A Program of Assessment Model for Point-of-Care Ultrasound Training for Pediatric Critical Care Providers: A Comprehensive Approach to Enhance Competency-Based Point-of-Care Ultrasound Training.

Point-of-care ultrasound (POCUS) is increasingly accepted in pediatric critical care medicine as a tool for guiding the evaluation and treatment of patients. POCUS is a complex skill that requires user competency to ensure accuracy, reliability, and patient safety. A robust competency-based medical education (CBME) program ensures user competency and mitigates patient safety concerns. A programmatic assessment model provides a longitudinal, holistic, and multimodal approach to teaching, assessing, and evaluating learners. The authors propose a fit-for-purpose and modifiable CBME model that is adaptable for different institutions' resources and needs for any intended competency level. This educational model drives and supports learning, ensures competency attainment, and creates a clear pathway for POCUS education while enhancing patient care and safety.

Cardiac Point-of-Care Ultrasound and Multi-Disciplinary Improvement Opportunities in Acute Systolic Heart Failure Management in a Pediatric Emergency Center.

Cardiac point-of-care ultrasound (POCUS) has the ability to rapidly assess function and identify systolic heart failure (HF), an often-missed diagnosis. POCUS has the potential to expedite medical intervention, improving overall outcomes. There have been limited studies describing pediatric emergency center (EC) utilization of cardiac POCUS and its impact on outcomes in pediatric patients. Authors performed a retrospective chart review at a tertiary children's hospital to identify all patients admitted from the EC to the Cardiac Intensive Care Unit (CICU) with acute systolic HF between January 2017 and August 2019. Outcome measures included EC length of stay (LOS), CICU LOS, and time until first IV HF medicine was administered. A total of 21 patients and 24 encounters meeting criteria were identified. Cardiac POCUS agreed with standard echocardiography in 8 of 9 cases. Patients who had a cardiac POCUS in the EC seemed more likely to receive their first dose of intravenous heart failure medication while in the Emergency Center (70% vs 43%). There was a trend toward significance, but it did not reach statistical significance (p = 0.1). EC and CICU LOS were not significantly different between POCUS and non-POCUS groups. Cardiac POCUS has the potential to have a valuable role in the early diagnosis of acute systolic HF in children. However, early diagnosis by POCUS did not translate into shorter EC or CICU LOS. This pilot data serves as a baseline for efforts to promote earlier clinical recognition of acute HF and more efficient collaboration between clinical services.

Diagnosing Acute Heart Failure in the Pediatric Emergency Department Using Point-of-Care Ultrasound.

BACKGROUND: Acute heart failure (AHF) in children is associated with significant disease burden with high rates of morbidity, mortality, and resource utilization. These children often present to the emergency department with clinical features that mimic common childhood illnesses. Cardiac point-of-care ultrasound (POCUS) can be an effective tool for rapidly identifying abnormal cardiac function. CASE REPORTS: This case series documents 10 children presenting with AHF between 2016 and 2019 and demonstrates how pediatric emergency physicians used cardiac POCUS to expedite their diagnosis, management, and disposition. All cardiac POCUS was performed before comprehensive echocardiograms were completed. One case is described in detail; the other cases are summarized in a Table. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition of AHF is critical to reduce pediatric morbidity and mortality. With proper training, cardiac POCUS can be an effective adjunct and should be considered for the early diagnosis and treatment of infants and children with AHF.

A Multi-institutional Case Series With Review of Point-of-Care Ultrasound to Diagnose Malrotation and Midgut Volvulus in the Pediatric Emergency Department.

Point-of-care ultrasound can be used to screen for malrotation with and without volvulus in the newborn with bilious vomiting, as well as children with unexplained intermittent abdominal pain. We discuss cases where infants and children presenting to pediatric emergency departments with bilious vomiting and/or intermittent abdominal pain were initially screened for small bowel pathology with point-of-care ultrasound. Bedside findings suggestive of midgut volvulus were confirmed with radiology-performed ultrasound or upper gastrointestinal fluoroscopy. In all cases, operative findings were consistent with malrotation of the small bowel with or without evidence of midgut volvulus.

