The Current State of Combined Pediatric Anesthesiology-Critical Care Practice: A Survey of Dual-Trained Practitioners in the United States.

BACKGROUND: Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition. METHODS: We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey. RESULTS: Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again. CONCLUSIONS: The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.

Sexual and reproductive healthcare for adolescent and young adult women with epilepsy: A qualitative study of pediatric neurologists and epileptologists.

OBJECTIVE: The objective of this study was to explore the attitudes and practices of pediatric neurologists and epileptologists regarding sexual and reproductive healthcare for adolescent and young adult women with epilepsy (WWE). BACKGROUND: Adolescent and young adult WWE have unique sexual and reproductive healthcare needs, including counseling on teratogenesis, folic acid, and interactions between contraception and antiseizure medications. There are no prior studies regarding sexual and reproductive healthcare practices of pediatric neurologists or epileptologists. DESIGN/METHODS: Individual semi-structured interviews were conducted with pediatric neurologists and epileptologists regarding their attitudes, practices, and experiences with sexual and reproductive healthcare for adolescent and young adult WWE. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis was conducted using a thematic analysis approach. RESULTS: Six child neurologists and 10 epileptologists (44% male) participated. Major themes included the following: (1) Sexual and reproductive healthcare is important for adolescent WWE, and neurologists have a key role in providing this care. (2) Sexual and reproductive healthcare should be comanaged with a primary care provider or women's health provider although neurologists have significant concerns regarding comanagement. (3) There is wide variability in sexual and reproductive healthcare practice among pediatric neurologists and epileptologists. Important subthemes included parent education and differences in sexual and reproductive healthcare practices for women with intellectual disabilities. (4) Many systemic and interpersonal barriers exist to delivering sexual and reproductive healthcare to adolescent and young adult WWE. Important barriers included limited time; provider, patient, or family discomfort; and lack of necessary knowledge or expertise. (5) Providers desire standardization of sexual and reproductive healthcare for adolescent WWE along with patient and provider education. CONCLUSION: This is the first study to assess attitudes and practices of pediatric neurologists and epileptologists regarding sexual and reproductive healthcare for adolescent and young adult WWE. Our findings suggest that there is a need for development of improved systems for sexual and reproductive healthcare delivery and comanagement for adolescent and young adult WWE. Providers identified many barriers and facilitators that might serve as the basis for interventions to improve care.

Clinical application of the PedsQL Epilepsy Module (PedsQL-EM) in an ambulatory pediatric epilepsy setting.

INTRODUCTION: Children with epilepsy report lower health-related quality of life (QOL) compared with healthy children and those with other chronic disorders. This study piloted the recently published Pediatric Quality of Life Inventory (PedsQL) Epilepsy Module (PedsQL-EM) in an ambulatory setting and studied epilepsy-related factors contributing to QOL in children with epilepsy. METHODS: Children with epilepsy aged 8-18 years who were ambulant and verbal were recruited from pediatric neurology clinics. Children and their caregivers completed age-appropriate versions of the PedsQL-EM (8-12 or 13-18 years) in the clinic waiting area. Treating neurologists completed medical questionnaires about their patients' epilepsy. RESULTS: We collected 151 parent-report and 127 self-report PedsQL-EMs. Administration time was 5-10 min with some children receiving assistance from the researcher. Mean age of children was 12.9+/-3.0, with 77 females (51%). Parents reported lower mean QOL scores across all subdomains compared with their children. Parents reported significantly lower QOL for children with earlier age at epilepsy onset, longer epilepsy duration, presence of seizures during the last month, more severe epilepsy, increased number of antiepileptic drugs (AEDs), and cognitive comorbidity. The same factors impacted on child self-reporting, but with more variability across subdomains. CONCLUSIONS: The PedsQL-EM is an epilepsy-specific measure of QOL that is quick and easy to administer and is sensitive to the clinical factors reported to impact on QOL in pediatric epilepsy.

