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Background: The insulin-like growth factor-1 (IGF-1) signaling pathway plays an important role in the pathology of Ewing sarcoma (ES). Retrospective studies have suggested that levels of IGF-1 and IGF binding protein 3 (IGFBP-3) are correlated with the outcome of patients with ES.Methods: The IGF-1 signaling pathway was investigated prospectively in 269 patients who had localized, previously untreated ES. Serum samples were obtained at diagnosis, and concentrations of IGF-1 and IGFBP-3 were determined by enzyme-linked immunosorbent assays. In addition, immunohistochemistry (IHC) was performed to assay for phosphorylated p70S6 kinase, protein kinase B (Akt), and forkhead box protein O1 (FOXO1) and to determine the presence of protein tyrosine phosphatase-L1 (PTPL1). IHC findings along with IGF-1 and IGFBP-3 concentrations were correlated with age, tumor location, sex, event-free survival, and overall survival.Results: Patients aged >18 years tended to have higher levels of IGF-1 (P = .10), lower levels of IGFBP-3 (P = .16), and decreased IGFBP-3:IGF-1 ratios (P = .01). No correlations were observed between sex, tumor location, or outcomes and concentrations of IGF-1 or IGFBP-3. Phosphorylation of p70S6 kinase, Akt, and FOXO1 was detected in the majority of patient tissues but was not associated with age, sex, or tumor location. PTPL1 was present in >80% of tumors and also was not correlated with age, sex, or tumor location. There was no difference in survival with respect to the presence of phosphorylated p70S6 kinase, phosphorylated FOXO1, phosphorylated Akt, or PTPL1.Conclusions: The baseline IGFBP-3:IGF-1 ratio was correlated with age but did not affect the outcomes of patients with ES. The authors concluded that additional investigation of the IGF-1 pathway is warranted in patients with ES, and especially in those who have received treatment with IGF-1 receptor antibody inhibitors. [ABSTRACT FROM AUTHOR]

Phenomenon: Marginalized individuals in medicine face many structural inequities which can have enduring consequences on their progress. Therefore, inequity must be addressed by dismantling underlying unjust policies, environments, and curricula. However, once these injustices have been taken apart, how do we build more just systems from the rubble? Many current strategies to address this question have foundational values of urgency, solutionism, and top-down leadership., Approach: This paper explores a counternarrative: Design Justice. As a set of guiding principles, Design Justice centers the experiences and perspectives of marginalized individuals and communities. These principles include mutual accountability and transparency, co-ownership, and community-led outcomes, and honoring local, traditional, Indigenous knowledge., Findings: Rooted in critical scholarship and critical design, Design Justice recognizes the interconnectedness of various forms of marginalization and works to critically examine power dynamics that exist in every design process. These co-created principles act as practical guardrails, directing progress toward justice., Insights: This paper begins with an overview of Design Justice's history in critical scholarship and critical design, providing foundational background knowledge for medical educators, scholars, and leaders in key concepts of justice and design. We explore how the Design Justice principles were developed and have been applied across sectors, highlighting its applications, including education applications. Finally, we raise critical questions about medical education prompted by Design Justice.

Context: Despite increasing discussion and scholarship, equity in assessment is rarely defined and distinguished in a way that allows for shared understanding in medical education. This paper seeks to clarify and expand the conversation about equity in assessment by critically reviewing three distinct and evolving orientations toward equity in assessment. Orientations refers to the positions, attitudes, interests or priorities individuals can hold toward equity in assessment. The three orientations include fairness-oriented assessment, assessment for inclusion and justice-oriented assessment. While fairness-oriented assessment is a prevailing orientation in medical education, assessment for inclusion and justice-oriented assessment, originally developed in other fields of education, deserve careful consideration., Methods: In this paper, the authors explore unique underpinning assumptions of each orientation by critically examining the foundational literature of each orientation. They reflect on the unique perspectives each orientation provides, including the actions one might take and what advantages and disadvantages might result from looking at equity in assessment from any one orientation., Conclusions: Informed by this reflection, the authors propose that to more effectively advance equity in assessment in medical education, those working in the field should clearly identify their respective orientations, intentionally choose methods, tools and measures aligned with their orientations and expand their work by exploring alternative orientations., (© 2024 The Author(s). Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background and Objectives: Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites., Methods: Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents., Results: We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged., Conclusions: Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected., (Copyright © 2024 by the American Academy of Pediatrics.)