Development of flow cytometric opsonophagocytosis and antibody-mediated complement deposition assays for non-typeable Haemophilus influenzae.

BACKGROUND: Haemophilus influenzae is found in the nasopharynx of 80% of the human population. While colonisation with non-typeable Haemophilus influenzae (NTHi) is usually asymptomatic, it is capable of causing acute and chronic otitis media (OM) in infants, invasive disease in susceptible groups and is the leading cause of exacerbations of patients with chronic obstructive pulmonary disease (COPD). Current methods for assessing functional antibody immunity to NTHi are limited and labour intensive. Flow cytometric assays could provide an attractive alternative to evaluate immune responses to candidate vaccines in clinical trials. RESULTS: We have developed a duplexed flow-cytometric uptake and oxidative burst opsonophagocytosis assay (fOPA). We have also developed a duplexed antibody-mediated complement C3b/iC3b and C5b-9 deposition assay (CDA). Antibody-mediated C3b/iC3b deposition correlated with opsonophagocytic uptake (r = 0.65) and with opsonophagocytic oxidative burst (r = 0.69). Both fOPA and CDA were reproducible, with the majority of samples giving a coefficient of variation (CV) of < 20% and overall assay CVs of 14% and 16% respectively. CONCLUSIONS: The high-throughput flow cytometric assays developed here were successfully optimised for use with NTHi. Assays proved to be sensitive and highly reproducible for the measurement of bacterial uptake and oxidative burst opsonophagocytosis and antibody-mediated deposition of C3b/iC3b and C5b-9. These assays are useful tools for use in large scale epidemiological studies and to assist in the assessment of functional antibody induced by NTHi candidate vaccines.

New Palpable Breast Lump With Recent Negative Mammogram: Is Repeat Mammography Necessary?

OBJECTIVE: The purpose of this article is to determine the utility of repeat mammography, compared with targeted ultrasound and previous mammogram, in the assessment of an interval palpable breast lump found within 1 year after a negative mammogram study. MATERIALS AND METHODS: Women who were examined for a new palpable lump with mammography and targeted ultrasound between January 2005 and December 2012, who also had a negative mammogram within the previous 6-12 months, were included. The following data were collected: age, mammographic findings, change from previous mammogram, ultrasound findings, BI-RADS category, and biopsy results. RESULTS: A total of 618 palpable lumps in 612 women (mean [± SD] age, 55.9 ± 11.2 years) were included in this study. In 314 of 618 cases (50.8%), a sonographic finding or mammographic change, or both was detected in the region of the palpable lump. Ultrasound detected a finding in 311 cases (50.3%), whereas repeat mammography detected a change in only 80 (12.9%) cases (p < 0.001). Of the 314 cases with imaging findings, 234 findings (74.5%) were detected by ultrasound alone. Repeat mammography identified a more prominent focal asymmetry in the palpable region in three cases with no sonographic correlate; none had malignancy. Eighty lesions were biopsied, and 48 (60.0%) of them were positive for malignancy. The repeat mammogram findings were unchanged for 10 of these lesions. CONCLUSION: Interval palpable breast lumps should be evaluated with targeted ultrasound. Mammography does not appear to add value beyond sonography performed by trained ultrasound technologists and should not be routinely performed.

Decreasing Diagnostic Hysteroscopy Performed in the Operating Room: A Quality Improvement Initiative.

OBJECTIVES: At our institution, diagnostic hysteroscopy (DH), often combined with uterine curettage, commonly has been performed in the main OR with the patient under general anaesthesia. Our objective was to create targeted interventions aimed at decreasing the number of DHs performed in the OR by 75% over one year. METHODS: This quality improvement initiative had a quasi-experimental (time-series) design. To obtain baseline numbers of DHs performed each month, we conducted a retrospective chart audit at a university teaching hospital. We implemented the following three groups of interventions: (1) staff education and case review, (2) accessible sonohysterography, and (3) an operative hysteroscopy education program. Procedures were tracked prospectively over a 12-month intervention period and an additional 12-month maintenance period. RESULTS: One hundred eleven DHs were performed at baseline. During the intervention period, 33 DHs were performed, a 70% reduction from baseline. This resulted in related savings of $126 984 and 12.5 surgical days. In the final quarter of the intervention period, there was an 81% reduction in the number of DHs with adequate preoperative evaluation compared with baseline. Twenty DHs were performed in the maintenance period, an 82% reduction from baseline. The absolute number of complications from DH remained constant during the study period. CONCLUSION: Carefully planned and targeted interventions to change the culture at our institution decreased the number of DHs performed in the main OR. These initiatives improved patient care, saved costs, and improved OR utilization. Long-term follow-up showed maintenance of the improvements in the year subsequent to the interventions.