Hymenoptera venom allergy among children in Italy: time for pediatricians to take action.

Hymenoptera venom allergy (HVA) is one of the most frequent causes of anaphylaxis following a bee, vespid or ant sting. Real-life data regarding the management of HVA in children are lacking. To address this unmet need, we carried out a survey defining the current management of HVA in children among pediatric allergists in Italy. Educational investments on the improvement of the management of pediatric patients with HVA are urgently needed, and our analysis represents a relevant instrument in targeting a roadmap with this aim. The time for pediatric allergists to take action has come, and a task force from the Rare Allergic Diseases Commission of the Italian Society of Pediatric Allergy and Immunology is working on the topic to improve pediatricians' knowledge and optimize the care of these patients.

Pediatric cervical spine injuries on CT: difference in accuracy of interpretations by pediatric versus non-pediatric radiologists.

PURPOSE: To retrospectively compare the accuracy of interpretation of initial cervical computerized tomography (CCT) by a non-pediatric radiologist (NPR) versus a pediatric radiologist (PR). METHODS: IRB approval and consent waiver were granted to review all injured children from 2010 to 2014 in the trauma registry with CT and magnetic resonance imaging (MRI) of the cervical spine. Patients with negative CCT who subsequently had positive MRI from a single institution comprised the study group. Patients with negative CCT and MRI, matched by age, gender, and severity scores, comprised the control group. The CCTs from both groups were initially interpreted at the time of service by a NPR. Subsequently, a single PR with 20 years of experience blinded to clinical/imaging data reinterpreted these CCT examinations. CT interpretations were then compared with MRI results and evaluated for statistical significance using SSPS software. The data analysis utilized summary statistics, two-tailed binomial test, and univariate χ2 test. Significance for all comparisons was assessed at P < 0.05. RESULTS: The study group was comprised of the 21 patients with negative CCT and positive MRI. Of the cohort included, 76% (16) were male and 24% (5) were female. The age range was 1 month-17 years, with a mean age of 9.7 years. CCT interpretation by NPR had a specificity of 91.7% (sensitivity 71.2%, positive predictive value 81.3%, and negative predictive value 86.3%) compared with results of MRI. Six of the 21 negative CCTs were interpreted by the PR as positive, mainly craniocervical junction injuries, and confirmed by MRI (28.6%, P < .001 compared with the NPR); no control CCT was interpreted by the PR as positive (sensitivity 100%, positive predictive value 100%, and negative predictive value 58.3%). CONCLUSION: In our retrospective study, a pediatric radiologist has improved recognition of pediatric cervical spine injuries on CT compared with non-pediatric radiologist.

Eating disorders in adolescents: role of the pediatrician. Recommendations of the Adolescence Branch of the Chilean Society of Pediatrics. / Trastornos de la conducta alimentaria en adolescentes: Rol del pediatra. Recomendaciones de la Rama de Adolescencia de la Sociedad Chilena de Pediatría.

Eating disorders (ED) have become relevant in Chilean pediatrics. Their treatment must be prefe rably carried out by multidisciplinary teams with specialty or a high degree of training in the pro blem. However, general pediatricians have a fundamental role both in the prevention and in the early detection of these pathologies. The purpose of this publication is to provide them with practical recommendations on interventions that can be carried out during adolescent care for the prevention of ED, the early detection and evaluation of those who already have them, and their timely referral to specialized treatment.

Poor adherence to early childhood blood pressure measurement guidelines in a large pediatric healthcare system.

