceptions can help guide pediatric residency program leadership in developing effective board exam preparation strategies and curricula for their residents.

Physician burnout is a highly complex phenomenon whose origins are multifactorial. As the medical profession works to better understand and reduce physician burnout, conceptual models can offer a framework to guide research and practice in the field of physician well-being. Conceptual models represent complex systems in a simplified fashion that facilitates understanding of and communication about those systems. This paper reviews seven conceptual models of physician well-being and discusses their strengths and limitations.

Myeloid sarcoma (MS) is an extramedullary collection of immature myeloid cells that can commonly occur with acute myeloid leukemia (AML). While head and neck presentations are not unheard of, there have been few published pediatric cases of external auditory canal MS. Here, we report a case of a 14-year-old male who presented with MS masquerading as bilateral acute otitis externa. To the best of our knowledge, this is the first reported case of a bilateral presentation leading to a new diagnosis of AML. A literature review of head and neck presentations of MS is included.

Objectives We conducted this study to characterize the frequency of insertion-, localization- and removal-related events and their clinically significant consequences among Nexplanon® (etonogestrel radiopaque contraceptive implant) users in the United States during standard clinical practice. Study design The Nexplanon Observational Risk Assessment (NORA) study was a large, prospective cohort study conducted in the United States. A total of 428 Health Care Professionals (HCPs) who had completed the Nexplanon clinical training program recruited women who were newly prescribed Nexplanon. We collected data on insertion-, localization- and removal-related events experienced during routine clinical practice via questionnaires completed by patients and HCPs. Recruitment began in December 2011 and follow-up ended in October 2017. Data analysis characterized the frequency of procedure-related events. Results We collected data on 7364 insertion procedures. The incidence of incorrect insertion (i.e., initially unrecognized non-insertion, partial insertion or deep insertion) was 12.6 per 1000 insertions (95% CI, 10.2–15.5). Pins and needles/numbness in the arm/hand/fingers was the most common patient-reported event. We obtained data on 5159 removal procedures, of which all were successful but one (due to the location of the implant in deep muscle tissue). No implants were localized outside the arm. The most common challenge reported by HCPs during implant removal was encasement of the implant within fibrotic tissue. Conclusions Events associated with the insertion, localization and removal of the Nexplanon contraceptive implant were rare and their clinical consequences were generally not suggestive of serious injury. Implications This study is the largest prospective evaluation of events associated with insertion and removal of Nexplanon during routine clinical practice. It demonstrates that complications associated with insertion and removal of Nexplanon are rare when performed by trained clinicians.

Benign adenoidal hypertrophy is the most common cause of nasopharyngeal obstruction. However, depending on size and location, masses may cause nasopharyngeal obstruction. We present our experiences with a ten-year-old female who presented with what appeared to be a large nasopharyngeal mass that was initially favored to be malignant and was ultimately found to be adenoid hypertrophy related to acute infection with adenovirus.

Background Although a huge portion of medical care involves communication, there is little time dedicated to these skills. Additionally, family-centered communication is collaborative and interactive, and these skills are best taught through case-based approaches rather than passive lecture-type didactics. Objectives: We aimed to develop a longitudinal communication curriculum utilizing learner-identified content, delivered via interactive workshops over a 6-month period, supplemented with and guided by family feedback. Methods The curriculum was developed using Kern's scholarly approach. A needs assessment for resident communication skills was conducted with a survey and focus group. The Communication Assessment Tool (CAT) was used for parent feedback of residents’ performance early in the curriculum. Content for workshop sessions was developed from needs assessments, CAT results, and input from program leadership. The curriculum underwent expert internal and external review. Pediatric interns were randomly assigned to a control or intervention group. Six sessions were delivered over 6-months to the intervention group. CAT feedback was shared with the intervention group as part of the curriculum. Results Survey and focus groups identified themes of 1) lack of comfort with communication skills in difficult encounters, and 2) desire for more feedback and practice with these encounters. Five hundred surveys were collected on 36 interns using the CAT prior to the intervention. A 5-point likert scale was graded as 5 or non-5 scores. Residents performed most poorly in discussion of next steps (38% non 5) and in showing interest in families’ ideas of their children's health (28% non 5). Discussion There are self- and patient-identified performance gaps in many pediatric interns, underscoring the need for formalized curricula to teach skills specific to communication in pediatrics, particularly with emphasis on shared decision making and teach back methods. Narrative feedback from resident curriculum participants has demonstrated increased confidence and comfort levels with difficult communication. Future directions include assessment of the patient and family impact of this curriculum using follow-up CAT surveys.

