Multistakeholder Perspectives on Interventions to Support Youth During Mental Health Boarding.

OBJECTIVE: To identify and prioritize opportunities to improve the psychiatric boarding experience for youth awaiting admission or transfer to inpatient psychiatric care. STUDY DESIGN: This study utilized an exploratory mixed methods design. The study team convened multidisciplinary stakeholder focus groups to discuss proposed hospital-based solutions to mental health boarding, potential psychosocial interventions deliverable during boarding, and outcomes measurement. Focus group responses were transcribed and analyzed to extract themes pertaining to these improvement opportunities. These results informed a follow-up survey which was then sent to the stakeholders to rate the feasibility and importance of modifications using a modified RAND-UCLA Appropriateness Method. RESULTS: Qualitative analyses revealed 9 themes across 2 domains related to psychiatric boarding care: in-hospital improvements and transitions of care. The follow-up survey identified 6 improvement opportunities rated as both feasible and important. Additionally, 6 psychosocial interventions, 2 delivery modalities, and 5 outcomes were rated as both feasible and important. CONCLUSIONS: Stakeholders concerned with the psychiatric boarding of youth identified numerous opportunities for improving the boarding process within 2 domains of in-hospital improvements and transitions of care. Most of the improvements were considered feasible and important with several serving as particularly viable strategies. These have the potential for implementation to improve the care of this vulnerable population and inform local and national quality improvement efforts.

Differences in Postmortem Investigation following Perinatal Death.

OBJECTIVE: The study aimed to describe the postmortem investigation patterns for perinatal deaths and compare the degree of investigation between stillbirths and early neonatal deaths. STUDY DESIGN: We conducted a single-center retrospective review of all perinatal deaths from 2011 to 2017. Perinatal death was defined as intrauterine fetal death at ≥20 weeks' gestation, plus neonatal deaths within the first 7 days of life. Rates of postmortem investigation were compared. RESULTS: There were 97 perinatal deaths, with 54 stillbirths (56%) and 43 neonatal deaths (44%). Stillbirths were significantly more likely to receive autopsy (p = 0.013) and postmortem genetic testing (p = 0.0004) when compared with neonatal deaths. Maternal testing was also more likely in stillbirths than neonatal deaths. A total of 32 deaths (33%) had no postmortem evaluation beyond placental pathology. CONCLUSION: Investigation following perinatal death is more likely in stillbirths than neonatal deaths. Methods to improve postmortem investigation following perinatal death are needed, particularly for neonatal deaths. KEY POINTS: · Investigation into perinatal death is recommended.. · Rates of investigation remain low.. · Neonatal deaths with less investigation than stillbirths..

Correlation of tumor microenvironment from biopsy and resection specimens in untreated colorectal cancer patients: a surprising lack of agreement.

BACKGROUND: Colorectal cancer (CRC) tumor microenvironment (TME) characteristics, such as tumor infiltrating lymphocyte (TIL) densities and PD-L1 status, are predictive of recurrence, disease-free survival, and overall survival. In many malignancies, TME characteristics are also predictive of response to immunotherapy. As window of opportunity studies using neoadjuvant immunotherapy become more common and treatment guidelines incorporate TME features, accurate assessment of the pre-treatment TME using the biopsy specimen is critical. However, no study has thoroughly evaluated the correlation between the TMEs of the biopsy and resection specimens. METHODS: We conducted a retrospective analysis of patients with stage I-III CRC with matched biopsy and resection specimens. CD3+, CD4+, CD8+, and FoxP3+ lymphocyte populations at the center of tumor (CT) and invasive margin (IM) and tumor PD-L1 status in the biopsy and resection specimens were evaluated. TIL populations were compared using Mann-Whitney U tests or Student's t tests and correlated using Pearson r. RESULTS: CD3+ and CD4+ densities were significantly higher in the CT of the biopsy relative to the resection specimen Comparing biopsy and resection specimens, no TIL population at either the CT or IM had a correlation coefficient > 0.5. Determining PD-L1 status based on biopsy tissue resulted in a sensitivity of 37.1%, specificity of 81.4%, and accuracy of 61.5%. CONCLUSIONS: These findings demonstrate significant discordance between the TME of the biopsy and resection specimens. Caution should be used when basing treatment decisions on pre-treatment endoscopic biopsy findings and when interpreting changes in the TME between pre-treatment biopsy and resection specimens after neoadjuvant therapy.