BACKGROUND: Children who were born prematurely, those with a very low birthweight, or who have survived the neonatal intensive care unit (NICU) are at risk for the development of hypertension and chronic kidney disease (CKD), and thus require blood pressure screening less than 3 years of age, per American Academy of Pediatrics (AAP) 2004 and 2017 guidelines. METHODS: We reviewed the practice patterns of a large pediatric health care system and assessed adherence to the AAP clinical practice guidelines on blood pressure measurements in children less than 3 years of age for hypertension and CKD with the following risk factors: prematurity, very low birthweight, and a neonatal intensive care setting encounter. This retrospective chart review included a total of 9965 patients with a median gestational age of 34 weeks. RESULTS: Overall, 38% of patients had at least one blood pressure measured less than 3 years of age. Primary care accounted for 41% of all outpatient encounters and 4% of all blood pressure measurements. Surgical specialties (i.e., ophthalmology, otolaryngology, and orthopedics) accounted for many non-primary care visits and were less likely than medical specialties (i.e., cardiology and nephrology) to obtain a blood pressure measurement (p < 0.0001). CONCLUSIONS: This study of a large healthcare system's practice revealed a lack of basic screening for hypertension in a population known to be at risk for hypertension and CKD.

Endotracheal intubation skills of pediatricians versus anesthetists in neonates and children.

This study compares the performance of pediatricians and anesthetists in neonatal and pediatric endotracheal intubations (ETI) during simulated settings. Participants completed a questionnaire and performed an ETI scenario on a neonatal and a child manikin. The procedures were recorded with head cameras and cameras attached to standard laryngoscope blades. The outcomes were successful intubation, time to successful intubation, number of attempts, complications, total performance score, end-assessment rating, and an assessment whether the participant was sufficiently able to perform an ETI. Fifty-two pediatricians and 52 anesthetists were included. For the neonatal ETI, the rate of successful intubation was in favor of anesthetists although not significant. Anesthetists performed significantly better in all other outcomes. Of the pediatricians, 65% was rated sufficiently adept to perform a neonatal ETI vs 100% of the anesthetists. Pediatricians (29%) overestimated while anesthetists (33%) underestimated their performance in neonatal ETI. For the pediatric ETI, all outcomes were significantly better for anesthetists. Only 15% of all pediatricians were considered sufficiently able to perform pediatric ETI vs 94% of the anesthetists.Conclusion: Anesthetists are far more adept in performing ETI in neonates and children compared with pediatricians in a simulated setting. Complications are expected to occur less frequently and less seriously when anesthetists perform ETI. What is Known: • Endotracheal intubation (ETI) performed by inexperienced care providers can lead to unsuccessful and/or prolonged intubation attempts. This can cause complications such as hypoxemia, trauma to the oropharynx and larynx, and prolonged interruption of resuscitation, which results in a high morbidity/mortality. • Fifty to 60 real-life ETI procedures are needed before ETI can be performed with a 90% success rate. Despite this, 18% of providers still require some assistance even after performing 80 intubations. Skill fade will occur if there is too little exposure. What is New: • This study shows that, on both neonatal and child manikins, anesthetists perform better in ETI compared with pediatricians. Besides this, complications are expected to occur less frequently and less seriously when anesthetists are performing the ETIs on neonates and children. • In those countries where there are no clear interprofessional agreements made in general hospitals on who will perform ETI on neonates and children in acute care settings, these agreements are urgently necessary.

Do Subspecialists Ask About and Refer Families with Psychosocial Concerns? A Comparison with General Pediatricians.

Objectives Calls for pediatricians to tend to children's psychosocial concerns have existed for decades because they are known to negatively impact child health. Children with chronic illnesses frequently have child- and family-level psychosocial concerns that complicate the care provided by their pediatric subspecialists. This study compares pediatricians who exclusively practice general pediatrics with subspecialists regarding their inquiring/screening and referring for psychosocial concerns. Physician and practice characteristics associated with these behaviors were examined. Methods We conducted a cross-sectional study using the 2013 American Academy of Pediatrics Periodic Survey of Fellows. Respondents included 304 pediatricians who exclusively practice general pediatrics and 147 subspecialists. The primary analysis compared the current practices of generalists vs. subspecialists with regard to inquiring/screening and referring children with 10 different psychosocial concerns. Covariates included socio-demographics, practice characteristics, and training experiences. Weighted univariate, bivariate and multivariable analyses were performed. Results Less than half of all pediatricians in the sample reported routinely inquiring/screening for most psychosocial concerns, and 2/3 of subspecialists failed to routinely inquire/screen for most of these conditions. Pediatricians who practice general pediatrics exclusively were more likely to inquire/screen (incident rate ratio (IRR) 1.41, p < .05) and refer (IRR 1.59, p < .001) for a greater number of psychosocial concerns than subspecialists, after adjusting for provider and practice characteristics. Having attended a child or adolescent mental health (MH) lecture/conference in the past 2 years was also related to inquiring/screening (IRR 1.24, p < .05). Conclusions Pediatricians infrequently inquire/screen and refer psychosocial concerns, with subspecialists addressing these concerns even less frequently.