Problem: Program evaluation approaches that center the achievement of specific, measurable, achievable, realistic, and time-bound goals are common in health professions education (HPE) but can be challenging to articulate when evaluating emergent programs. Principles-focused evaluation is an alternative approach to program evaluation that centers on adherence to guiding principles, not achievement of goals. The authors describe their innovative application of principles-focused evaluation to an emergent HPE program., Approach: The authors applied principles-focused evaluation to the Children's Hospital of Philadelphia Medical Education Collaboratory, a works-in-progress program for HPE scholarship. In September 2019, the authors drafted 3 guiding principles. In May 2021, they used feedback from Collaboratory attendees to revise the guiding principles: Advance Excellence , Build Bridges , and Cultivate Learning ., Outcomes: In July 2021, the authors queried participants about the extent to which their experience with the Collaboratory adhered to the revised guiding principles. Twenty of the 38 Collaboratory participants (53%) responded to the survey. Regarding the guiding principle Advance Excellence , 9 respondents (45%) reported that the Collaboratory facilitated engagement in scholarly conversation only by a small extent, and 8 (40%) reported it facilitated professional growth only by a small extent. Although some respondents expressed positive regard for the high degree of rigor promoted by the Collaboratory, others felt discouraged because this degree of rigor seemed unachievable. Regarding the guiding principle Build Bridges , 19 (95%) reported the Collaboratory welcomed perspectives within the group. Regarding the guiding principle Cultivate Learning , 19 (95%) indicated the Collaboratory welcomed perspectives within the group and across disciplines, and garnered collaboration., Next Steps: Next steps include improving adherence to the principle of Advancing Excellence , fostering a shared mental model of the Collaboratory's guiding principles, and applying a principles-focused approach to the evaluation of multi-site HPE programs., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Objective: Training disruptions, such as planned curricular adjustments or unplanned global pandemics, impact residency training in ways that are difficult to quantify. Informatics-based medical education tools can help measure these impacts. We tested the ability of a software platform driven by electronic health record data to quantify anticipated changes in trainee clinical experiences during the COVID-19 pandemic., Methods: We previously developed and validated the Trainee Individualized Learning System (TRAILS) to identify pediatric resident clinical experiences (i.e. shifts, resident provider-patient interactions (rPPIs), and diagnoses). We used TRAILS to perform a year-over-year analysis comparing pediatrics residents at a large academic children's hospital during March 15-June 15 in 2018 (Control #1), 2019 (Control #2), and 2020 (Exposure)., Results: Residents in the exposure cohort had fewer shifts than those in both control cohorts (P < .05). rPPIs decreased an average of 43% across all PGY levels, with interns experiencing a 78% decrease in Continuity Clinic. Patient continuity decreased from 23% to 11%. rPPIs with common clinic and emergency department diagnoses decreased substantially during the exposure period., Conclusions: Informatics tools like TRAILS may help program directors understand the impact of training disruptions on resident clinical experiences and target interventions to learners' needs and development., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed., Objective: To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication., Design: Prospective Type 2 Hybrid effectiveness implementation study., Settings and Participants: Residents from diverse specialties across 32 hospitals (12 community, 20 academic)., Intervention: External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews., Main Outcome and Measures: Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality., Results: 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic)., (© 2022 Society of Hospital Medicine.)

The present study aims to vermiremediate allopathic pharmaceutical industry sludge (AS) amended with cattle dung (CD), in different feed mixtures (AS:CD) i.e (AS 0 ) 0:100 [Positive control], (AS 25 ) 25:75, (AS 50 ) 50:50, (AS 75 ) 75:25 and (AS 100 ) 100:0 [Negative Control] for 180 days using earthworm Eisenia fetida. The earthworms could thrive and grow well up to the AS 75 feed mixture. In the final vermicompost, there were significant decreases in electrical conductivity (29.18-18.70%), total organic carbon (47.48-22.39%), total organic matter (47.47-22.36%), and C: N ratio (78.15-54.59%). While, significant increases in pH (9.06-16.47%), total Kjeldahl nitrogen (69.57-139.58%), total available phosphorus (30.30-81.56%), total potassium (8.92-22.22%), and total sodium (50.56-62.12%). The heavy metals like Cr (50-18.60%), Cd (100-75%), Pb (57.14-40%), and Ni (100-50%) were decreased, whereas Zn (8.37-53.77%), Fe (199.03-254.27%), and Cu (12.90-100%) increased significantly. The toxicity of the final vermicompost was shown to be lower in the Genotoxicity analysis, with values ranging between (76-42.33%). The germination index (GI) of Mung bean (Vigna radiata) showed a value ranging between 155.02 and 175.90%. Scanning electron microscopy (SEM) analysis showed irregularities with high porosity of texture in the final vermicompost than in initial mixtures. Fourier Transform-Infrared Spectroscopy (FT-IR) spectra of final vermicompost had low peak intensities than the initial samples. The AS 50 feed mixture was the most favorable for the growth and fecundity of Eisenia fetida, emphasizing the role of cattle dung in the vermicomposting process. Thus, it can be inferred that a cost-effective and eco-friendly method (vermicomposting) with the proper amendment of cattle dung and employing Eisenia fetida could transform allopathic sludge into a nutrient-rich, detoxified, stable, and mature vermicompost for agricultural purposes and further could serve as a stepping stone in the allopathic pharmaceutical industry sludge management strategies in the future., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness., Objective: To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families., Design, Setting, and Participants: This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?", Main Outcomes and Measures: Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics., Results: Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions., Conclusions and Relevance: This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.