Decidual Granulomata of Unclear Significance.

Granulomatous inflammation is a histologic finding with a relatively wide variety of causes. In general, considerations include infectious etiologies, autoimmune conditions, or foreign body reactions. Granulomatous inflammation is uncommonly seen in the placenta. We present a unique case of a young woman with preterm labor and rupture of membranes whose placenta demonstrated perivascular decidual granulomata in the membranes and the basal plate.

Effect of intravenous fluid warming on core body temperature during elective orthopedic procedures.

The effects of intravenous (IV) fluid warming on core body temperature in a group of dogs undergoing an elective orthopedic procedure was studied. An IV fluid warmer was used alone or in conjunction with forced warmed air to determine the individual or additive effects of IV fluid warming. These effects were compared to those in dogs with no heat support or those with only forced warmed air in a randomized prospective study design. The conclusion was that IV fluid warming had no effect on the maintenance or preservation of core body temperature in this population of dogs, and that, as previous reports have shown, forced warmed air decreased the rate of heat loss during anesthetic procedures. One possible explanation for the lack of benefit is the location of the fluid warmer in relation to the patient. To our knowledge, this is the first study to examine the effects of IV fluid warming on core body temperature in dogs undergoing an elective orthopedic procedure.

Effet du réchauffement du liquide intraveineux sur la température corporelle centrale durant des procédures orthopédiques électives. Les effets du réchauffement du liquide intraveineux (IV) sur la température corporelle centrale dans un groupe de chiens soumis à une procédure orthopédique élective fut étudiée. Un réchaud à fluide IV était utilisé seul ou conjointement avec de l'air chaud forcé afin de déterminer les effets individuels ou additifs du réchauffement du liquide IV. Ces effets furent comparés à ceux de chiens sans support de chaleur ou ceux avec uniquement de l'air chaud forcé dans une étude prospective randomisée. La conclusion était à l'effet que le réchauffement du liquide IV n'avait aucun effet sur le maintien ou la préservation de la température corporelle centrale dans cette population de chiens, et que, tel que démontré par des études antérieures, de l'air chaud forcé diminuait le taux de perte de chaleur durant les procédures anesthésiques. Une explication possible pour l'absence de bénéfice serait la localisation du chauffe liquide relativement au patient. À notre connaissance, ceci constitue la première étude à examiner les effets du réchauffement du liquide IV sur la température corporelle centrale chez des chiens soumis à une procédure orthopédique élective.(Traduit par Dr Serge Messier).

Effects of Left Versus Right Dorsolateral Prefrontal Cortex Repetitive Transcranial Magnetic Stimulation on Affective Flexibility in Healthy Women: A Pilot Study.

OBJECTIVE: To determine the antidepressant mechanism of action for repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex (DLPFC) in healthy women. Our primary hypothesis was that a single session of left DLPFC rTMS, compared with a session of right DLPFC rTMS, would result in better (reduced) negative nonaffective switch costs in healthy women. BACKGROUND: The antidepressant mechanism of action for rTMS is not clear. It is possible that rTMS to the DLPFC improves emotion regulation, which could be a part of its antidepressant mechanism. METHODS: Twenty-five healthy women were randomized to receive left high-frequency (HF) rTMS versus right HF rTMS in one session and then contralateral stimulation during a second session. Emotion regulation was assessed via switch costs for reappraisal of negatively valenced information on an affective flexibility task. RESULTS: For negative nonaffective switch costs, the interaction effect in the two-way ANOVA was not significant (F1,19=3.053, P=0.097). Given that left HF rTMS is the approved treatment for depression, post hoc t tests were completed with particular interest in the left-side findings. These tests confirmed that negative nonaffective switch costs significantly improved immediately after left rTMS (t1,19=2.664, P=0.015) but not right rTMS. CONCLUSIONS: These findings suggest that left DLPFC HF rTMS may lead to antidepressant effects by improving the regulation of emotion.

