Developing a digitally innovative ethics and professionalism curriculum for neonatal-perinatal medicine fellows: a 3-year multicenter pilot study.

OBJECTIVES: The purpose of this study was to develop and regionally pilot a digitally innovative curriculum in ethics and professionalism in neonatology and study the effects on trainee knowledge and confidence. STUDY DESIGN: We developed 13 modules in ethics for neonatology fellows and piloted them at three academic institutions utilizing a flipped-classroom approach. Baseline surveys in ethics knowledge and confidence in approaching ethical dilemmas were compared with repeat surveys after curriculum completion. Pre- and post-tests were also administered for all 13 modules. RESULTS: Forty-four of 49 eligible fellows participated (90% response rate). Pre/post comparisons demonstrated significant improvements in overall knowledge and in 8/13 modules, as well as improvement in overall confidence and individually when navigating 16/22 ethical dilemmas. CONCLUSIONS: After completing this curriculum, participants' knowledge scores and reported confidence in approaching ethical challenges significantly improved. Future steps include assessing the effects of this innovative curriculum via an ongoing international pilot.

Practices and education surrounding anticipated periviable deliveries among neonatal-perinatal medicine and maternal-fetal medicine fellowship programs.

OBJECTIVES: To explore national practices of periviable decision-making and care, and to determine and compare trainee education in this domain, within neonatal-perinatal medicine (NPP) and maternal-fetal medicine (MFMP) fellowship programs. STUDY DESIGN: A 75-item survey was sent to NPP and MFMP program directors in the United States. RESULTS: In all, 79 of 168 surveys were completed (47%). MFMPs reported offering active interventions for bigger or more mature fetuses (versus NPPs). Variability exists in estimated frequency of simultaneous antenatal counseling by both specialties (range 0 to 90%) and of inter-specialty communication before consultation (range 5 to 100%). One-quarter of MFMPs reported no fellow education regarding periviable deliveries, versus 2% of NPPs (P=0.002); 40% of MFMPs teach fellows about periviable ethics, versus 63% of NPPs (P=0.05). NPPs more frequently utilize role modeling (P=0.01) and simulation (P=0.01) as learning methods. CONCLUSION: NPPs and MFMPs report different, often asynchronous, practices and fellow education regarding antenatal counseling and resuscitation at periviability.

Ethics and professionalism education during neonatal-perinatal fellowship training in the United States.

OBJECTIVE: The objectives of this study were to determine the perceived adequacy of ethics and professionalism education for neonatal-perinatal fellows in the United States, and to measure confidence of fellows and recent graduates when navigating ethical issues. STUDY DESIGN: Neonatal-Perinatal Fellowship Directors, fellows and recent graduates were surveyed regarding the quality and type of such education during training, and perceived confidence of fellows/graduates in confronting ethical dilemmas. RESULT: Forty-six of 97 Directors (47%) and 82 of 444 fellows/graduates (18%) completed the surveys. Over 97% of respondents agreed that ethics training is 'important/very important'. Only 63% of Directors and 37% of fellows/graduates rated ethics education as 'excellent/very good' (P=0.004). While 96% of Directors reported teaching of ethics, only 70% of fellows/graduates reported such teaching (P<0.001). Teaching methods and their perceived effectiveness varied widely. CONCLUSION: Training in ethics and professionalism for fellows is important, yet currently insufficient; a more standardized curriculum may be beneficial to ensure that trainees achieve competency.

Ethics of emerging technologies and their transition to accepted practice: intestinal transplant for short bowel syndrome.

Parental counseling becomes complex when considering the use of emerging technologies, especially if it is unclear whether the level of evidence is sufficient to transform the proposed therapy into accepted practice. This paper addresses ethical issues underlying medical decision-making and counseling in the setting of emerging treatments, when long-term outcomes are still in the process of being fully validated. We argue that the ethical transition of emerging technologies, ideally from ethically impermissible to permissible, to obligatory, depends primarily on two factors: outcome data (or prognosis) and treatment feasibility. To illustrate these points, we will use intestinal transplant for short bowel syndrome (SBS) as a specific example. After reviewing the data, this paper will identify the ethical justifications for both comfort care only and intestinal transplant in patients with ultra SBS, and argue that both are ethically permissible, but neither is obligatory. The approach outlined will not only be valuable as ultra SBS outcomes data continue to change, but will also be applicable to other novel therapies as they emerge in perinatal medicine.

