Supportive and collaborative interdependence: Distinguishing residents' contributions within health care teams.

INTRODUCTION: Individual assessments disregard team contributions, while team assessments disregard an individual's contributions. Interdependence has been put forth as a conceptual bridge between our educational traditions of assessing individual performance and our imminent challenge of assessing team-based performance without losing sight of the individual. The purpose of this study was to develop a more refined conceptualisation of interdependence to inform the creation of measures that can assess the interdependence of residents within health care teams. METHODS: Following a constructivist grounded theory approach, we conducted 49 semi-structured interviews with various members of health care teams (e.g. physicians, nurses, pharmacists, social workers and patients) across two different clinical specialties-Emergency Medicine and Paediatrics-at two separate sites. Data collection and analysis occurred iteratively. Constant comparative inductive analysis was used, and coding consisted of three stages: initial, focused and theoretical. RESULTS: We asked participants to reflect upon interdependence and describe how it exists in their clinical setting. All participants acknowledged the existence of interdependence, but they did not view it as part of a linear spectrum where interdependence becomes independence. Our analysis refined the conceptualisation of interdependence to include two types: supportive and collaborative. Supportive interdependence occurs within health care teams when one member demonstrates insufficient expertise to perform within their scope of practice. Collaborative interdependence, on the other hand, was not triggered by lack of experience/expertise within an individual's scope of practice, but rather recognition that patient care requires contributions from other team members. CONCLUSION: In order to assess a team's collective performance without losing sight of the individual, we need to capture interdependent performances and characterise the nature of such interdependence. Moving away from a linear trajectory where independence is seen as the end goal can also help support efforts to measure an individual's competence as an interdependent member of a health care team.

Impostorism and anxiety contribute to burnout among resident physicians.

PURPOSE: Physician burnout is an issue that has come to the forefront in the past decade. While many factors contribute to burnout the impact of impostorism and self-doubt has largely been ignored. We investigated the relationship of anxiety and impostorism to burnout in postgraduate medical learners. MATERIALS AND METHODS: Postgraduate learners in four diverse training programs: Family Medicine (FM), Paediatric Medicine (PM), Anesthesiology (AN), and General Surgery (GS) were surveyed to identify the incidence of impostorism (IP), anxiety, and burnout. IP, anxiety, and burnout were evaluated using the Clance Impostor Phenomenon Scale (CIPS), Maslach Burnout Inventory-Human Services Survey (MBI-HSS), and the General Anxiety Disorder-7 (GAD-7) questionnaires, respectively. Burnout was defined as meeting burnout criteria on all three domains. Relationships between IP, anxiety, and burnout were explored. RESULTS: Two hundred and sixty-nine residents responded to the survey (response rate 18.8%). Respondents were distributed evenly between specialties (FM = 24.9%, PM = 33.1%, AN = 20.4%, GS = 21.6%). IP was identified in 62.7% of all participants. The average score on the CIPS was 66.4 (SD = 14.4), corresponding to 'frequent feelings of impostorism.' Female learners were at higher risk for IP (RR = 1.27, 95% CI: 1.03-1.57). Burnout, as defined by meeting burnout criteria on all three subscales, was detected in 23.3% of respondents. Significant differences were seen in burnout between specialties (p = 0.02). GS residents were more likely to experience burnout (31.7%) than PM and AN residents (26.7 and 10.0%, respectively, p = 0.02). IP was an independent risk factor for both anxiety (RR = 3.64, 95% CI:1.96-6.76) and burnout (RR = 1.82, 95% CI: 1.07-3.08). CONCLUSIONS: Impostorism is commonly experienced by resident learners independent of specialty and contributes to learner anxiety and burnout. Supervisors and Program Directors must be aware of the prevalence of IP and the impact on burnout. Initiatives to mitigate IP may improve resident learner wellness and decrease burnout in postgraduate learners.