Patient costs and outcomes before and after the institution of a pre-eclampsia quality improvement initiative in a southwestern tertiary facility.

The study objective was to evaluate the effect of the California Maternal Quality Care Collaborative (CMQCC) initiative, as implemented in a southwestern U.S. tertiary hospital, on associated patient costs and outcomes. Using a quasi-experimental study design, we collected existing data (cost and patient outcomes) comparing two six-month period at the baseline and one-year follow-up. Following descriptive statistics, Chi-square tests and t-tests were used to compare categorical and continuous variables, respectively. One hundred and eighty-nine women met the inclusion criteria for the study (93 and 96 women in the baseline and follow-up period, respectively). There was no significant difference in maternal health outcomes between both periods. However, there was a significant difference for newborns with almost 90% (95%CI = 0.06-0.92; p = .027) reduction in stillbirths in the follow-up period. There was also a significant reduction in the days between discharge and follow-up appointments (p < .01). Importantly, the initiative bears no additional financial burden on patients, as hospitalisation cost was unchanged. Impact statement What is already known on this subject? In 2013, the California Maternal Quality Care Collaborative (CMQCC) set up a task force to develop guidelines for managing patients with preeclampsia based on global best practices. A previous study showed that despite system-level implementation challenges, the initiative led to significant increase in blood pressure treatments within one-hour and reduced severe maternal morbidity. What do the results of this study add? This study follows patients from admission, beyond the one-hour post-treatment and into the post-partum phase, to understand if outcomes of the initiative extend beyond the admission. While the study findings do not show any statistically significant difference in readmission before and after the initiative, nor any marked difference in maternal outcomes, it shows a significant difference in the prevalence of stillbirths at no additional cost to the patient. What are the implications of these findings for clinical practice and/or further research? Based on these findings, there is a case for scaling-up the initiative as in addition to its evidenced improvements in maternal outcomes; it is effective in improving newborn health outcomes at no additional cost. Further research, using larger sample size and exploring different care levels would be useful to verify these findings.

Cervical Cancer Screening Beliefs and Prevalence of LSIL/HSIL Among a University-Based Population in Cameroon.

OBJECTIVE: The aim of the study was to determine beliefs and utilization of cervical cancer screening and prevalence of low-grade squamous intraepithelial lesion/high-grade squamous intraepithelial lesion among a university-based population in the Southwest region of Cameroon. MATERIALS AND METHODS: A public-private partnership was established between the University of Arizona, University of Buea, and the Cameroon Baptist Convention Health Services. A single-day screening clinic using visual inspection with acetic acid and Lugol's iodine solution (VILI) was provided at the University of Buea. Screening results were documented as negative, low-grade, high-grade, or suspicious for cancer. Thermocoagulation and loop electrosurgical excisional procedure was available for low- and high-grade lesions, respectively. A survey was conducted before screening and factors associated with screening practices were evaluated. RESULTS: Of 120 clinic participants, 107 (89.2%) believed that treatment of precancerous lesions helped prevent cervical cancer, but most (67.5%) had never been screened. Eighty women (66.7%) were aware of the human papillomavirus (HPV) vaccine, and only 2 had received vaccination. Among 115 patients screened, the prevalence of abnormal screening was 6.09%. Low-grade lesions were treated with thermocoagulation and high-grade lesions were treated with loop electrosurgical excisional procedure. CONCLUSIONS: Despite knowledge of cervical cancer screening benefits, the majority had not been screened or vaccinated. This study suggests a desire for additional screening services in this population and validates the utility of public-private partnerships in low-income regions.

Mature Cystic Teratoma: AIRP Best Cases in Radiologic-Pathologic Correlation.

Editor's Note.-RadioGraphics continues to publish radiologic-pathologic case material selected from the American Institute for Radiologic Pathology (AIRP) "best case" presentations. The AIRP conducts a 4-week Radiologic Pathology Correlation Course, which is offered five times per year. On the penultimate day of the course, the best case presentation is held at the American Film Institute Silver Theater and Cultural Center in Silver Spring, Md. The AIRP faculty identifies the best cases, from each organ system, brought by the resident attendees. One or more of the best cases from each of the five courses are then solicited for publication in RadioGraphics. These cases emphasize the importance of radiologic-pathologic correlation in the imaging evaluation and diagnosis of diseases encountered at the institute and its predecessor, the Armed Forces Institute of Pathology (AFIP).