Who is performing medical procedures in the neonatal intensive care unit?

OBJECTIVE: Owing to resident work-hour reductions and more permanent personnel in the newborn intensive care unit (NICU), we sought to determine if pediatric housestaff are missing learning opportunities in procedural training due to non-participation. STUDY DESIGN: A prospective, observational study was conducted at an academic NICU using self-reported data from neonatal personnel after attempting 188 procedures on 109 neonates, and analyzed using Fisher's exact and χ (2)-tests. RESULT: Housestaff first attempted 32% of procedures (P<0.001) and were less likely to make attempts early in the academic year (P<0.001). There was no significant difference in attempts based on urgency of situation (P=0.742). Of procedures performed by non-housestaff personnel, 93% were completed while housestaff were present elsewhere in the unit. CONCLUSION: Pediatric housestaff performed the minority of procedures in the NICU, even in non-urgent situations, and were often uninvolved in other procedures, representing missed learning opportunities.

Seed size variation and predation of seeds produced by wild and crop-wild sunflowers.

The movement of pollen between crop and wild sunflowers (both Helianthus annuus) has led to concerns about the possible introduction of crop transgenes into wild populations. The persistence of crop traits in wild populations will depend in part on the relative fitness of crop-wild hybrid vs. wild plants. Using seeds from two large experimental field plots, we found that seeds produced by crop-wild plants were twice the size of wild seeds and differed in coloration. Head diameter, date of flowering, identity of mother plant, and levels of predispersal predation explained some variation in mean seed size. We hypothesized that postdispersal vertebrate seed predation would be affected by seed size, with hybrid seeds preferentially eaten. In each of three field trials, significantly more hybrid seeds were eaten (62% of hybrid seed; 42% of wild seed). Within the category of wild seeds, larger seeds were preferentially eaten; however among hybrid seeds, predation was not significantly related to seed size. In this study, differential predation thus reduces hybrid fitness and would presumably slow the spread of transgenes into wild populations.

Increased pre-dispersal seed predation in sunflower crop-wild hybrids.

The fitness of crop-wild hybrids can influence gene flow between crop and wild populations. Seed predation levels in crop-wild hybrid plants can be an important factor in determining plant fitness, especially in large-seeded crops such as sunflower. To determine patterns of pre-dispersal seed predation, seeds were collected from wild sunflowers (Helianthus annuus L.) and wild×crop F1 hybrids at three experimental field sites in eastern Kansas. Seed heads were dissected and each seed was counted and scored for categories of seed damage by lepidopteran and coleopteran larvae. Hybrid seed heads showed significantly higher levels of insect-damaged seeds. The average hybrid plant had 36.5% of its seeds (or 45.1 seeds per plant) eaten by insect larvae while the average wild plant lost only 1.8% (or 95 seeds) to seed predators. Hybrid populations had higher levels of total insect damage even when date of flowering, flower head diameter, and the number of open heads within the study site were accounted for. These results suggest that the reduced fecundity of F1 crop-wild sunflower hybrids demonstrated in other studies may be augmented by the increased seed predation in hybrid flower heads. Fecundity estimates of crop-wild hybrid and wild plants that disregard differential seed predation levels may not accurately reflect the actual relative contributions of hybrid and wild plants to future generations.

Increases in diagnostic yield of fiberoptic bronchoscopy by fluoroscopy.

Fiberoptic bronchoscopy was performed in 46 patients in the evaluation of pulmonary lesions. Twenty-five of the patients had lung cancer; the remainder had benign lesions. Definitive diagnosis was established in all patients by a combination of forceps biopsy, brush biopsy, bronchial aspiration, and post-bronchoscopy sputum studies. All endoscopically visible lesions were diagnosed by forceps biopsy. Fluoroscopic localization of biopsy forceps and brush made the yield in peripheral, nonvisualized lesions almost equal to that of more central lesions. Fluoroscopic control markedly increases the diagnostic yield in fiberoptic bronchoscopy.

Acute respiratory failure and hypothyroidism.

A 64-year-old woman presented in severe respiratory failure along with congestive heart failure, chronic obstructive lung disease, and hypothyroidism. Any of the latter may lead to acute respiratory failure, and all may have played a role in the patient reported here.