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

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.

Objectives The objective was to measure the rate of unintended pregnancies in women using levonorgestrel-releasing intrauterine systems (LNG IUSs, releasing 20 mcg LNG daily) and copper intrauterine devices (IUDs) in a typical population of IUD users and to describe associated complications. Methods A multinational, prospective, non-interventional cohort study of new users of LNG IUS and copper IUDs was performed. Following a baseline survey, study participants and their physicians completed one follow-up questionnaire after 12 months. A multifaceted four-level follow-up procedure minimized loss to follow-up. Patient-reported outcomes were validated by the treating physicians. Results A total of 61,448 women with a newly inserted IUD were enrolled in six European countries between 2006 and 2012. The copper IUD cohort contained more than 30 different types. Validated 1-year follow-up information for 58,324 users between 18 and 50 years of age (70% using LNG IUS, 30% using copper IUDs) was collected. A total of 118 contraceptive failures occurred (26 LNG, 92 copper). Both types of IUD were highly effective, with overall Pearl indices of 0.06 [95% confidence interval (CI): 0.04–0.09] and 0.52 (95% CI: 0.42–0.64) for LNG IUS and copper IUDs, respectively. The adjusted hazard ratio for LNG IUS vs. copper IUDs was 0.16 (95% CI: 0.10–0.25). Tenty-one pregnancies (7 LNG IUS, 14 copper IUD) were ectopic, yielding an adjusted hazard ratio for ectopic pregnancy of 0.26 (95% CI: 0.10–0.66). Conclusions The contraceptive failure rate was low with both IUDs. However, the LNG IUS was associated with a significantly lower risk of pregnancy, including ectopic pregnancy, than the copper IUDs. Implications To our knowledge, this is the first large-scale, multinational, prospective epidemiological study to measure and compare the contraceptive effectiveness of LNG IUSs and copper IUDs during routine clinical practice. Clinicians and patients should be aware of differences in rates of unintended pregnancies and associated complications in relation to IUD us.

Childhood acute lymphoblastic leukemia achieves excellent cure rates in part due to induction chemotherapy including high dose corticosteroids. Hypertension (HTN) is a known complication of corticosteroids, but incidence and risk factors for steroid-induced HTN are poorly understood. We sought to describe these using a large pediatric health database. Of the 5578 unique patients receiving induction chemotherapy, 14.7% received anti-HTN medications during their initial hospital admission. We found that age below 1 year, obesity, secondary diabetes mellitus, and abnormal glucose were associated with developing steroid-induced HTN. We also found that ICD-9 codes had poor sensitivity for detecting treatment of HTN, suggesting underreporting by physicians.

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.

Objective The objective of the study was to determine if delivery and lactation are risk factors for complete intrauterine device perforations. Study design We performed a reanalysis of the European Active Surveillance Study on Intra-Uterine Devices data set using complete penetration of the myometrium as the definition for perforation. Results Of the 61,448 women enrolled (70% levonorgestrel, 30% copper devices), we identified 58 complete perforations, 30 of which occurred in lactating women. Incidence per 1000 insertions was 4.5 (95% confidence interval [CI]: 3.0–6.4) for lactating and 0.6 (95% CI: 0.4–0.9) for nonlactating women. Time since delivery was also associated with perforation risk. Conclusions Lactation and delivery are independent cofactors for perforation. Results do not differ when restricting the definition of perforation.

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.

