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Background: Physician communication during goals of care (GOC) discussions impact experiences for patients and families at end-of-life (EOL). Simulation allows training in a safe environment where feedback from simulated patients (SP), clinicians, and self-reflection can be incorporated. Objectives: To determine if multisource feedback from SP scenarios enriches feedback provided to trainees. Design: Fourth-medical students participated in two SP GOC discussions during an advanced care planning (ACP) curriculum. Students received feedback from SPs and faculty and completed a video review with self-reflection. Setting and Subjects: Forty-seven fourth-year medical students at the University of Cincinnati College of Medicine participated in the curriculum from 2019-2021. Measurements: An inductive thematic analysis of the narrative data was performed examining all sources of feedback from the SP sessions. Results: Six themes emerged from the feedback: the warning shot: words to say and why it helps; acknowledging emotion: verbal vs non-verbal responses; organization: necessity of a clear path; body language: adding to and distracting from the conversation; terminology to avoid: what jargon encompasses and how it impacts patients; and silence: perceived importance by everyone. SP feedback focused on the personal emotional impact of a student's word choice and body language. Faculty feedback focused on specific learning points through examples from the conversation and expanded to hypothetical scenarios. Student self-reflection after video review allowed students to see challenges that they did not notice while immersed in the encounter. Conclusion: Multisource feedback from simulated GOC discussions provides unique insights for students to guide their development in leading difficult conversations. [ABSTRACT FROM AUTHOR]

1. Describe common causes of feeding intolerance in pediatric patients and understand visceral hyperalgesia as a cause of refractory abdominal symptoms in multiple patient populations. 2. Develop an approach to the treatment of visceral hyperalgesia. While visceral hyperalgesia is increasingly recognized in patients with serious neurologic impairment, it is less commonly considered in patients who do not fall into this category. This presentation will review the importance of recognizing and treating visceral hyperalgesia in pediatric palliative care patients who present with feeding intolerance of unclear etiology. Visceral hyperalgesia is an altered sensation of pain in response to a gastrointestinal stimulus. Children with severe neurologic impairment (SNI) experience increased gastrointestinal symptoms due to a constellation of sources. While visceral hyperalgesia is increasingly recognized in patients with SNI, it is less commonly considered in patients who do not fall into this category. The patient is a 14-month-old with complex congenital heart disease and post-operative left parietal stroke with minimal deficit. He was admitted to the hospital for feeding intolerance and subsequently transferred to the CICU for supportive care in the setting of heart failure symptoms while awaiting heart transplant. The palliative care team was consulted for support in the setting of heart transplantation and symptom management of refractory feeding intolerance. Prior to involvement of the palliative care team, he had been started on gabapentin and clonidine, and a gastrostomy-jejunostomy (GJ) tube had been placed in hopes that post-pyloric feeds would improve his symptoms. However, he continued to experience abdominal discomfort, irritability, retching, and emesis on low volume continuous feeds. His mother reported that "things he shouldn't notice, he notices" with regards to feeds and medications going through his GJ tube. Due to suspicion for visceral hyperalgesia, He was started on nortriptyline, which was well tolerated. Two weeks after initiation of nortriptyline, the patient's mother reported complete cessation of discomfort and irritability, and the patient was able to tolerate full volume feeds. Visceral hyperalgesia is a common cause of feeding intolerance in pediatric patients with SNI and should be considered in all patients with refractory gastrointestinal symptoms. It is commonly managed with gabapentinoids, tricyclic antidepressants, and alpha antagonists. This presentation will review the importance of recognizing and treating visceral hyperalgesia in pediatric palliative care patients who present with feeding intolerance of unclear etiology. Managing Suffering and Distress; Emergencies / Refractory Symptom Management [ABSTRACT FROM AUTHOR]

Purpose: To examine the long-term outcome of the staged excision via the square procedure for the treatment of periocular thin cutaneous melanoma., Methods: A retrospective chart review of 95 periocular cutaneous melanoma-in-situ and microinvasive melanoma tumors that were treated with the square procedure between April 1, 1994 and December 31, 2018 at the University of Michigan. Demographic and clinical data were evaluated., Results: Of 95 cases, 19 (20%) were atypical junctional melanocytic proliferation with features of early melanoma-in-situ, 63 (66.3%) were melanoma-in-situ and 13 (13.7) were microinvasive melanoma with Breslow depth less than 1 mm. Tumor-free margins were achieved with a median margin of 10 mm (range 5-40 mm). Most cases (68.4%) required multiple excision stages. Surgical revision was necessary in 17.9% of cases and was associated with larger defect size. Local recurrence was noted in 8 patients (8.4%) at a median of 42 months postreconstruction. No tumor characteristics were found to predict recurrence., Conclusions: The square procedure for periocular melanoma offers an 8.4% recurrence rate, consistent with literature reports on similar staged excision approaches. The staged excision provides an excellent option for comprehensive margin review and tumor control with acceptable cosmetic results after reconstruction., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)