Background: Little is known about using telehealth patient visits as an educational mode. Therefore, rapid implementation of telehealth during the COVID-19 pandemic had to be done without understanding how to optimize telehealth for education. With the likely sustained/post-pandemic use of telehealth in ambulatory patient care, filling gaps in our understanding of how telehealth can be used for instruction in this context is critical. This study sought to understand perceptions of pediatric postgraduate trainees and supervisors on the use of telehealth for instruction in ambulatory settings with the goal of identifying effective ways to enhance learning during telehealth visits., Methods: In May-June of 2020, the authors purposefully sampled first- and third-year postgraduate trainees and supervising attendings from pediatric fellowship programs at one institution that implemented telehealth for instructional activities. They conducted semi-structured interviews; interviews lasted a median of 51 min (trainees) and 41 min (supervisors). They conducted interviews and data analysis iteratively until reaching saturation. Using thematic analysis, they created codes and constructed themes from coded data. They organized themes using the Replace-Amplify-Transform (RAT) model, which proposes that technology can replace in-person learning and/or amplify and transform learning., Results: First-year trainees (n = 6), third-year trainees (n = 5) and supervisors (n = 6) initially used telehealth to replace in-person learning. However, skills that could be practiced in telehealth visits differed from in-person visits and instructional activities felt rushed or awkward. Trainees and supervisors adapted and used telehealth to amplify learning by enhancing observation and autonomy. They also transformed learning, using telehealth to develop novel skills., Conclusions: To harness telehealth for instructional activities, our findings indicated that trainees and supervisors should shift from using it as a direct replacement for in-person education to taking advantage of novel opportunities to amplify and transform education in PGME. The authors provide data-driven recommendations to help PGME trainees, supervisors and educators capitalize on the educational advantages of telehealth., (© 2022. The Author(s).)

Purpose: Workplace-based assessment (WBA) serves a critical role in supporting competency-based medical education (CBME) by providing assessment data to inform competency decisions and support learning. Many WBA systems have been developed, but little is known about how to effectively implement WBA. Filling this gap is important for creating suitable and beneficial assessment processes that support large-scale use of CBME. As a step toward filling this gap, the authors describe what is known about WBA implementation and use to identify knowledge gaps and future directions., Method: The authors used Arksey and O'Malley's 6-stage scoping review framework to conduct the review, including: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) consulting with relevant stakeholders., Results: In 2019-2020, the authors searched and screened 726 papers for eligibility using defined inclusion and exclusion criteria. One hundred sixty-three met inclusion criteria. The authors identified 5 themes in their analysis: (1) Many WBA tools and programs have been implemented, and barriers are common across fields and specialties; (2) Theoretical perspectives emphasize the need for data-driven implementation strategies; (3) User perceptions of WBA vary and are often dependent on implementation factors; (4) Technology solutions could provide useful tools to support WBA; and (5) Many areas of future research and innovation remain., Conclusions: Knowledge of WBA as an implemented practice to support CBME remains constrained. To remove these constraints, future research should aim to generate generalizable knowledge on WBA implementation and use, address implementation factors, and investigate remaining knowledge gaps., (Copyright © 2021 by the Association of American Medical Colleges.)

Purpose: To describe trajectories in level of supervision ratings for linked entrustable professional activities (EPAs) among pediatric learners in medical school, residency, fellowship., Method: The authors performed secondary analyses of 3 linked datasets of level of supervision ratings for the Core EPAs for Entering Residency, the General Pediatrics EPAs, and the Subspecialty Pediatrics EPAs. After identifying 9 activities in common across training stages and aligning the level of entrustment-supervision scales across the datasets, piecewise ordinal and linear mixed effects models were fitted to characterize trajectories of supervision ratings., Results: Within each training period, learners were rated as needing less supervision over time in each activity. When transitioning from medical school to residency or during the first year of residency, learners were rated as needing greater supervision in activities related to patient management, teamwork, emergent care, and public health/QI than in earlier periods. When transitioning from residency to fellowship, learners were always rated as needing greater supervision than they had been accorded at the end of residency and sometimes even more than they had been accorded at the start of residency., Conclusions: Although development over training is often imagined as continuous and monotonically increasing competence, this study provides empirical evidence supporting the idea that entrustment is a set of discrete decisions. The relaxation of supervision in training is not a linear process. Even with a seamless curriculum, supervision is tightly bound to the training setting. Several explanations for these findings are discussed., (Copyright © 2021 by the Association of American Medical Colleges.)