Background Access to effective family planning is of great importance for women with sickle cell disease (SCD) due to the increased frequency of pregnancy complications. However, little is known regarding use of hormonal contraception, complications of contraception, and pregnancy in young women with SCD. Study Design We abstracted diagnostic codes, procedure codes and pharmacy claims from women with SCD, aged 13–21 years, enrolled in Michigan Medicaid between 1/1/2000 and 12/31/2003 with ≥9 months of continuous eligibility. Results We identified 250 women with SCD with an average period of continuous Medicaid enrollment of 20 months. Claims for hormonal contraception could be identified in only 20 patients (8%, 95% CI 5–12%). The most commonly prescribed method ( n =12) was depot medroxyprogesterone (DMPA) acetate. Venous thromboembolism and osteopenia were rarely identified ( n ≤10) and occurred only in women with no recorded use of hormonal contraception. In the total population, 64 patients had one pregnancy and 16 had ≥2 pregnancies during the 4-year study period. Among adolescents (13–18 years), 49 (30%) of 195 patients (95% CI 24–37%) had 59 pregnancies. By 12 weeks postpartum, few patients ( n ≤10) with a record of delivery had hormonal contraception claims. Conclusions In a publicly insured population of young women with SCD, pregnancy was more commonly identified than hormonal contraception use. Our work suggests that significant gaps may exist in family planning care for young women with SCD.

INTRODUCTION:To characterize the frequency of insertion- and removal-related events among Nexplanon users in the US during standard clinical practice.METHODS:This large, prospective, non-interventional cohort study followed 7,369 new users of Nexplanon recruited by US health care professionals (HCPs

Residency is a high-risk period for physician burnout. We aimed to determine the short-term stability of factors associated with burnout, application of these data to previous conceptual models, and the relationship of these factors over 3 months. Physician wellness questionnaire results were analyzed at 2 time points 3 months apart. Associations among variables within and across time points were analyzed. Logistic regression was used to predict burnout and compassionate care. A total of 74% of residents completed surveys. Over 3 months, burnout ( P = .005) and empathy ( P = .04) worsened. The most significant cross-sectional relationship was between stress and emotional exhaustion (time 1 r = 0.61, time 2 r = 0.68). Resilience was predictive of increased compassionate care and decreased burnout ( P < .05). Mindfulness was predictive of decreased burnout ( P < .05). Mitigating stress and fostering mindfulness and resilience longitudinally may be key areas of focus for improved wellness in pediatric residents. Larger studies are needed to better develop targeted wellness interventions.

Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study's purpose was to elicit residents' perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency.Resident focus groups and program director interviews were conducted in 2012-2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory.Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through.Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

The application of the best practices of teaching adults to the education of adults in medical education settings is important in the process of transforming learners to become and remain effective physicians. Medical education at all levels should be designed to equip physicians with the knowledge, clinical skills, and professionalism that are required to deliver quality patient care. The ultimate outcome is the health of the patient and the health status of the society. In the translational science of medical education, improved patient outcomes linked directly to educational events are the ultimate goal and are best defined by rigorous medical education research efforts. To best develop faculty, the same principles of adult education and teaching adults apply. In a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education, the use of experiential learning, feedback, effective relationships with peers, and diverse educational methods were found to be most important in the success of these programs. In this article, we present 5 examples of applying the best practices in teaching adults and utilizing the emerging understanding of the neurobiology of learning in teaching students, trainees, and practitioners. These include (1) use of standardized patients to develop communication skills, (2) use of online quizzes to assess knowledge and aid self-directed learning, (3) use of practice sessions and video clips to enhance significant learning of teaching skills, (4) use of case-based discussions to develop professionalism concepts and skills, and (5) use of the American Academy of Pediatrics PediaLink as a model for individualized learner-directed online learning. These examples highlight how experiential leaning, providing valuable feedback, opportunities for practice, and stimulation of self-directed learning can be utilized as medical education continues its dynamic transformation in the years ahead.