Bereavement care in Japanese pediatrics: Pediatrician awareness in practice.

BACKGROUND: A child's death affects not only family members but also the health-care professionals involved in patient care. The education system for bereavement care in Japan, however, is not set up in a systematic way, and the care provided is based on the individual experience of the health-care professional. The aim of this study was to investigate pediatrician awareness of and actual circumstances involved in bereavement care in Japan. METHODS: A qualitative descriptive study was conducted at four facilities in Japan. Data collected using semi-structured interviews of 11 pediatricians were assessed using inductive qualitative analysis. RESULTS: Pediatrician recognition of the elements of bereavement care was categorized as follows: (i) developing relationships with families before a child's death is important in bereavement care; (ii) after the child dies, family involvement is left to the doctor's discretion; (iii) coping with a child's death myself through past experience is essential; (iv) doctors involved in a child's death also experience mental burden; and (v) a system for the family's bereavement care must be established. Two categories were established according to actual circumstances involved in bereavement care: (i) attention must be given to the emotions of the families who lost a child; and (ii) doctor involvement with bereaved families depends on doctor awareness and expertise. CONCLUSION: Japanese pediatricians provided bereavement care to families who lost their children in a non-systematic manner. This is necessitates improvement of the self-care of health-care professionals with regard to grief by improving bereavement care-related education. Additionally, health-care professionals must be trained, and a national-level provision system must be established to provide high-quality bereavement care to families who lose a child.

Physicians Knowledge and Practice of Safe Sleep Recommendations for Infants in South Dakota.

INTRODUCTION: Safe sleep recommendations for infants have been evolving over the past three decades. It has been shown that physicians' recommendations strongly influence parents' choice of infant sleep position. However, the proportion of physicians and/or nurses giving infant sleep advice to parents is reportedly low. METHODS: A survey was conducted in South Dakota to evaluate pediatricians' and family practitioners' knowledge of safe sleep recommendations for infants. Survey questions assessed their beliefs regarding risk factors for sudden infant death syndrome (SIDS) and their recommendations for safe sleep environments provided to parents/caregivers. RESULTS: Among the respondents, 98 percent felt that it is important to discuss SIDS with every parent and 80 percent of them indicated a need within their profession to have further information on the topic of SIDS. However, 31 percent of physicians with 16 years or more since training and 64.5 percent of those with less than 16 years since training did provide safe sleep advice to parents and caregivers. CONCLUSIONS: Despite the knowledge of SIDS risk factors, gaps were seen in dissemination of information regarding all risk factors to parents. While sleep position, postnatal exposures and breast feeding were more likely to be addressed, other elements of a safe sleep environment such as bedding surface, bed sharing, pacifier use and room ventilation were less likely to be covered. These findings indicate the need for improved health care provider education/communication in South Dakota.

Detection and management of Anaphylaxis in children. / Reconocimiento y manejo de la Anafilaxia en pediatría.