To establish a research and development agenda for Entrustable Professional Activities (EPAs) for the coming decade, the authors, all active in this area of investigation, reviewed recent research papers, seeking recommendations for future research. They pooled their knowledge and experience to identify 3 levels of potential research and development: the micro level of learning and teaching; the meso level of institutions, programs, and specialty domains; and the macro level of regional, national, and international dynamics. Within these levels, the authors categorized their recommendations for research and development. The authors identified 14 discrete themes, each including multiple questions or issues for potential exploration, that range from foundational and conceptual to practical. Much research to date has focused on a variety of issues regarding development and early implementation of EPAs. Future research should focus on large-scale implementation of EPAs to support competency-based medical education (CBME) and on its consequences at the 3 levels. In addition, emerging from the implementation phase, the authors call for rigorous studies focusing on conceptual issues. These issues include the nature of entrustment decisions and their relationship with education and learner progress and the use of EPAs across boundaries of training phases, disciplines and professions, including continuing professional development. International studies evaluating the value of EPAs across countries are another important consideration. Future studies should also remain alert for unintended consequences of the use of EPAs. EPAs were conceptualized to support CBME in its endeavor to improve outcomes of education and patient care, prompting creation of this agenda., (Copyright © 2021 by the Association of American Medical Colleges.)

Background: Miscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency., Methods: We conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016-2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process., Results: Across 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI -39% to -7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention., Conclusions: Implementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED., Competing Interests: Competing interests: NS, AJS and DCW have consulted with and hold equity in the I-PASS Patient Safety Institute, which seeks to train institutions in best handoff practices and aid in their implementation. NS, AJS and DCW also reported receiving honoraria and travel reimbursement from multiple academic and professional organisations for delivering lectures on handoffs and patient safety., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate response process validity evidence for clinical competency committee (CCC) assessments of first-year residents on a subset of General Pediatrics Entrustable Professional Activities (EPAs) and milestones in the context of a national pilot of competency-based, time-variable (CBTV) advancement from undergraduate to graduate medical education., Method: Assessments of 2 EPAs and 8 milestones made by the trainees' actual CCCs and 2 different blinded "virtual" CCCs for 48 first-year pediatrics residents at 4 residency programs between 2016 and 2018 were compared. Residents had 3 different training paths from medical school to residency: time-variable graduation at the same institution as their residency, time-fixed graduation at the same institution, or time-fixed graduation from a different institution. Assessments were compared using ordinal mixed-effects models., Results: Actual CCCs assigned residents higher scores than virtual CCCs on milestones and one EPA's supervision levels. Residents who graduated from a different institution than their residency received lower milestone ratings than either group from the same institution; CBTV residents received higher ratings on one milestone (ICS4) and similar ratings on all others compared with non-CBTV residents who completed medical school at the same institution., Conclusions: First-year residents who graduated from CBTV medical school programs were assessed as having the same level of competence as residents who graduated from traditional medical school programs, but response process evidence suggests that members of CCCs may also draw on undocumented personal knowledge of the learner to draw conclusions about resident competence.

Introduction: The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. Frontline providers are the key individuals participating in handoffs of patient care. It is important they receive robust handoff training., Methods: The I-PASS Mentored Implementation Handoff Curriculum frontline provider training materials were created as part of the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach with an emphasis on adult learning theory principles. The training includes an overview of I-PASS handoff techniques, TeamSTEPPS team communication strategies, verbal handoff simulation scenarios, and a printed handoff document exercise., Results: As part of the SHM I-PASS Mentored Implementation Program, 2,735 frontline providers were trained at 32 study sites (16 adult and 16 pediatric) across North America. At the end of their training, 1,762 frontline providers completed the workshop evaluation form (64% response rate). After receiving the training, over 90% agreed/strongly agreed that they were able to distinguish a good- from a poor-quality handoff, articulate the elements of the I-PASS mnemonic, construct a high-quality patient summary, advocate for an appropriate environment for handoffs, and participate in handoff simulations. Universally, the training provided them with knowledge and skills relevant to their patient care activities., Discussion: The I-PASS frontline training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation., (© 2020 O'Toole et al.)

Importance: Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence., Objective: To measure the development of pediatric trainees' clinical skills over time using EPA-based assessment data., Design, Setting, and Participants: Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018., Interventions: Longitudinal, prospective assessment using EPAs., Main Outcomes and Measures: Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA., Results: Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to "unsupervised practice" varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician)., Conclusions and Relevance: This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

This article provides an overview of the role played by the clinical learning environment in providing opportunities for assessment of trainee performance and how those assessments can guide learning. It reviews the importance of competency models as frameworks to facilitate the creation of a shared mental model of what is to be learned between learners and supervisors. In addition, it discusses how assessment can be used to drive mastery learning as well as the components necessary for a program of assessment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians., Method: The authors conducted a prospective cohort study from 2011 to 2013 in seven pediatric academic medical centers in the United States and Canada. Resident physicians were screened for burnout and depression using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS). A two-step surveillance methodology, involving a research nurse and two physician reviewers, was used to measure and categorize errors. Bivariate and mixed-effects regression models were used to evaluate the relationship between burnout, depression, and rates of harmful, nonharmful, and total errors., Results: A total of 388/537 (72%) resident physicians completed the MBI-HSS and HANDS surveys. Seventy-six (20%) and 178 (46%) resident physicians screened positive for depression and burnout, respectively. Screening positive for depression was associated with a 3.0-fold higher rate of harmful errors (incidence rate ratio = 2.99 [95% CI 1.40-6.36], P = .005). However, there was no statistically significant association between depression and total or nonharmful errors or between burnout and harmful, nonharmful, or total errors., Conclusions: Resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors. This association suggests resident physician mental health could be an important component of patient safety. If further research confirms resident physician depression increases the risk of harmful errors, it will become imperative to determine what interventions might mitigate this risk.

Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or 'audience'. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of 'front-stage' (observed) versus 'backstage' (unobserved) handoffs as distinct performances, tailored to an "audience". Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence.

In 2011, the Education in Pediatrics Across the Continuum (EPAC) Study Group recruited four medical schools (University of California, San Francisco; University of Colorado; University of Minnesota; and University of Utah) and their associated pediatrics clerkship and residency program directors to be part of a consortium to pilot a model designed to advance learners from undergraduate medical education (UME) to graduate medical education (GME) and then to fellowship or practice based on competence rather than time spent in training. The central design features of this pilot included predetermined expectations of performance and transition criteria to ensure readiness to progress from UME to GME, using the Core Entrustable Professional Activities for Entering Residency (Core EPAs) as a common assessment framework. Using this framework, each site team (which included, but was not limited to, the EPAC course, pediatric clerkship, and pediatric residency program directors) monitored learners' progress, with the site's clinical competency committee marking the point of readiness to transition from UME to GME (i.e., the attainment of supervision level 3a). Two of the sites implemented time-variable transition from UME to GME, based on when a learner met the performance expectations and transition criteria. In this Article, the authors describe each of the four sites' implementation of Core EPA assessment and their approach to gathering the data necessary to determine readiness for transition. They conclude by offering recommendations and lessons learned from the pilot's first seven years of development, adaptation, and implementation of assessment strategies across the sites, and discussing next steps.

Introduction: The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. I-PASS champions are a critical part of the implementation and sustainment of this curriculum, and therefore, a rigorous program to support their training is necessary., Methods: The I-PASS Handoff champion training materials were created for the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach and adult learning theory. The training includes an overview of I-PASS handoff techniques, an opportunity to practice evaluating handoffs with the I-PASS observation tools using a handoff video vignette, and other key implementation principles., Results: As part of the SHM I-PASS Mentored Implementation Program, 366 champions were trained at 32 sites across North America and participated in a total of 3,491 handoff observations. A total of 346 champions completed the I-PASS Champion Workshop evaluation form at the end of their training (response rate: 94.5%). After receiving the training, over 90% agreed/strongly agreed that it provided them with knowledge or skills critical to their patient care activities and that they were able to distinguish the difference between high- and poor-quality handoffs, competently use the I-PASS handoff assessment tools, and articulate the importance of handoff observations., Conclusion: The I-PASS champion training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation., Competing Interests: None to report.

Background: Miscommunication during patient transfers is a leading cause of medical errors. Inpatient standardization of handoff communication has been associated with reduced medical errors, but less is known about best practices for handoffs from referring providers to the emergency department (ED). The study aims were to identify (1) stakeholder perceptions of current handoff processes and (2) key handoff elements and strategies to optimize patient care on transfer., Methods: A mixed-methods needs assessment study was conducted at a tertiary care children's hospital with a communication center that receives verbal handoff via telephone from referring providers and provides written summary to the ED. ED, primary care providers, and communication center staff were surveyed to understand perceptions of handoff processes and ideal handoff elements. Focus groups were conducted to refine concepts. Descriptive statistics, chi-square analysis, and qualitative content analysis were used to analyze responses., Results: The survey response rate was 129/152 providers (85%). Forty-two percent of respondents described the quality of the handoff process as "very good" or "excellent"; 43% reported miscommunication occurring "sometimes" or "frequently." Within the I-PASS framework-Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver-respondents identified 10 key elements to obtain through a receiver-driven process to optimize care on transfer. Free-text responses revealed a perceived need to standardize communication., Conclusion: A minority of providers perceived handoff quality between outpatient practices and the ED as "very good" or "excellent"; almost half perceived regular miscommunication. A receiver-driven process is a novel approach that may help ensure standardized communication of key handoff elements in this context., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Introduction: Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process., Methods: The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program., Results: Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% ( N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often., Discussion: The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution., Competing Interests: None to report.