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in the pediatric and adolescent population. Though treatments for localized disease have reasonable long-term success rates, if disease is diffuse at diagnosis, outcomes are far poorer. Additional and/or alternative therapies are critical for improved clinical outcomes. One potentially therapeutic target is the signal transducer and activator of transcription 3 (STAT3) pathway. STAT3 has been shown to have constitutive activation in human rhabdomyosarcoma cells; thus, inhibition of STAT3 signaling may be a mechanism to induce tumor cell death. Celecoxib has been shown, by computer modeling, to bind STAT3 at the SH2 domain and competitively inhibit native peptide binding necessary for phosphorylation and subsequent propagation of the STAT3 signaling cascade. We found that celecoxib inhibits IL-6-induced and persistent STAT3 phosphorylation and inhibits cell viability in human rhabdomyosarcoma cells. We found that genes downstream of STAT3 (BCL-2, survivin, cyclin D1) were downregulated with celecoxib. Celecoxib also inhibits colony formation and cell migration. Our results suggest that, though known more commonly as a cyclooxygenase-2 (COX-2) inhibitor, celecoxib could act through the STAT3 pathway as well. More importantly, its effect on cell migration and clonogenic colony forming ability make it a potentially useful therapeutic agent for rhabdomyosarcoma, especially in metastatic disease whose clinical outcome is marginal at best with current therapies.

Osteopetrosis (OP) is a clinically and genetically heterogeneous disorder characterized by increased bone density. Associations between OP and other clinical entities are rare but include muscular degeneration, Dandy-Walker syndrome, craniosynostosis, and poikiloderma. Infantile OP has also been diagnosed in a group of infants with neuronal storage disease. An association between OP and juvenile xanthogranuloma (JXG) has never been previously reported. Herein we present a case of an intermediate form of OP in a newborn who presented with hepatosplenomegaly and pancytopenia. Histologic evaluation of a bone marrow biopsy demonstrated abnormally thickened bony trabeculae. A liver biopsy demonstrated prominent expansion of portal areas by a histiocytic infiltrate expressing CD45, CD14, CD68, CD163, factor XIIIa, and fascin, while the biopsy was negative for S100 and CD1a. These findings were those associated with JXG. Genetic testing demonstrated a mutation involving the Pleckstrin homology domain-containing family M member 1 (PLEKHM1) gene. A different mutation in this gene has been previously reported in one other patient with OP. Our case is the 2nd reported case with PLEKHM1 mutation in a patient with a mild form of OP. It also demonstrates the 1st reported occurrence of OP concomitantly with JXG.

Objectives The objectives were to identify and compare the incidence of uterine perforation and other medically adverse events associated with levonorgestrel-releasing intrauterine systems (LNG-IUSs, releasing 20 mcg LNG daily) and copper intrauterine devices (IUDs) under routine conditions of use in a study population representative of typical users. Methods and materials This is a multinational, prospective, non-interventional cohort study with new users of LNG-IUSs and copper IUDs. In addition to a baseline questionnaire, women and their treating health care professional completed a single follow-up questionnaire after 12months. All patient-reported outcomes were validated by the treating physicians. Results A total of 61,448 women in six European countries were followed between 2006 and 2013 for more than 68,000 women-years of observation (70% LNG, 30% copper devices). Overall, 81 uterine perforations were reported: 61 for LNG-IUSs [1.4 per 1000 insertions (95% confidence interval {CI}: 1.1–1.8)] and 20 for copper IUDs [1.1 per 1000 insertions (95% CI: 0.7–1.7)], for an adjusted risk ratio (RR adj ) of 1.6 (95% CI: 1.0–2.7) when adjusted for age, body mass index, breastfeeding at time of insertion and parity. Breastfeeding at time of insertion was associated with a sixfold increase (RR 6.1, 95% CI: 3.9–9.6), with no differences between LNG and copper IUD users. Sixty-three of the total 81 perforations were associated with previously suspected risk factors (e.g., breastfeeding, time since last delivery ≤36weeks). No perforations led to serious illness or to injury of intra-abdominal or pelvic structures. Conclusions Uterine perforation incidence in this study was low, with a benign clinical course thereafter. The LNG-IUSs and copper IUDs did not have clinically important differences in perforation rates. Implications The European Active Surveillance Study on Intrauterine Devices is the first large-scale, prospective, noninterventional study to compare the perforation risk in LNG-IUS and copper IUD users. It is the first to examine the independent roles that breastfeeding status and postpartum status have on perforation risk. Conducted during routine clinical practice, the findings are generalizable to broader populations.