INTRODUCTION: Anaphylaxis is an emergency condition. According to the latest international guide lines, early recognition and treatment with intramuscular epinephrine are associated with increased survival. OBJECTIVE: To determine the level of knowledge of pediatricians in a tertiary Pediatric Hos pital about the diagnostic criteria and treatment of anaphylaxis. MATERIAL AND METHOD: A cross-sec tional descriptive study was conducted, designing, applying, and validating an anonymous survey to physicians with complete residency in pediatrics who are on call at a third level hospital. The statisti cal analysis was made using the SPSS v.21 software, presenting measures of central tendency (median, range, and frequency table) and Chi-square test for comparison. A value of p < 0.05 was considered significant. RESULTS: 71 physicians completed the survey with a median of three years after the end of residency.35% of them identified all clinical criteria, 99% (70) indicated epinephrine, 73% chose the intramuscular route, and 55% indicated the correct dose. Only 48% of responders chose the dose and administration route correctly. In general, 21% recognized anaphylaxis and used epinephrine correctly. Physicians with less than five years of experience performed better in the intramuscular administration of epinephrine (83% vs 52% p = 0.005) and in the detection of gastrointestinal symp toms (60% vs 35% p = 0.043). CONCLUSIONS: There are difficulties in the identification and proper management of anaphylaxis by pediatricians of a tertiary Pediatric Hospital in a theoretical clinical setting. Although most of pediatricians chose epinephrine as a first-line drug, half of them did not indicate it correctly, and only one-third recognized anaphylaxis in all scenarios.

Interprofessional Pulmocheck care pathway: An innovative approach to managing pediatric asthma care in the Netherlands.

OBJECTIVES: Under-diagnosis and suboptimal asthma control in children persists. An innovative care pathway was developed by a hospital department of pediatrics with the aim to detect pulmonary problems in children and provide appropriate treatment possibilities through systematic feedback towards the referring primary care physician. Primary care physicians can use this pathway to refer children with asthma-like symptoms for a one-day assessment. Goals are to measure the usage of the pathway by primary care general practitioners (GPs), the outcomes in terms of new diagnoses of asthma, the reduction in regular referrals, generated recommendations/therapy and the adequacy of asthma follow-up. METHODS: We collected all feedback letters sent to the GP concerning children who underwent the Pulmocheck in 2010, 2011 and 2012. Furthermore, all GPs, who had referred a child to the Pulmocheck in this period and that subsequently was diagnosed with asthma and was further managed in primary care, were sent a follow-up questionnaire in 2014. RESULTS: There were 121 referrals from 51 GPs in 3 years to this pathway. In 59.5% of these referrals a new diagnosis of asthma was established. In 90.9% one or more changes in clinical management were advised. The response rate to the follow-up questionnaires was 65.7% of which 4.8% of the children with new established asthma were reviewed four times or more in the follow-up period, 17.4% two times, 65.2% once, and in 8.7% were not followed. CONCLUSIONS: The specialty pediatric asthma care pathway revealed a high number of children with newly diagnosed asthma, but was also helpful to exclude this diagnosis. However, the referral rate of GPs to this pathway was low, but in the children, that were referred several changes in the clinical management were advised and the frequency of monitoring of the children with diagnosed asthma was not in accordance with the asthma guidelines.

Newborn Resuscitation Skills in Health Care Providers at a Zambian Tertiary Center, and Comparison to World Health Organization Standards.