Background: Depression and burnout are highly prevalent among residents, but little is known about modifiable personality variables, such as resilience and stress from uncertainty, that may predispose to these conditions. Residents are routinely faced with uncertainty when making medical decisions., Objective: To determine how stress from uncertainty is related to resilience among pediatric residents and whether these attributes are associated with depression and burnout., Methods: We surveyed 86 residents in pediatric residency programs from 4 urban freestanding children's hospitals in North America in 2015. Stress from uncertainty was measured with the use of the Physicians' Reaction to Uncertainty Scale, resilience with the use of the 14-item Resilience Scale, depression with the use of the Harvard National Depression Screening Scale; and burnout with the use of single-item measures of emotional exhaustion and depersonalization from the Maslach Burnout Inventory., Results: Fifty out of 86 residents responded to the survey (58.1%). Higher levels of stress from uncertainty correlated with lower resilience (r = -0.60; P < .001). Five residents (10%) met depression criteria and 15 residents (31%) met burnout criteria. Depressed residents had higher mean levels of stress due to uncertainty (51.6 ± 9.1 vs 38.7 ± 6.7; P < .001) and lower mean levels of resilience (56.6 ± 10.7 vs 85.4 ± 8.0; P < .001) compared with residents who were not depressed. Burned out residents also had higher mean levels of stress due to uncertainty (44.0 ± 8.5 vs 38.3 ± 7.1; P = .02) and lower mean levels of resilience (76.7 ± 14.8 vs 85.0 ± 9.77; P = .02) compared with residents who were not burned out., Conclusions: We found high levels of stress from uncertainty, and low levels of resilience were strongly correlated with depression and burnout. Efforts to enhance tolerance of uncertainty and resilience among residents may provide opportunities to mitigate resident depression and burnout., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Although high glucocorticoid receptor (GR) expression in early-stage estrogen receptor (ER)-negative breast cancer is associated with shortened relapse-free survival (RFS), how associated GR transcriptional activity contributes to aggressive breast cancer behavior is not well understood. Using potent GR antagonists and primary tumor gene expression data, we sought to identify a tumor-relevant gene signature based on GR activity that would be more predictive than GR expression alone. Experimental Design: Global gene expression and GR ChIP-sequencing were performed to identify GR-regulated genes inhibited by two chemically distinct GR antagonists, mifepristone and CORT108297. Differentially expressed genes from MDA-MB-231 cells were cross-evaluated with significantly expressed genes in GR-high versus GR-low ER-negative primary breast cancers. The resulting subset of GR-targeted genes was analyzed in two independent ER-negative breast cancer cohorts to derive and then validate the GR activity signature (GRsig). Results: Gene expression pathway analysis of glucocorticoid-regulated genes (inhibited by GR antagonism) revealed cell survival and invasion functions. GR ChIP-seq analysis demonstrated that GR antagonists decreased GR chromatin association for a subset of genes. A GRsig that comprised n = 74 GR activation-associated genes (also reversed by GR antagonists) was derived from an adjuvant chemotherapy-treated Discovery cohort and found to predict probability of relapse in a separate Validation cohort (HR = 1.9; P = 0.012). Conclusions: The GRsig discovered herein identifies high-risk ER-negative/GR-positive breast cancers most likely to relapse despite administration of adjuvant chemotherapy. Because GR antagonism can reverse expression of these genes, we propose that addition of a GR antagonist to chemotherapy may improve outcome for these high-risk patients. Clin Cancer Res; 24(14); 3433-46. ©2018 AACR ., (©2018 American Association for Cancer Research.)

Increased glucocorticoid receptor (GR) expression and activity following androgen blockade can contribute to castration-resistant prostate cancer (CRPC) progression. Therefore, we hypothesized that GR antagonism will have therapeutic benefit in CRPC. However, the FDA-approved nonselective, steroidal GR antagonist, mifepristone, lacks GR specificity, reducing its therapeutic potential. Here, we report that two novel nonsteroidal and highly selective GR modulators (SGRM), CORT118335 and CORT108297, have the ability to block GR activity in prostate cancer and slow CRPC progression. In contrast to mifepristone, these novel SGRMs did not affect androgen receptor (AR) signaling, but potently inhibited GR transcriptional activity. Importantly, SGRMs decreased GR-mediated tumor cell viability following AR blockade. In vivo , SGRMs significantly inhibited CRPC progression in high GR-expressing, but not in low GR-expressing xenograft models. Transcriptome analysis following AR blockade and GR activation revealed that these SGRMs block GR-mediated proliferative gene expression pathways. Furthermore, GR-regulated proliferation-associated genes AKAP12, FKBP5, SGK1, CEBPD , and ZBTB16 are inhibited by CORT108297 treatment in vivo Together, these data suggest that GR-selective nonsteroidal SGRMs potently inhibit GR activity and prostate cancer growth despite AR pathway inhibition, demonstrating the therapeutic potential of SGRMs in GR-expressing CRPC. Mol Cancer Ther; 16(8); 1680-92. ©2017 AACR ., (©2017 American Association for Cancer Research.)