Improving Pediatric Emergency Care by Implementing an Eligible Learner Endotracheal Intubation Policy.

OBJECTIVES: Although endotracheal intubations (ETIs) are high-risk, low-frequency events, there are no nationally accepted training pathways or measures to ensure ETI competence for emergency department (ED) providers. Our objective was to determine whether implementation of an eligible learner ETI policy (ELETIP) led to improved first ETI attempt success rates and decreased immediate airway-related complications. METHODS: This was a retrospective cross-sectional before-and-after study of outcomes after ELETIP implementation. The primary outcome was proportion of successful first ETI attempts; secondary outcomes were number of intubation attempts, time to intubation, need to call anesthesia for intubation, and airway-related complications. RESULTS: Three hundred ninety patients were included (median age, 1.3 y; range, 1 day-24.7 y): 219 (56%) and 171 (44%) in the pre- and post-ELETIP periods, respectively. First successful ETI attempts increased from 65.1% to 75.7% (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.07-2.62). Secondary outcomes included mean number of intubation attempts (1.6-1.4, P = 0.01), time to intubation (5.6-4.9 minutes, P = 0.07), anesthesia intubations in the ED (5.9%-2.9%; OR, 0.48; 95% CI, 0.17-1.37), and intubation-related complications (32%-25.7%; OR, 0.74; 95% CI, 0.47-1.15). CONCLUSIONS: An ELETIP is effective in improving ED care by increasing first ETI attempt success rates while decreasing overall intubation attempts. Physicians and physician learners with anesthesia training for critical airway management training have high ETI attempt success rates. Airway management training is essential to physician education and airway management skills for improving outcomes.

Do acting interns need residents? A comparison of acting intern experience on hospital medicine resident versus nonresident teams.

BACKGROUND: The clinical demands for hospitalist groups have grown at academic medical centers, without similar growth of teaching opportunities for faculty. Traditional resident teaching teams are often crowded with learners which can limit acting intern (or subintern) patient encounters. Medical students are often placed on nonresident teaching teams, although there are few studies on learner experience on a nonresident teaching team model. METHODS: To address these concerns, we created two nonresident teaching teams composed of one attending and two acting interns. We compared acting intern experience on the nonresident teaching teams to the traditional resident teams to determine if there were significant differences in student experience by reviewing course evaluation data on the two team models. RESULTS: Of the 276 students who completed the Internal Medicine Acting Internship from 2019 to 2023, 224 students (81%) completed the course evaluation. The course was highly rated, and the ratings were similar in both models demonstrating that the nonresident teaching team model is an effective option for acting interns. CONCLUSION: The nonresident teaching team model can offload crowded teaching teams, add additional acting intern experiences, and add teaching opportunities for hospital medicine attendings.

Detection and Characterization of Endplate Structural Defects on CT: A Diagnostic Accuracy Study.