Mechanically stimulated bone cells secrete paracrine factors that regulate osteoprogenitor recruitment, proliferation, and differentiation.

Bone formation requires the recruitment, proliferation and osteogenic differentiation of mesenchymal progenitors. A potent stimulus driving this process is mechanical loading, yet the signalling mechanisms underpinning this are incompletely understood. The objective of this study was to investigate the role of the mechanically-stimulated osteocyte and osteoblast secretome in coordinating progenitor contributions to bone formation. Initially osteocytes (MLO-Y4) and osteoblasts (MC3T3) were mechanically stimulated for 24 hrs and secreted factors within the conditioned media were collected and used to evaluate mesenchymal stem cell (MSC) and osteoblast recruitment, proliferation and osteogenesis. Paracrine factors secreted by mechanically stimulated osteocytes significantly enhanced MSC migration, proliferation and osteogenesis and furthermore significantly increased osteoblast migration and proliferation when compared to factors secreted by statically cultured osteocytes. Secondly, paracrine factors secreted by mechanically stimulated osteoblasts significantly enhanced MSC migration but surprisingly, in contrast to the osteocyte secretome, inhibited MSC proliferation when compared to factors secreted by statically cultured osteoblasts. A similar trend was observed in osteoblasts. This study provides new information on mechanically driven signalling mechanisms in bone and highlights a contrasting secretome between cells at different stages in the bone lineage, furthering our understanding of loading-induced bone formation and indirect biophysical regulation of osteoprogenitors.

Effect of Symptom Over-Reporting on Heart Rate Variability in Veterans With Posttraumatic Stress Disorder.

Physiological assessment of posttraumatic stress disorder (PTSD) presents an additional avenue for evaluating the severity of PTSD symptoms. We investigated whether the presence of a high number of uncommon symptoms attenuated the relation between self-reported PTSD symptoms and heart rate variability (HRV). Participants were 115 veterans from Operation Iraqi Freedom and Operation Enduring Freedom with or without PTSD. Symptom over-report was assessed using the Miller Forensic Assessment of Symptoms Test (M-FAST). Participants completed the Clinician-Administered PTSD Scale and M-FAST and underwent physiological assessment to determine HRV. These data were then entered into a hierarchical linear regression equation to test the moderating effect of over-reporting on the relation between PTSD symptom severity and HRV. The result of this analysis failed to demonstrate a significant moderating effect of over-reporting on the PTSD and HRV relation. HRV was a significant predictor of PTSD symptom severity, and this relation did not differ across levels of over-reporting. These findings did not support the hypothesis that over-reporting would attenuate the relation between PTSD and HRV. Clinical and research implications and directions for future investigation are discussed.

Oral fluorescein angiography in the diagnosis of paediatric optic nerve abnormalities.

OBJECTIVE: FFA is a well-established investigation for the diagnosis of optic nerve abnormalities, requiring an intravenous cannula and extended imaging acquisition time. Cannulation can present a challenge in paediatric patients and whilst oral FFA has been used for decades, it has been limited by imaging technology and unconfirmed image acquisition timings. For years, we have used a modern ultra-widefield retinal camera, and established imaging time-points to demonstrate dynamic optic nerve head changes upon ingestion of fluorescein and collected a database of oFFA images for various presentations. METHODS: Using an established protocol, optic nerve colour images were obtained, followed by oral administration of fluorescein dye. The optic nerves are then imaged at established intervals. An interpretation of oFFA tutorial was delivered to consultant ophthalmologists and trainees. Subsequently, these groups were assessed using a series of fifteen cases with the sensitivity and specificity of the test determined. RESULTS: Our study presents a series of images and descriptions for common optic nerve abnormalities in paediatric populations. In the interpretation part of the study, overall sensitivity of 76.8% in the consultant group vs 63.3% in the combined consultant + trainees and specificity of 87.5% vs 68.4% in the combined group. CONCLUSIONS: This is the first study that describes characteristic features of several common, and serious, optic nerve abnormalities specifically for oFFA interpretation in a paediatric population. It also highlights the rapid accumulation of oFFA interpretation skills in non-specialist consultant and trainee ophthalmologists such as to obtain a high diagnostic accuracy with high sensitivity and specificity.