Fulminant bilateral papilloedema during low-dose steroid taper in a child with systemic idiopathic arthritis treated with tocilizumab.

Systemic juvenile idiopathic arthritis (SJIA) is one of the most severe forms of arthritis that affects children younger than 16 years of age at onset. SJIA often requires corticosteroids to control the inflammation. However, long-term corticosteroid use may have adverse effects, including intracranial hypertension (IH). Biologic therapies have been used as corticosteroid sparing agents. We report the first case of a child with steroid-dependent SJIA treated with tocilizumab, an IL-6 receptor monoclonal antibody, who developed fulminant IH, bilateral papilloedema and vision loss when oral prednisone was weaned from 2 to 1 mg per day. Despite repeated lumbar punctures and high dose acetazolamide, he required urgent unilateral optic nerve sheath fenestration (ONSF). This endoscopic surgical intervention released the pressure exerted by the cerebrospinal fluid on the optic nerve and stopped the progression of vision loss. Nine weeks after the diagnosis of bilateral papilloedema, his vision was completely restored in one eye and partially recovered in the contralateral one. Long-term treatment with corticosteroids even at very low dose and tocilizumab may predispose to severe IH, papilloedema and vision loss. The role that tocilizumab might have played in this case in unclear. Early recognition and prompt treatment of papilloedema is crucial in avoiding permanent vision loss. Fulminant papilloedema in an immunocompromised child carries additional significant challenges. Early ONSF is a safe and effective intervention in refractory papilloedema. Children with severe papilledema secondary to IH should be managed by a multidisciplinary team in tertiary centres.

Renal Infarcts-A Perplexing Case in the Middle of the COVID-19 Pandemic.

Renal infarction is a rare finding in children. Associations between SARS-CoV-2 infections and thromboembolic events including renal infarcts have been described in adults. Although a similar association in children has not yet been described with this pandemic, the pediatric literature is still evolving with the recognition of new manifestations including the post-infectious Multisystem Inflammatory Syndrome in Children (MIS-C). We report the rare event of multiple renal infarcts in a 6-year-old boy manifesting several features of MIS-C 9 weeks following a self-limiting febrile illness characteristic of COVID-19. An underlying Factor V Leiden mutation was identified in this child but felt to be insufficient on its own to explain his clinical presentation. As SARS-CoV-2 testing was delayed, the failure to identify viral RNA or antibodies may not exclude the virus' potential role in precipitating the infarct in this host. Given that renal infarcts have been described in adult patients with COVID-19, reporting this perplexing case where SARS-CoV-2 may have played a role, may help identify this potential complication.

PTHrP-related Hypercalcaemia in Infancy and Congenital Anomalies of the Kidney and Urinary Tract (CAKUT).

BACKGROUND: Severe hypercalcaemia is a rare but clinically significant condition in infancy and childhood. Parathyroid hormone-related peptide (PTHrP)-mediated hypercalcaemia resulting from a malignancy is rare and only a handful of case reports have outlined its incidence alongside a benign condition. OBJECTIVES: To describe the diagnostic workup and management of an infant with hypercalcaemia, renal dysplasia, and elevated PTHrP levels. DESIGN: Case report. SETTING: The Victoria Hospital campus of the London Health Sciences Centre in London, Ontario, Canada. PATIENTS: A child with congenital anomalies of the kidneys and urinary tract (CAKUT), stage 2 chronic kidney disease (CKD), and renal dysplasia who presented with severe hypercalcaemia. MEASUREMENTS: Weight, renal ultrasound, creatinine, cystatin C, eGFR, calcium, urea, bicarbonate, serum sodium, fractional sodium excretion, urine calcium to creatinine ratio, PTH, TSH, Free T4, AM cortisol, HMA, VMA, 25-vitamin D, 1,25 dihydroxy-vitamin D, calcitriol, vitamin A, ACE levels, skull and chest x-rays, alkaline phosphatase, CBC, tumour lysis profile, catecholamine breakdown, whole-body MRI, PTHrP. METHODS: Full diagnostic workup and patient management. Patient treated with intravenous hydration, furosemide, calcitonin and CalciLo. RESULTS: PTHrP was elevated and no evidence of a malignancy was found. Treatment consisting of a low-calcium CalciLo diet (in place of breast milk) adequately controlled the patient's hypercalcaemia. Hypercalcaemia associated with CAKUT in infancy is not all that uncommon and was reported in 15/99 infants in another study, most of whom had a suppressed PTH similar to that of our patient. PTHrP was not measured in these cases and may have also been elevated. LIMITATIONS: The study is limited in that it is a description of a single patient case. Future measurement of PTHrP in similar patients is necessary to confirm our results. CONCLUSIONS: The possibility of elevated PTHrP levels must be considered in patients with known renal dysplasia who are differentially diagnosed with hypercalcaemia.