STUDY DESIGN: Diagnostic test study. OBJECTIVE: To determine the reliability and validity or diagnostic accuracy of two previously described endplate structural defect (EPSD) assessment methods. SUMMARY OF BACKGROUND DATA: Studies of EPSD may further the understanding of pathoanatomical mechanisms underlying back pain. However, clinical imaging methods used to document EPSD have not been validated, leaving uncertainty about what the observations represent. METHODS: Using an evaluation manual, 418 endplates on CT sagittal slices obtained from 19 embalmed cadavers (9 men and 10 women, aged 62-91 y) were independently assessed by two experienced radiologists and a novice for EPSD using the two methods. The corresponding micro-CT (µCT) from the harvested T7-S1 spines were assessed by another independent rater with excellent intra-rater reliability (Kappa=0.96). RESULTS: Inter-rater reliability was good for presence (Kappa=0.60-0.69) and fair for specific phenotypes (Kappa=0.43-0.58) of EPSD. Erosion, for which the Brayda-Bruno classification lacked a category, was mainly (82.8%) classified as wavy/irregular, while many notched defects (n=15, 46.9%) and Schmorl's nodes (n=45, 79%) were recorded as focal defects using Feng's classification. When compared to µCT, endplate fractures (n=53) and corner defects (n=28) were routinely missed on CT. Endplates classified as wavy/irregular on CT corresponded to erosion (n=29, 21.2%), jagged defects (n=21, 15.3%), calcification (n=19, 13.9%), and other phenotypes on µCT. Some focal defects on CT represented endplate fractures (n=21, 27.6%) on µCT. Overall, with respect to the presence of an EPSD, there was a sensitivity of 70.9% and specificity of 79.1% using Feng's method, and 79.5% and 57.5% using Brayda-Bruno's. Poor to fair inter-rater reliability (k=0.26-0.47) was observed for defect dimensions. CONCLUSION: There was good inter-rater reliability and evidence of criterion validity supporting assessments of EPSD presence using both methods. However, neither method contained all needed EPSD phenotypes for optimal sensitivity, and specific phenotypes were often misclassified.

Effectiveness of standardized combination therapy for migraine treatment in the pediatric emergency department.

OBJECTIVE: To compare outcomes of pediatric migraine patients treated in an emergency department (ED) before and after implementation of a standardized combination intravenous therapy regimen aimed toward improving and standardizing abortive migraine therapy. BACKGROUND: In a pediatric ED, migraines represent 8-18% of all headache visits. Despite this large number, no standard treatment for acute migraine therapy currently exists. METHODS: The study utilized a retrospective chart review of patients seeking acute migraine treatment at a tertiary care, pediatric ED from August 2006 to March 2010. Inclusion criteria were pediatric migraine patients as defined by International Headache Society guidelines. The comparison population received various migraine therapies based on attending practice preference. After October 2008, patients received standardized intravenous combination therapy involving a normal saline fluid bolus, ketorolac, prochlorperazine, and diphenhydramine. Occasionally, metoclopramide was substituted during prochlorperazine shortages. Reduction in headache pain score was the primary outcome. Secondary outcome measures included length of ED stay, hospital admission rate, and ED readmission rate within 48 hours. RESULTS: The study yielded 87 patients who received standardized combination therapy and 165 comparison patients. No significant difference in patient characteristics existed when evaluating patient demographics, outpatient medication use, and initial headache pain score. When compared with the non-standardized therapy population, the combination therapy patients revealed significant reductions in pain score (decrease of 5.3 vs. 6.9, difference -1.6, 95% confidence interval -2.2 to -0.8, P < .001), length of ED stay (5.3 vs. 4.4 hours, difference 0.9, 95% confidence interval 0.2-1.6, P = .008), and hospital admission rate (32% vs. 3%, P < .001) without changes in ED return rate (7% vs. 2%, P = .148). CONCLUSION: Standardized combination therapy is effective for acute pediatric migraine therapy in the ED by significantly reducing headache pain scores, length of ED stay, and hospital admission rates.

The rise and fall of troponin in a patient with polymyositis.

Troponins are an excellent sensitive marker for myocardial ischaemic damage. However, there are several non-ischaemic cardiac and non-cardiac reasons for troponin elevation. Many cases of troponin T elevation and some troponin I cases have been reported in the literature due to inflammatory muscle disease. Here, we report a woman in her 50s who initially presents with fatigue and weakness, and is found to have elevated troponin T. The patient was appropriately worked up for cardiac causes with ECG and echocardiogram. She had positive antinuclear antibodies, antineutrophil cytoplasmic antibody and myositis panel. The elevation of troponins was attributed to polymyositis and treated with methotrexate and prednisone with recovery of patient's symptoms. This article emphasises the struggle of diagnosis in a patient with no reported medical history, having low to moderate risk of silent myocardial infarction.

Development of A Standardized Opsonophagocytosis Killing Assay for Group B Streptococcus and Assessment in an Interlaboratory Study.