The Impact of Adjustment on Workplace Attitudes and Behaviors Among Health Care Workers During the COVID-19 Pandemic.

OBJECTIVE: We examined the impact of health care workers' (HCWs) adjustment to the COVID-19 pandemic on their work-related attitudes and behaviors. METHODS: HCWs ( n = 1468) participated in an observational longitudinal study in which they completed surveys of anxiety and occupational health between 2020 and 2021. RESULTS: Most HCWs reported anxiety that was consistently below the diagnostic threshold (68%) or fell below the threshold within a year (16%). Others reported consistently high (14%) or increasing (2%) anxiety, especially women, younger HCWs, those with a weakened immune system, and allied health professionals. Consistently high or increasing anxiety was associated with poorer job satisfaction, work engagement, perceived supervisor support, burnout, and turnover intentions. CONCLUSIONS: Resources to support HCWs may be focused on those who report consistently high or increasing anxiety to minimize the effects of crises and disasters on the workforce.

Challenging Interactions Between Patients With Severe Health Anxiety and the Healthcare System: A Qualitative Investigation.

OBJECTIVE: Patients with severe health anxiety have complex interpersonal relationships with medical providers and others in their social context, often resulting in conflictual interactions with providers and perception of poor medical care. An adequate understanding of the causes and consequences of these interactions is lacking, particularly 1 informed by the experience of the patient. This study used qualitative methods to explore the development and maintenance of health anxiety from the perspective of patients with lived experience of coping with health anxiety and their interactions with the healthcare system. METHOD: We conducted qualitative interviews with 11 primary care patients purposely sampled to describe their experience living with health anxiety, provider interactions, and social and family interactions surrounding health and health anxiety. We extracted themes related to living with health anxiety and interactions with providers and other significant relationships. RESULTS: Thematic content analysis revealed 5 themes including 3 causal themes, 1 response theme, and 1 theme reflecting factors that mitigate health anxiety. Causal themes included subthemes reflecting predisposing factors of the self, key stimulus events from patient learning history, and maladaptive social interaction factors. The response theme was comprised of 2 subthemes: logical conclusions and health anxiety symptoms. The mitigating factors theme included subthemes of a trusting care relationship and recognition of disconfirming evidence. CONCLUSION: The themes and constituent subthemes identified in this study largely map onto cognitive-behavioral theory of health anxiety, demonstrating alignment between patient experience and theory. The resulting model also identifies potential points of intervention in the developmental and maintenance process. We provide recommendations to maximize those points of intervention.

Understanding Medication Nonadherence in Crohn's Disease Patients: A Qualitative Evaluation.

BACKGROUND: Immune-modifying medications are widely available and recognized as valuable by most gastroenterologists. However, approximately 40% of patients with Crohn's disease (CD) do not comply with regimens using these medications, resulting in complications, hospitalization, and surgeries. We sought to identify factors that motivate adherence or nonadherence with medication recommendations for CD. METHODS: We conducted qualitative interviews with patients living with CD who were identified as adherent or nonadherent to immune-modifying medication recommendations by their treating gastroenterologist. Semistructured interview guides were developed based on an established framework for understanding health behaviors. We conducted content analysis of the resulting qualitative data using an inductive-deductive approach to identify emergent themes that influence medication decision-making. RESULTS: Twenty-five patients with CD completed interviews for this study. Interviews were independently coded and analyzed for thematic content. Two broad domains emerged comprising (1) themes reflected in the Theoretical Domains Framework and (2) novel themes specific to medication decision-making in CD. Adherent patients conveyed a sense of trust in science and healthcare provider expertise, while nonadherent patients were more likely to express beliefs in their ability to self-manage CD, concern about risks associated with medication, and a general ambivalence to treatment. CONCLUSIONS: There are clear cognitive, behavioral, and relational factors that guide patients' medication-related decision-making. Several of the factors share features of other behavioral change and decision-making processes, while others are specific to the experience of patients with CD. A fuller understanding of these factors is essential to developing effective behavioral interventions to improve adherence to evidence-based treatment recommendations.

