The State of Mastery Learning in Pediatric Graduate Medical Education: A Scoping Review.

Objective: The aim of this study was to characterize the state of mastery learning interventions, identify gaps in current approaches, and highlight opportunities to improve the rigor of ML in pediatric graduate medical education (GME) training programs. Methods: In October 2022, we searched Ovid, PubMed, Scopus, and ERIC. Two reviewers independently screened 165 citations and reviewed the full manuscripts of 20 studies. We developed a modified data abstraction tool based on the Recommendations for Reporting Mastery Education Research in Medicine (ReMERM) guidelines and extracted variables related to mastery learning curricular implementation and design and learner assessment. Results: Eleven studies of ML approaches within pediatric GME were included in the full review, with over half published after 2020. ML interventions were used to teach both simple and complex tasks, often in heterogeneous learner groups. While deliberate practice and feedback were consistently reported features of ML in pediatrics, opportunities for improvement include clearly defining mastery, conducting learning over multiple sessions, presenting sufficient validity evidence for assessment tools, adhering to rigorous standard setting processes, and reporting psychometric data appropriate for ML. Conclusion: In pediatric GME, ML approaches are in their infancy. By addressing common shortcomings in the existing literature, future efforts can improve the rigor of ML in pediatric training programs and its impact on learners and patients.

While mastery learning is a well-described, effective educational intervention utilized in multiple medical specialties, we perceived a relative lack of published studies on mastery learning in pediatric graduate medical education. Mills-Rudy's team searched the current literature to identify gaps in mastery learning approaches in pediatrics training and to highlight ways to improve the rigor of mastery learning in pediatric training programs. Their search yielded 11 studies of mastery learning approaches in pediatric graduate medical education. They identified major gaps in curriculum development and implementation as well as learner assessment. Opportunities to improve mastery learning in pediatrics include clearly defining mastery, conducting learning over several sessions, presenting sufficient validity evidence for assessment tools, adhering to rigorous standard setting processes, and reporting psychometric data appropriate for mastery learning. Future mastery learning interventions in pediatrics can address these gaps to improve the rigor of mastery learning in pediatric training programs.

Effectiveness of Bile Acid Sequestrants in Microscopic Colitis and Utility of Bile Acid Testing: A Systematic Review and Meta-analysis.

INTRODUCTION: Bile acid sequestrants (BAS) are an option for microscopic colitis (MC) refractory or intolerant to budesonide. There are inconsistent data on the prevalence of bile acid malabsorption (BAM) and utility of bile acid testing in MC. The aim of this systematic review and meta-analysis was to evaluate these outcomes. METHODS: A systematic search of randomized control trials and observational studies of adults with MC treated with BAS was conducted using MEDLINE, Embase, Cochrane, and Scopus from inception to January 22, 2024. Data were extracted on (i) prevalence of BAM, (ii) clinical response and adverse events, and (iii) recurrence after BAS discontinuation. Data were pooled using random-effects models to determine weighted pooled estimates and 95% confidence intervals (CIs). RESULTS: We included 23 studies (1 randomized control trial, 22 observational), with 1,011 patients with MC assessed for BAM and 771 treated with BAS. The pooled prevalence of BAM was 34% (95% CI 0.26-0.42, I2 = 81%). The pooled response rate with BAS induction for all patients with MC, irrespective of BAM, was 62% (95% CI 0.55-0.70, I2 = 71%). There was a higher pooled response rate in patients with BAM compared with those without BAM ( P < 0.0001). The pooled rate of BAS-related adverse effects was 9% (95% CI 0.05-0.14, I2 = 58%). DISCUSSION: One-third of patients with MC had BAM, and almost two-thirds of all patients responded to BAS with limited side effects. Patients with MC and BAM were more likely to respond to therapy, supporting the value of bile acid testing.

Laryngeal chondromas: Current knowledge and future directions.