BACKGROUND: Birth asphyxia is a leading cause of early neonatal death. In 2013, 32% of neonatal deaths in Zambia were attributable to birth asphyxia and trauma. Basic, timely interventions are key to improving outcomes. However, data from the World Health Organization suggest that resuscitation is often not initiated, or is conducted suboptimally. Currently, there are little data on the quality of newborn resuscitation in the context of a tertiary center in a lower-middle income country. We aimed to measure the competencies of clinical practitioners responsible for newborn resuscitation. METHODS: This observational study was conducted over 5 months in Zambia. Health care professionals were recruited from anesthesia, pediatrics, and midwifery. Newborn skills and knowledge were examined using the following: (1) multiple-choice questions; (2) a ventilation skills test; and (3) 2 low-medium fidelity simulation scenarios. Participant demographics including previous resuscitation training and a self-efficacy rating score were noted. The primary outcome examined performance scores in a simulated scenario, which assessed the care of a newborn that failed to respond to basic interventions. Secondary outcome measures included apnea times after delivery and performance in the other assessments. RESULTS: Seventy-eight participants were enrolled into the study (13 physician anesthesiology residents, 13 pediatric residents, and 52 midwives). A significant difference in interprofessional performance was observed when examining checklist scores for the unresponsive newborn simulated scenario (P = .006). The median (quartiles) checklist score (out of 18) was 14.0 (13.0-14.75) for the anesthesiologists, 11.0 (8.5-12.3) for the pediatricians, and 10.8 (8.3-13.9) for the midwives. A score of 14 or more was required to pass the scenario. There was no significant difference in performance between participants with and without previous newborn resuscitation training (P = .246). The median (quartiles) apnea time after delivery was significantly different between all groups (P = .01) with anesthetic and pediatric residents performing similarly, 61 (37-97) and 63 (42.5-97.5) seconds, respectively. The midwifery participants displayed a significantly longer apnea time, 93.5 (66.3-129) seconds. Self-efficacy rating scores displayed no correlation between confidence level and the primary outcome, Spearman coefficient 0.06 (P = .55). CONCLUSIONS: Newborn resuscitation skills among health care professionals are varied. Midwives lead the majority of deliveries with anesthesiologists and pediatricians only being present at operative or high-risk births. It is therefore common that midwifery practitioners will initiate resuscitation. Despite this, midwives perform poorly when compared to anesthesia and pediatric residents. To address this discrepancy, a multidisciplinary, simulation-based newborn resuscitation program should be considered with continual clinical reenforcement of best practice.

Awareness of retinopathy of prematurity among pediatricians in West Bank, Palestine: a descriptive study.

BACKGROUND: Retinopathy of prematurity (ROP) is a disorder of the developing retina of preterm infants due to defective vasculogenesis. The aim of the study was to analyze the level of awareness, knowledge, attitude and practice of pediatricians about ROP in the West Bank, Palestine. METHODS: A questionnaire was designed on the knowledge, attitude, and practice (KAP) pattern. The questionnaire included questions about pediatrician's educational and practicing profile, knowledge of screening guidelines, risk factors for ROP, referral facilities and barriers for referral. The questionnaire was given to70 practicing specialists and residents in hospitals having neonatal intensive care units in the West Bank, Palestine. It was a self-administered questionnaire, collected between November 2016 and February 2017. RESULTS: A total of 70 pediatricians from 11 different hospitals without ROP screening service participated in the study. The mean age of the participants was 33.04 ± 7.74. Of which, 62.9% were males and 37.1% were females. Fifty-nine (84.3%) answered that ROP is preventable, while 11 (15.7%) responded that ROP is not preventable. Nine (12.9%) pediatricians had no idea as to which part of the eye is affected in ROP. Among the participants, 29 (41.4%) did not know when ROP screening should be started. Sixty-three (90%) pediatricians were sure that ROP is treatable. Regarding barriers for ROP screening, 'ophthalmologist not available' reason was expressed by 37.1% (26/70), 'discharge person not writing' by 20% (14/70) and 'parents not agreeing' by 18.6% (13/70) of the participants. Knowledge on the use of laser as a treatment modality of ROP was shown by 39 (55.7%) participants, and the use of anti-VEGF was shown by 6 (8.6%) participants, whereas 25 (35.7%) of the participants didn't know about the treatment modalities. CONCLUSION: The study findings suggest that a large majority of pediatricians were aware of ROP as a preventable disease, but had less information about ROP screening guidelines and service delivery. The study suggests the need to increase the awareness of pediatricians by dissemination of information about ROP and creating a close coordination between them and ophthalmologists to address barriers for service delivery in Palestine.

Thrown into the world of independent practice: from unexpected uncertainty to new identities.