This study identified the determinants of medication adherence in a sample of patients receiving treatment for Crohn's disease. A total of 13 determinants across 2 domains were identified as contributing to patient decisions regarding the use of immune-modifying medications.

I-CARE: Feasibility, Acceptability, and Appropriateness of a Digital Health Intervention for Youth Experiencing Mental Health Boarding.

PURPOSE: Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE. METHODS: A mixed-methods approach was used to evaluate I-CARE, offered to youth 12-17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically. RESULTS: Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5-12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents' prior knowledge of psychosocial skills and clinicians' competing demands were reported barriers. DISCUSSION: I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization.

Virilization by an Ovarian Tumor: Presentation Is Not Always Acute.

Androgen-producing steroid cell ovarian tumors are rare, comprising less than 1% of ovarian neoplasms, and can present with infertility and rapid virilization. Here we discuss the case of a 28-year-old woman who presented with an unusually insidious 2-year history of infertility, hirsutism, and clitoromegaly who was found to have an elevated serum testosterone and a left ovarian mass. She underwent oophorectomy and pathology revealed a steroid cell tumor, not otherwise specified (NOS), with no malignant features. Following surgery, the patient's hyperandrogenic symptoms resolved with normalization of testosterone within 6 months, and she was able to conceive spontaneously. In reproductive-aged women with progressive hyperandrogenic symptoms, androgen-producing tumors, including those of ovarian origin, should be suspected. Thorough investigation, including plasma hormone levels and tumor histology, can lead to accurate diagnosis and management. Treatment should be guided by histology and surgical staging, with consideration for future fertility desires. Women who have not completed childbearing can undergo unilateral oophorectomy or tumor resection for benign tumors, with close monitoring of sex hormone levels postoperatively.

The Impact of the Extracellular Matrix Environment on Sost Expression by the MLO-Y4 Osteocyte Cell Line.

Bone is a dynamic organ that can adapt its structure to meet the demands of its biochemical and biophysical environment. Osteocytes form a sensory network throughout the tissue and orchestrate tissue adaptation via the release of soluble factors such as a sclerostin. Osteocyte physiology has traditionally been challenging to investigate due to the uniquely mineralized extracellular matrix (ECM) of bone leading to the development of osteocyte cell lines. Importantly, the most widely researched and utilized osteocyte cell line: the MLO-Y4, is limited by its inability to express sclerostin (Sost gene) in typical in-vitro culture. We theorised that culture in an environment closer to the in vivo osteocyte environment could impact on Sost expression. Therefore, this study investigated the role of composition and dimensionality in directing Sost expression in MLO-Y4 cells using collagen-based ECM analogues. A significant outcome of this study is that MLO-Y4 cells, when cultured on a hydroxyapatite (HA)-containing two-dimensional (2D) film analogue, expressed Sost. Moreover, three-dimensional (3D) culture within HA-containing collagen scaffolds significantly enhanced Sost expression, demonstrating the impact of ECM composition and dimensionality on MLO-Y4 behaviour. Importantly, in this bone mimetic ECM environment, Sost expression was found to be comparable to physiological levels. Lastly, MLO-Y4 cells cultured in these novel conditions responded accordingly to fluid flow stimulation with a decrease in expression. This study therefore presents a novel culture system for the MLO-Y4 osteocyte cell line, ensuring the expression of an important osteocyte specific gene, Sost, overcoming a major limitation of this model.

Healthcare quality during pediatric mental health boarding: A qualitative analysis.