Objective: Cartilaginous tumors of the larynx are rare, representing less than 1% of all laryngeal tumors. Chondromas are benign mesenchymal tumors characterized by a slow-paced growth, primarily originated in the cricoid cartilage, followed by the thyroid, arytenoid, and epiglottic cartilages. This scoping review aims to understand the extent of evidence on the epidemiology, clinical characteristics, morbidity, and recurrence of the laryngeal chondroma (LC). Data sources: MEDLINE (Ovid), Embase (Elsevier), Web of Science (Clarivate), Cochrane Central Register of Controlled Trials and Systematic Reviews, Lilacs, Scopus, and Google Scholar databases. Review methods: The scoping review was conducted from 1816 to 2023, for observational studies describing LC. Titles and abstracts were screened for relevance, followed by an evaluation of the full text for eligibility. The data were collected from the qualifying articles, and a narrative summary of the outcomes was prepared. Results: One hundred and nineteen studies met the inclusion criteria. Ninety-four case reports, 22 case series, and 3 cohorts. Two hundred and four participants with a diagnosis of LC were described. Male:female ratio was 2.8:1. The most common localization was the cricoid (113; 47.08%), followed by the thyroid (45; 18.75%), and the arytenoid cartilage (27; 11.25%). Dyspnea (78.85%) and hoarseness (74.28%) were the most reported symptoms. The recurrence rate was 11.25%, and complications were uncommon following the resection. Conclusion: This scoping review found a low-frequency rate over all the cartilaginous laryngeal tumors. Most patients were treated with resection, with a low rate of malignancy conversion. This population has low attributable mortality, morbidity, and recurrence according to the current literature.

Point-of-Care Ultrasound Psychomotor Learning Curves: A Systematic Review of the Literature.

OBJECTIVES: Use of point-of-care ultrasound (POCUS) in clinical medicine and inclusion in medical training is increasing. Some professional societies recommend that 25-50 POCUS examinations be completed for each application learned; however, the amount of practice required is not well studied. As such, a better understanding of the learning curves of POCUS psychomotor skills is needed. This systematic review characterizes the learning curves for POCUS psychomotor skill acquisition. METHODS: With the assistance of a research librarian, the available literature through August 28, 2023, was identified. The titles and abstracts, and then the full text were reviewed by two reviewers to screen for inclusion. All studies included after full-text review then underwent data extraction and analysis. RESULTS: The search identified 893 unique studies. Forty-five studies underwent full-text review, with 17 meeting full inclusion criteria. Substantial heterogeneity was noted in study design, duration of education, number and type of learners, and methods for statistical analysis. Clear and validated definitions for learning endpoints, such as plateau points or competency, are lacking. Learning curves and endpoints differ for different applications of POCUS. CONCLUSION: The results are overall supportive of the recommendations to complete 25-50 examinations per application of POCUS learned. However, specific applications require more practice than others. Certain applications, such as cardiac and the Focused Assessment with Sonography in Trauma (FAST) exams, are closer to 50; while others, such as soft tissue, airway, and eye require no more than 25.

Outcomes of Vasopressin-Receptor Agonists Versus Norepinephrine in Adults With Perioperative Hypotension: A Systematic Review.

Consensus statements recommend the use of norepinephrine and/or vasopressin for hypotension in cardiac surgery. However, there is a paucity of data among other surgical subgroups and vasopressin analogs. Therefore, the authors conducted a systematic review of randomized controlled trials (RCTs) to compare vasopressin-receptor agonists with norepinephrine for hypotension among those undergoing surgery with general anesthesia. This review was registered prospectively (CRD42022316328). Literature searches were conducted by a medical librarian to November 28, 2023, across MEDLINE, EMBASE, CENTRAL, and Web of Science. The authors included RCTs enrolling adults (≥18 years of age) undergoing any surgery under general anesthesia who developed perioperative hypotension and comparing vasopressin receptor agonists with norepinephrine. The risk of bias was assessed by the Cochrane risk of bias tool for randomized trials (RoB-2). Thirteen (N = 719) RCTs were included, of which 8 (n = 585) enrolled patients undergoing cardiac surgery. Five trials compared norepinephrine with vasopressin, 4 trials with terlipressin, 1 trial with ornipressin, and the other 3 trials used vasopressin as adjuvant therapy. There was no significant difference in all-cause mortality. Among patients with vasoplegic shock after cardiac surgery, vasopressin was associated with significantly lower intensive care unit (N = 385; 2 trials; mean 100.8 v 175.2 hours, p < 0.005; median 120 [IQR 96-168] v 144 [96-216] hours, p = 0.007) and hospital lengths of stay, as well as fewer cases of acute kidney injury and atrial fibrillation compared with norepinephrine. One trial also found that terlipressin was associated with a significantly lower incidence of acute kidney injury versus norepinephrine overall. Vasopressin and norepinephrine restored mean arterial blood pressure with no significant differences; however, the use of vasopressin with norepinephrine was associated with significantly higher mean arterial blood pressure versus norepinephrine alone. Further high-quality trials are needed to determine pooled treatment effects, especially among noncardiac surgical patients and those treated with vasopressin analogs.