One of the most exciting yet stressful times in a physician's life is transitioning from supervised training into independent practice. The majority of literature devoted to this topic has focused upon a perceived gap between clinical and non-clinical skills and interventions taken to address it. Building upon recent streams of scholarship in identity formation and adaptation to new contexts, this work uses a Heideggerian perspective to frame an autoethnographical exploration of the author's transition into independent paediatric practice. An archive of reflective journal entries and personal communications was assembled from the author's first 3 years of practice in four different contexts and analyzed using Heidegger's linked existentials of understanding, attunement and discourse. Insights from his journey suggest this period is a time of anxiety and vulnerability when one questions one's competence and very identity as a medical professional. At the same time, it illustrates the inseparable link between practitioners and the network of relationships in which they are bound, how these relationships contextually vary and how recognizing and tuning to these differences may allow for a more seamless transition. While this work is the experience of one person, its insights support the ideas that change is a constant in professional practice and competence is contextual. As a result, developing educational content that inculcates contextual flexibility and an increased comfort level with uncertainty may prepare our trainees not just to navigate the unavoidable novelty of transition, but lay the groundwork for professional identities attuned to engage more broadly with change itself.

Measuring empathy in pediatrics: validation of the Visual CARE measure.

BACKGROUND: Empathy is a key element of "Patient and Family Centered Care", a clinical approach recommended by the American Academy of Pediatrics. However, there is a lack of validated tools to evaluate paediatrician empathy. This study aimed to validate the Visual CARE Measure, a patient rated questionnaire measuring physician empathy, in the setting of a Pediatric Emergency Department (ED). METHODS: The empathy of physicians working in the Pediatric ED of the University Hospital of Udine, Italy, was assessed using an Italian translation of the Visual Care Measure. This test has three versions suited to different age groups: the 5Q questionnaire was administered to children aged 7-11, the 10Q version to those older than 11, and the 10Q-Parent questionnaire to parents of children younger than 7. The internal reliability, homogeneity and construct validity of the 5Q and 10Q/10Q-Parent versions of the Visual Care Measure, were separately assessed. The influence of family background on the rating of physician empathy and satisfaction with the clinical encounter was also evaluated. RESULTS: Seven physicians and 416 children and their parents were included in the study. Internal consistency measured by Cronbach's alpha was 0.95 for the 10Q/10Q-Parent versions and 0.88 for the 5Q version. The item-total correlation was > 0.75 for each item. An exploratory factor analysis showed that all the items load onto the first factor. Physicians' empathy scores correlated with patients' satisfaction for both the 10Q and 10Q-Parent questionnaires (Spearman's rho = 0.7189; p < 0.001) and for the 5Q questionnaire (Spearman's rho = 0.5968; p < 0,001). Trust in the consulting physician was lower among immigrant parents (OR 0.43. 95% CI 0.20-0.93). CONCLUSIONS: The Visual Care Measure is a reliable second-person test of physician empathy in the setting of a Pediatric Emergency Room. More studies are needed to evaluate the reliability of this instrument in other pediatric settings distinct from the Emergency Room and to further evaluate its utility in measuring the impact of communication and empathy training programmes for healthcare professionals working in pediatrics.

Patient perspectives on how physicians communicate diagnostic uncertainty: An experimental vignette study.