BACKGROUND: Following initial evaluation and management, youth requiring inpatient psychiatric care often experience boarding, defined as being held in the emergency department or another location while awaiting inpatient care. Although mental health boarding is common, little research has examined the quality of healthcare delivery during the boarding period. OBJECTIVE: This study aimed to explore the perspectives and experiences of multidisciplinary clinicians and parents regarding mental health boarding and to develop a conceptual model to inform quality improvement efforts. DESIGN, SETTING, & PARTICIPANTS: We conducted semistructured interviews with clinicians and parents of youth experiencing boarding. Interviews focused on experiences of care and perceived opportunities for improvement were continued until thematic saturation was reached. Interviews were recorded, transcribed, and analyzed to identify emergent themes using a general inductive approach. Axial coding was used to inform conceptual framework development. RESULTS: Interviews were conducted with 19 clinicians and 11 parents. Building on the Donabedian structure-process-outcome model of quality evaluation, emergent domains, and associated themes included: (1) infrastructure for healthcare delivery, including clinician training, healthcare team composition, and the physical environment; (2) processes of healthcare delivery, including clinician roles and responsibilities, goals of care, communication with families, policies/procedures, and logistics of inter-facility transfer; and (3) measurable outcomes, including patient safety, family experience, mental health status, timeliness of care, and clinician moral distress. CONCLUSION: This qualitative study summarizes clinician and family perspectives about care for youth experiencing boarding. The conceptual model resulting from this analysis can be applied to implement and evaluate quality improvement endeavors to support this vulnerable population.

Impact of Question Bank Use for In-Training Examination Preparation by OBGYN Residents - A Multicenter Study.

OBJECTIVE: To examine the impact of access to and utilization of a commercially available question bank (TrueLearn) for in-training examination (ITE) preparation in Obstetrics and Gynecology (OBGYN). DESIGN: This was a retrospective cohort study examining the impact of TrueLearn usage on ITE examination performance outcomes. Produced by the educational arm of the American College of Obstetricians and Gynecologists, the Council on Resident Education in Obstetrics and Gynecology (CREOG) exam is a multiple-choice test given to all residents annually. Residency programs participating in this study provided residency program mean CREOG scores from the year prior (2015), and the first (2016) and second (2017) years of TrueLearn usage. Programs also contributed resident-specific CREOG scores for each resident for 2016 and 2017. This data was combined with each resident's TrueLearn usage data that was provided by TrueLearn with residency program consent. The CREOG scores consisted of the CREOG score standardized to all program years, the CREOG score standardized to the same program year (PGY) and the total percent (%) correct. TrueLearn usage data included number of practice questions completed, number of practice tests taken, average number of days between successive tests, and percent correct of answered practice questions. SETTING: OBGYN Residency Training Programs. PARTICIPANTS: OBGYN residency programs that purchased and utilized TrueLearn for the 2016 CREOG examination were eligible for participation (n = 14). Ten residency programs participated, which consisted of 212 residents in 2016 and 218 residents in 2017. RESULTS: TrueLearn was used by 78.8% (167/212) of the residents in 2016 and 84.9% (185/218) of the residents in 2017. No significant difference was seen in the average CREOG scores available on a per- program level before versus after the first year of implementation either using the CREOG score standardized to all PGYs (mean difference 1.0; p = 0.58) or standardized to the same PGY (mean difference 3.1; p = 0.25). Using resident-level data, there was no significant difference in mean CREOG score standardized to all PGYs between users and non-users of TrueLearn in 2016 (mean, 199.4 vs 196.7; p = 0.41) or 2017 (mean, 198.2 vs 203.4; p = 0.19). The percent of practice questions answered correctly on TrueLearn was positively correlated with the CREOG score standardized to all PGYs (r = 0.47 for 2016 and r = 0.60 for 2017), as well as with the CREOG total percent correct (r = 0.47 for 2016 and r = 0.61 for 2017). Based on a simple linear regression, for every 500 practice questions completed, the CREOG score significantly increased for PGY-2 residents by an average (±SE) of 7.3 ± 2.8 points (p = 0.013); the average increase was 0.7 ± 2.5 (p = 0.79) for PGY-3 residents and 5.8 ± 3.3 points (p = 0.09) for PGY-4 residents. CONCLUSIONS: Adoption of an online question bank did not result in higher mean CREOG scores at participating institutions. However, performance on the TrueLearn questions correlated with ITE performance, supporting predictive validity and the use of this question bank as a formative assessment for resident education and exam preparation.