Background: In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow., Methods: To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program., Results: As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASS SM Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS., Conclusion: Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond., (Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Importance: Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection., Objective: To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports., Design, Setting, and Participants: We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient., Main Outcomes and Measures: Error and AE rates., Results: Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates., Conclusions and Relevance: Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Objective: 1) To develop validity evidence for the use of the Verbal Handoff Assessment Tool (VHAT) and examine the reliability of VHAT scores, and 2) to determine whether implementation of a resident handoff bundle (RHB) was associated with improved verbal patient handoffs among pediatric resident physicians., Methods: In a pre-post design, prospectively audio recorded verbal patient handoffs conducted at Boston Children's Hospital before and after implementation of the RHB were rated using the VHAT, which was developed for this study (primary outcome). Using generalizability theory, we evaluated the reliability of VHAT scores., Results: Overall, VHAT scores increased after RHB implementation (mean 142 vs 191, possible score 0-500; P < .0001). When accounting for clustering according to resident physician, hospital unit, unit census, and patient complexity, implementation of the RHB was associated with a 63-point increase in VHAT score. Using generalizability theory, we determined that a resident's mean VHAT score on the basis of a handoff of 15 patients assessed by a single observer was sufficiently reliable for relative ranking decisions (ie, norm-based; generalizability coefficient, 0.81), whereas a VHAT score on the basis of a handoff of 21 patients would be sufficiently reliable for high-stakes, standard-based decisions (Phi, 0.80)., Conclusions: Verbal handoffs improved after implementation of a RHB, although gains were variable across the 2 clinical units. The VHAT shows promise as an assessment tool for resident handoff skills. If used for competency or entrustment decisions, a resident's mean VHAT score should be on the basis of observation of verbal handoff of ≥21 patients., (Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Unlabelled: In estrogen receptor (ER)-negative breast cancer, high tumor glucocorticoid receptor (GR) expression has been associated with a relatively poor outcome. In contrast, using a meta-analysis of several genomic datasets, here we find that tumor GR mRNA expression is associated with improved ER(+) relapse-free survival (RFS; independently of progesterone receptor expression). To understand the mechanism by which GR expression is associated with a better ER(+) breast cancer outcome, the global effect of GR-mediated transcriptional activation in ER(+) breast cancer cells was studied. Analysis of GR chromatin immunoprecipitation followed by high-throughput sequencing in ER(+)/GR(+) MCF-7 cells revealed that upon coactivation of GR and ER, GR chromatin association became enriched at proximal promoter regions. Furthermore, following ER activation, increased GR chromatin association was observed at ER, FOXO, and AP1 response elements. In addition, ER associated with GR response elements, suggesting that ER and GR interact in a complex. Coactivation of GR and ER resulted in increased expression (relative to ER activation alone) of transcripts that encode proteins promoting cellular differentiation (e.g., KDM4B, VDR) and inhibiting the Wnt signaling pathway (IGFBP4). Finally, expression of these individual prodifferentiation genes was associated with significantly improved RFS in ER(+) breast cancer patients. Together, these data suggest that the coexpression and subsequent activity of tumor cell GR and ER contribute to the less aggressive natural history of early-stage breast cancer by coordinating the altered expression of genes favoring differentiation., Implications: The interaction between ER and GR activity highlights the importance of context-dependent nuclear receptor function in cancer. Mol Cancer Res; 14(8); 707-19. ©2016 AACR., Competing Interests: of Potential Conflict of Interest: Drs. Pan, Kocherginsky, and Conzen have a patent issued “Methods and compositions related to glucocorticoid receptor (GR) antagonists and breast cancer.” This patent covers ER-negative breast cancer and therefore is not directly relevant to this work in estrogen receptor-positive (ER+) breast cancer. However, it may be considered broadly relevant to the work. There are no other conflicts of interest to report., (©2016 American Association for Cancer Research.)

Background and Purpose: Multiple rehabilitation factors including overall wellness need to be considered when an athlete returns to sport after an injury. The purpose of this case report is to describe a multidisciplinary approach for return to sport of a Division I collegiate football player following a traumatic ankle fracture requiring surgical repair. The assessment and treatment approach included the use of a performance-based physical therapy outcome measure, self-reported functional abilities, body composition assessments, and nutritional counseling., Case Description: A 21 year-old running back fractured his lateral malleolus due to a mechanism of injury of excessive eversion with external rotation of the ankle. Surgical intervention included an open reduction internal fixation (ORIF) of the fibula and syndesmosis. In addition to six months of rehabilitation, the patient received consultations from the team sports nutritionist specialist to provide dietary counseling and body composition testing. The Comprehensive High-level Activity Mobility Predictor-Sport (CHAMP-S), a performance-based outcome measure, self-report on the Foot and Ankle Disability Index (FADI-ADL, FADI-S), and body composition testing using whole body densitometry (BOD POD®), were administered throughout rehabilitation., Outcomes: The subject was successfully rehabilitated, returned to his starting role, and subsequently was drafted by a National Football League (NFL) franchise. High-level mobility returned to above pre-injury values, achieving 105% of his preseason CHAMP-S score at discharge. Self-reported function on the FADI-ADL and FADI-Sport improved to 100% at discharge. Body fat percentages decreased (13.3% to 11.9%) and fat mass decreased (12.0 kg to 11.0kg). Lean body mass (78.1 kg to 81.5 kg) and lbm/in increased (1.14 kg/in to 1.19 kg/in). His BMI changed from 29.8 kg/m(2) to 30.6 kg/m(2)., Discussion: This case report illustrates the positive effects of a multidisciplinary approach where combining physical therapy and nutritional counseling demonstrated value with return to sport preparation and success following ankle fracture. A targeted physical therapy program combined with a personalized nutrition intervention based on body composition assessment assisted this athlete in avoiding deconditioning (atrophy, decreased aerobic capacities, and increases in body fat) often observed during postoperative care., Level of Evidence: 5.