OBJECTIVE: We evaluated the effects of three different strategies for communicating diagnostic uncertainty on patient perceptions of physician competence and visit satisfaction. DESIGN/SETTING: Experimental vignette-based study design involving pediatric cases presented to a convenience sample of parents living in a large US city. PARTICIPANTS/INTERVENTION(S): Three vignettes were developed, each describing one of three different ways physicians communicated diagnostic uncertainty to parents-(i) explicit expression of uncertainty ('not sure' about diagnosis), (ii) implicit expression of uncertainty using broad differential diagnoses and (iii) implicit expression of uncertainty using 'most likely' diagnoses. Participants were randomly assigned to one of the three vignettes and then answered a 37-item web-based questionnaire. MAIN OUTCOME MEASURE(S): Outcome variables included parent-perceived technical competence of physician, trust and confidence, visit satisfaction and adherence to physician instructions. Differences between the three groups were compared using analysis of variance, followed by individual post hoc analyses with Bonferroni correction. RESULTS: Seventy-one participants completed the vignette questions. Demographic characteristics and scores on activation (parent activation measure [PAM]) and intolerance to uncertainty were similar across the three groups. Explicit expression of uncertainty was associated with lower perceived technical competence, less trust and confidence, and lower patient adherence as compared to the two groups with implicit communication. These latter two groups had comparable outcomes. CONCLUSION: Parents may react less negatively in terms of perceived competence, physician confidence and trust, and intention to adhere when diagnostic uncertainty is communicated using implicit strategies, such as using broad differential diagnoses or most likely diagnoses. Evidence-based strategies to communicate diagnostic uncertainty to patients need further development.

Assessments of neurocognitive and behavioral function in the mucopolysaccharidoses.

The mucopolysaccharidoses (MPS) are a group of rare, inherited lysosomal storage disorders in which accumulation of glycosaminoglycans (GAGs) leads to progressive tissue and organ dysfunction. In addition to a variety of somatic signs and symptoms, patients with rapidly progressing MPS I (Hurler), II, III, and VII can present with significant neurological manifestations, including impaired cognitive abilities, difficulties in language and speech, behavioral abnormalities, sleep problems, and/or seizures. Neurological symptoms have a substantial impact on the quality of life of MPS patients and their families. Due to the progressive nature of cognitive impairment in these MPS patients, neurocognitive function is a sensitive indicator of disease progression, and a relevant outcome when testing efficacy of therapies for these disorders. In order to effectively manage and develop therapies that address neurological manifestations of MPS, it is important to use appropriate neurocognitive assessment tools that are sensitive to changes in neurocognitive function in MPS patients. This review discusses expert opinions on key issues and considerations for effective neurocognitive testing in MPS patients. In addition, it describes the neurocognitive assessment tools that have been used in clinical practice for these patients. The content of this review is based on existing literature and information from a meeting of international experts with extensive experience in managing and treating MPS disorders.

The use of multi-criteria decision making models in evaluating anesthesia method options in circumcision surgery.

BACKGROUND: Determining the most suitable anesthesia method for circumcision surgery plays a fundamental role in pediatric surgery. This study is aimed to present pediatric surgeons' perspective on the relative importance of the criteria for selecting anesthesia method for circumcision surgery by utilizing the multi-criteria decision making methods. METHODS: Fuzzy set theory offers a useful tool for transforming linguistic terms into numerical assessments. Since the evaluation of anesthesia methods requires linguistic terms, we utilize the fuzzy Analytic Hierarchy Process (AHP) and fuzzy Technique for Order Preference by Similarity to Ideal Solution (TOPSIS). Both mathematical decision-making methods are originated from individual judgements for qualitative factors utilizing the pair-wise comparison matrix. Our model uses four main criteria, eight sub-criteria as well as three alternatives. To assess the relative priorities, an online questionnaire was completed by three experts, pediatric surgeons, who had experience with circumcision surgery. RESULTS: Discussion of the results with the experts indicates that time-related factors are the most important criteria, followed by psychology, convenience and duration. Moreover, general anesthesia with penile block for circumcision surgery is the preferred choice of anesthesia compared to general anesthesia without penile block, which has a greater priority compared to local anesthesia under the discussed main-criteria and sub-criteria. CONCLUSIONS: The results presented in this study highlight the need to integrate surgeons' criteria into the decision making process for selecting anesthesia methods. This is the first study in which multi-criteria decision making tools, specifically fuzzy AHP and fuzzy TOPSIS, are used to evaluate anesthesia methods for a pediatric surgical procedure.