CONTEXTE: L'hypercalcémie aigue est rare, bien qu'elle constitue un trouble important de la petite enfance et de l'enfance du point de vue clinique. Rares sont les hypercalcémies à médiation de peptide lié à l'hormone parathyroïdienne (PTHrP) qui résultent d'une malignité, et seules quelques observations cliniques témoignent de leur incidence dans les cas de troubles bénins. OBJECTIFS: Décrire le bilan diagnostic et la prise en charge d'un petit enfant atteint d'hypercalcémie, de dysplasie rénale, et présentant des taux élevés de PTHrP. TYPE D'ÉTUDE: Observation clinique. CONTEXTE: Le campus de l'Hôpital Victoria du Centre de services de santé de London (London Health Sciences Centre), à London, en Ontario, au Canada. PARTICIPANTS: Un enfant atteint d'anomalies congénitales du rein et des voies urinaires (CAKUT), d'insuffisance rénale chronique (IRC) de stade 2 et de dysplasie rénale, qui présentait une hypercalcémie aigue. MESURES: Le poids, l'échographie rénale, la créatinine, la cystatine C, le R-EGF, le calcium, l'urée, le bicarbonate, le sodium sérique, la fraction d'excrétion du sodium, le ratio calcium/créatine dans l'urine, la PTH, la TSH, le T4 libre, le taux de cortisol le matin, l'acide homomandelique, l'acide vanillylmandelique , le 25-vitamine D, le 1,25 dihydroxy-vitamine D, le calcitriol, la vitamineA, les taux d'enzyme de conversion de l'angiotensine, les radiographies thoraciques et crâniennes, la phosphatase alcaline, la formule sanguine complète, le profil de lyse tumorale, les taux de catécholamine, la résonnance magnétique du corps entier, le taux de PTHrP. MÉTHODES: Bilan diagnostic et prise en charge du patient. Le patient a reçu une hydratation intraveineuse, du furosémide, de la calcitonine et du Calcilo. RÉSULTATS: Le taux de PTHrP était élevé et on n'a découvert aucune trace d'une malignité. Le traitement, qui consistait en un régime faible en calcium de Calcilo (en remplacement du lait maternel), a permis de limiter adéquatement l'hypercalcémie du patient. L'hypercalcémie associée à des anomalies congénitales du rein et des voies urinaires dans la petite enfance n'est pas si rare. Une autre étude a fait état de 15/99 petits enfants, dont la plupart présentait un faible taux de PTH semblable à celui de notre patient. Le PTHrP, qui n'a pas été mesuré dans ces cas, pourrait également avoir été élevé. LIMITES DE L'ÉTUDE: L'étude est limitée en ceci qu'elle consiste en la description d'un seul cas. Des mesures du taux de PTHrP chez des patients similaires seront nécessaires pour confirmer nos résultats. CONCLUSIONS: L'éventualité de taux élevés de PTHrP doit être envisagée chez les patients atteints de dysplasie rénale et chez lesquels on a autrement diagnostiqué une hypercalcémie.