Purpose: Long-term survivors of Ewing sarcoma (EWS) are at considerable risk for future complications, including late relapse and death. Data on prognostic factors for late death in those who have survived beyond 5 years are lacking., Methods: We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results database. We obtained clinical features and outcome data on 1,351 patients with EWS who had survived 60 months or more. From these data, we performed univariate and multivariable analyses of overall survival (OS) using log-rank tests and Cox proportional hazard models., Results: Of 1,351 patients in the cohort, there were 209 deaths, 144 (69%) of which were reported to be due to EWS. The OS for 5-year survivors at 10 years was 87.5% (95% confidence interval 85.4-89.3%). Univariate adverse prognostic factors for late death in 5-year survivors included age ≥ 18 years at initial diagnosis, male sex, and axial/pelvic primary site. Initial stage was not prognostic. Independent adverse prognostic factors for late death included black race (hazard ratio [HR] 2.16, P = 0.01), age ≥ 18 years at diagnosis (HR 2.02, P < 0.001), male sex (HR 1.43, P = 0.01), and axial/pelvic primary site (HR 1.43, P = 0.02)., Conclusions: The majority of late deaths in 5-year survivors are due to EWS. Black race, age ≥18 at diagnosis, male sex, and axial/pelvic primary site (but not stage at diagnosis) are independently associated with increased risk of late death., (© 2016 Wiley Periodicals, Inc.)

Warming global temperatures are driving changes in species distributions, growth and timing, but much uncertainty remains regarding how climate change will alter species interactions. Consumer-Resource interactions in particular can be strongly impacted by changes to the relative performance of interacting species. While consumers generally gain an advantage over their resources with increasing temperatures, nonlinearities can change this relation near temperature extremes. We use an experimental approach to determine how temperature changes between 5 and 30 °C will alter the growth of the algae Scenedesmus obliquus and the functional responses of the small-bodied Daphnia ambigua and the larger Daphnia pulicaria. The impact of warming generally followed expectations, making both Daphnia species more effective grazers, with the increase in feeding rates outpacing the increases in algal growth rate. At the extremes of our temperature range, however, warming resulted in a decrease in Daphnia grazing effectiveness. Between 25 and 30 °C, both species of Daphnia experienced a precipitous drop in feeding rates, while algal growth rates remained high, increasing the likelihood of algal blooms in warming summer temperatures. Daphnia pulicaria performed significantly better at cold temperatures than D. ambigua, but by 20 °C, there was no significant difference between the two species, and at 25 °C, D. ambigua outperformed D. pulicaria. Warming summer temperatures will favour the smaller D. ambigua, but only over a narrow temperature range, and warming beyond 25 °C could open D. ambigua to invasion from tropical species. By fitting our results to temperature-dependent functions, we develop a temperature- and density-dependent model, which produces a metric of grazing effectiveness, quantifying the grazer density necessary to halt algal growth. This approach should prove useful for tracking the transient dynamics of other density-dependent consumer-resource interactions, such as agricultural pests and biological-control agents., (© 2016 The Authors. Journal of Animal Ecology © 2016 British Ecological Society.)

Entrustable professional activities (EPAs) provide a framework to standardize medical education outcomes and advance competency-based assessment. Direct observation of performance plays a central role in entrustment decisions; however, data obtained from these observations are often insufficient to draw valid high-stakes conclusions. One approach to enhancing the reliability and validity of these assessments is to create videos that establish performance standards to train faculty observers. Little is known about how to create videos that can serve as standards for assessment of EPAs.The authors report their experience developing videos that represent five levels of performance for an EPA for patient handoffs. The authors describe a process that begins with mapping the EPA to the critical competencies needed to make an entrustment decision. Each competency is then defined by five milestones (behavioral descriptors of performance at five advancing levels). Integration of the milestones at each level across competencies enabled the creation of clinical vignettes that were converted into video scripts and ultimately videos. Each video represented a performance standard from novice to expert. The process included multiple assessments by experts to guide iterative improvements, provide evidence of content validity, and ensure that the authors successfully translated behavioral descriptions and vignettes into videos that represented the intended performance level for a learner. The steps outlined are generalizable to other EPAs, serving as a guide for others to develop videos to train faculty. This process provides the level of content validity evidence necessary to support using videos as standards for high-stakes entrustment decisions.