Continuous white noise exposure during sleep and childhood development: A scoping review.

BACKGROUND: White noise machines are widely used as a sleep aid for young children and may lead to poor hearing, speech, and learning outcomes if used incorrectly. OBJECTIVE: Characterize the potential impact of chronic white noise exposure on early childhood development. METHODS: Embase, Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, and Web of Science were searched from inception through June 2022 for publications addressing the effects of chronic noise exposure during sleep on early development in animals and children. PRISMA-ScR guidelines were followed. Among 644 retrieved publications, 20 met inclusion criteria after review by multiple authors. Seven studies evaluated animal models and 13 studies examined pediatric subjects, including 83 animal and 9428 human subjects. RESULTS: White noise machines can exceed 91 dB on maximum volume, which exceeds the National Institute for Occupational Safety and Health noise exposure guidelines for a 2-h work shift in adults. Evidence suggests deleterious effects of continuous moderate-intensity white noise exposure on early development in animal models. Human subject data generally corroborates these models; however, studies also suggest low-intensity noise exposure may be beneficial during sleep. CONCLUSIONS: Existing data support the limitation of maximal sound intensity and duration on commercially available white noise devices. Further research into the optimal intensity and duration of white noise exposure in children is needed.

Disease-specific survival of malignant melanoma after Mohs micrographic surgery is not impacted by initial margins: A systematic review and meta-analysis.

Background: During Mohs surgery for melanoma, evidence has demonstrated that many surgeons opt for smaller initial margins than traditionally recommended (0.5 cm for in situ and 1 cm for invasive). Literature regarding surgical outcomes based on initial margin is sparse. Objective: To determine differences in disease-specific survival of melanoma after Mohs micrographic surgery for varied initial surgical margins. Methods: A literature search was conducted on February 14, 2022, from MEDLINE via PubMed (1946-present), Embase (1974-present), Central (1991-present), and Scopus (1960-present). The primary outcome was disease-specific mortality. Results: Nineteen studies were included for final analysis. The overall disease-specific mortality rate of melanoma in all included studies was 0.5% (CI, 0.1-0.8; P, .010). Disease-specific mortality for 1 to 5, 5, and 6 to 10 mm categories were 0.4% (CI, 0.0-0.9; P, .074), 0.7% (CI, 0.2-1.3; P, .2-1.3), and 0.4% (CI, -0.9 to 1.8; P, .524), respectively. None of the variances across initial margin categories were statistically significant. Limitations: Early-stage melanomas have low overall mortality rates. In our associated article, initial margins of 5 to 10 mm were shown to have the lowest rates of local recurrence. Conclusions: In this systematic review and meta-analysis, melanoma-specific mortality was not significantly impacted by the initial surgical margin taken during Mohs micrographic surgery.

Effects of coaching on medical student well-being and distress: a systematic review protocol.

INTRODUCTION: Medical students experience higher rates of distress and burnout compared with their age-similar peers overall. Coaching has been proposed as one means of combating distress and burnout within the medical profession. The purpose of this systematic review is to synthesise the current evidence on the effects of coaching interventions on medical student well-being, including engagement, resilience, quality of life, professional fulfilment and meaning in work and distress, including burnout, anxiety and depressive symptoms. METHODS AND ANALYSIS: We will conduct a systematic review of interventional and observational comparative studies that assess the effects of coaching interventions on well-being, including engagement, resilience, quality of life, professional fulfilment and meaning in work and distress, including burnout, anxiety and depressive symptoms among undergraduate medical students internationally. We will search PubMed (MEDLINE), Embase (OVID), PsycINFO (OVID), Scopus, ERIC, Cochrane Database of Systematic Reviews (OVID) and Cochrane Central Register of Controlled Trials (OVID) from their respective inception dates using the following search terms: (medical students OR medical student OR undergraduate medical education) AND (coach OR coaching OR coaches). Studies in any language will be eligible. Studies that report one or more outcomes of distress or well-being among medical students who receive a coaching intervention will be included. Data on participant and intervention characteristics, outcomes and instruments used will be collected as well as quality/risk of bias assessments. Two reviewers will screen studies against the inclusion criteria and perform data extraction. We will conduct a narrative synthesis, with meta-analysis if evidence permits quantitative pooling of results. Heterogeneity of results across studies according to study design, learner level and study risk of bias will be evaluated, as well as publication bias. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. Results will be disseminated by publication in a scientific journal. PROSPERO REGISTRATION NUMBER: CRD42022322503.

Appraisal of Postoperative Outcomes of Volatile and Intravenous Anesthetics: A Network Meta-Analysis of Patients Undergoing Cardiac Surgery.

OBJECTIVES: To determine the relative efficacy of specific regimens used as primary anesthetics, as well as the potential combination of volatile and intravenous anesthetics among patients undergoing cardiac, thoracic, and vascular surgery. DESIGN: This frequentist, random-effects network meta-analysis was registered prospectively (CRD42022316328) and conducted according to the PRISMA-NMA framework. Literature searches were conducted up to April 1, 2022 across relevant databases. Risk of bias (RoB) and confidence of evidence were assessed by RoB-2 and CINeMA, respectively. Pooled treatment effects were compared with propofol monotherapy. SETTING: Fifty-three randomized controlled trials (N = 8,085) were included, of which 46 trials (N = 6,604) enrolled patients undergoing cardiac surgery. PARTICIPANTS: Trials enrolling adults (≥18) undergoing cardiac, thoracic, and vascular surgery, using the same induction regimens, and comparing volatile and/or total intravenous anesthesia for the maintenance of anesthesia. Given that the majority of trials focused on those undergoing cardiac surgery and the heterogeneity, analyses were restricted to this population. MEASUREMENT AND MAIN RESULTS: Outcomes of interest included intensive care unit (ICU) length of stay (LOS), myocardial infarction, in-hospital and 30-day mortality, stroke, and delirium. Across 19 trials (N = 1,821; 9 arms; I2 = 64.5%), sevoflurane combined with propofol decreased ICU LOS (mean difference [MD] -18.26 hours; 95% CI -34.78 to -1.73 hours), whereas midazolam with propofol (MD 17.51 hours; 95% CI 2.78-32.25 hours) was associated with a significant increase in ICU LOS, when compared with propofol monotherapy. Among 27 trials (N = 4,080; 10 arms; I2 = 0%), midazolam was associated with significantly greater risk of myocardial infarction versus propofol (risk ratio 1.94; 95% CI 1.01-3.71). There were no significant differences across other outcomes. CONCLUSION: In patients undergoing cardiac surgery, sevoflurane with propofol was associated with decreased ICU LOS compared with propofol monotherapy. Midazolam with propofol increased ICU LOS compared with propofol alone. The combined use of intravenous and volatile anesthetics should be explored further. Future trials in thoracic and vascular surgery are warranted.

Do magnetic resonance imaging features differ between persons with multiple sclerosis of various races and ethnicities?

Those of African American or Latin American descent have been demonstrated to have more severe clinical presentations of multiple sclerosis (MS) than non-Latin American White people with MS. Concurrently, radiological burden of disease on magnetic resonance imaging (MRI) in African Americans with MS has also been described as being more aggressive. Here, we review MRI studies in diverse racial and ethnic groups (adult and pediatric) investigating lesion burden, inflammation, neurodegeneration, and imaging response to disease modifying therapy. We also discuss why such disparities may exist beyond biology, and how future studies may provide greater insights into underlying differences.

Listening to Learners to Prepare for the Future: A Mayo Clinic College of Medicine and Science Benchmarking Survey.

In 2022, a benchmarking survey was completed to gage learner satisfaction with library services, spaces, and resources across 10 Mayo Clinic Libraries. The discussion for this project began around a previously published survey of what medical students wanted from their library. Librarians were asked if Mayo Clinic Libraries could do a similar survey, as a full survey of the Mayo Clinic College of Medicine and Science had not been done. Overall, the findings were positive and provide a baseline for future surveys.

Relationship Between Alcohol Intolerance and Aspirin-Exacerbated Respiratory Disease (AERD): Systematic Review.

OBJECTIVE: Previous studies have suggested that patients with aspirin-exacerbated respiratory disease (AERD) have a high likelihood of alcohol intolerance. The purpose of this systematic review is to identify if there is sufficient evidence to confirm this correlation and the impact of medical therapy on subsequent alcohol tolerance. DATA SOURCES: PubMed, EMBASE, SCOPUS, EBSCO, Google Scholar, Cochrane Library, and Grey literature. We also performed snowballing on the identified observational studies (OS) for additional data. REVIEW METHODS: A systematic review was conducted from 1968 to 2022 to identify those studies describing AERD symptomatology triggered by alcohol intake. The primary outcome was to analyze the current literature for the association between alcohol intolerance and AERD symptoms. The secondary outcome looked for improvement in alcohol tolerance after aspirin desensitization or biological therapy. RESULTS: A total of 775 studies were identified and 40 abstracts were evaluated. From these, 5 studies met the inclusion criteria. Of the 5 manuscripts, there was 1 case-control, 2 cohort, and 2 cross-sectional studies. A total of 522 participants with AERD and a history of alcohol consumption were included, with 52.8% reporting at least 1 sinopulmonary exacerbation after alcohol intake. One of 3 studies noted improvement in alcohol tolerance after medical therapy with aspirin desensitization. CONCLUSION: The current literature suggests that patients with AERD have a high risk of alcohol intolerance. Additionally, aspirin desensitization may improve alcohol tolerance in this patient population.

Local Recurrence Rates of Malignant Melanoma After Mohs Micrographic Surgery Are Lowest With 5- to 10-mm Initial Margins: A Systematic Review and Meta-Analysis.

BACKGROUND: Current consensus guidelines have discouraged the use of sub-0.5-cm (in situ) and sub-1-cm (invasive) margins when performing Mohs micrographic surgery (Mohs) for melanoma, with minimal evidence to guide this recommendation. OBJECTIVE: To compare melanoma local recurrence rates after Mohs based on initial margin size. MATERIALS AND METHODS: A systematic review and meta-analysis was conducted with search terms including Mohs micrographic surgery, surgical margin, recurrent disease, and melanoma. RESULTS: Forty-three studies were included. The 5- to 10-mm margin category had a statistically significant lower local recurrence compared with 1- to 5-mm and 5-mm categories. Recurrence for 1- to 5-mm, 5-mm, 5- to 10-mm, and 10-mm categories were 2.3% (CI 0.8-3.5, p < .001), 1.4% (CI 0.6-2.2, p < .001), 0.3% (CI 0.2-0.5, p < .001), and 6.1% (CI -6.7 - 18.8, p = .349), respectively. Number of stages for 1 to 5, 5, 5 to 10, and 10-mm categories were 1.8, 1.8, 1.6, and 1.6, respectively. There was no statistically significant difference between the groups (p = .694). CONCLUSION: Five- to 10-mm margins were associated with the lowest local recurrence rates. A 5- to 10-mm initial margin should be considered where other factors (tumor characteristics, anatomical or functional considerations) allow.