The placental transfer of antibodies that mediate bacterial clearance via phagocytes is likely important for protection against invasive group B Streptococcus (GBS) disease. A robust functional assay is essential to determine the immune correlates of protection and assist vaccine development. Using standard reagents, we developed and optimized an opsonophagocytic killing assay (OPKA) where dilutions of test sera were incubated with bacteria, baby rabbit complement (BRC) and differentiated HL60 cells (dHL60) for 30 min. Following overnight incubation, the surviving bacteria were enumerated and the % bacterial survival was calculated relative to serum-negative controls. A reciprocal 50% killing titer was then assigned. The minimal concentrations of anti-capsular polysaccharide (CPS) IgG required for 50% killing were 1.65-3.70 ng/mL (depending on serotype). Inhibition of killing was observed using sera absorbed with homologous CPS but not heterologous CPS, indicating specificity for anti-CPS IgG. The assay performance was examined in an interlaboratory study using residual sera from CPS-conjugate vaccine trials with international partners in the Group B Streptococcus Assay STandardisatiON (GASTON) Consortium. Strong correlations of reported titers between laboratories were observed: ST-Ia r = 0.88, ST-Ib r = 0.91, ST-II r = 0.91, ST-III r = 0.90 and ST-V r = 0.94. The OPKA is an easily transferable assay with accessible standard reagents and will be a valuable tool to assess GBS-specific antibodies in natural immunity and vaccine studies.

Adequacy Rate of Magnesium Citrate Bowel Preparation in a Large Retrospective Cohort.

INTRODUCTION: Magnesium Citrate (MC) is not FDA approved as a colonoscopy preparation. Advantages include low cost, small volume and accessibility without prescription. We retrospectively evaluated bowel preparations used in a private gastroenterology practice. The sample size is the largest for any similar studies (n =19,173). METHODS: Electronic Medical Records were queried for colonoscopies between 2010-2016. Bowel preps, indications (screening vs. other) and preparation adequacy were all recorded. Adequacy rates were calculated and compared using generalized linear modeling. Data were analyzed using SAS. RESULTS: The most common prep used was MC 2 bottles; screening (n=6,064, with 98.94% adequacy) and non-screening (n=3,251, with 99.29% adequacy), followed by MC 3 bottles; screening (n=2,757 with 90.35% adequacy), and non-screening (n=1,925 with 92.92% adequacy). CONCLUSION: MC bowel preparation is adequate, well tolerated, and inexpensive. In a large retrospective analysis, it compares favorably to other preparations.

Spontaneous Remission of Metastatic Castration-Resistant Prostate Cancer: Coley's Toxin Revisited?

Metastatic castration-resistant prostate cancer (mCRPC) is an incurable disease associated with poor survival outcomes. Immunotherapy was first pioneered by William Coley in the early 20th century with the injection of live and heat-killed bacteria. Despite the recent emergence of cancer immunotherapy, mCRPC remains an elusive immune target. Spontaneous remission of mCRPC following microbial infection has not been described in the literature to date. We present evidence of spontaneous biochemical and radiologic regression in a patient with mCRPC following multiple episodes of sepsis.

Solutions to Address Inequity in Diabetes Technology Use in Type 1 Diabetes: Results from Multidisciplinary Stakeholder Co-creation Workshops.

Background: Racial-ethnic inequity in type 1 diabetes technology use is well documented and contributes to disparities in glycemic and long-term outcomes. However, solutions to address technology inequity remain sparse and lack stakeholder input. Methods: We employed user-centered design principles to conduct workshop sessions with multidisciplinary panels of stakeholders, building off of our prior study highlighting patient-identified barriers and proposed solutions. Stakeholders were convened to review our prior findings and co-create interventions to increase technology use among underserved populations with type 1 diabetes. Stakeholders included type 1 diabetes patients who had recently onboarded to technology; endocrinology and primary care physicians; nurses; diabetes educators; psychologists; and community health workers. Sessions were recorded and analyzed iteratively by multiple coders for common themes. Results: We convened 7 virtual 2-h workshops for 32 stakeholders from 11 states in the United States. Patients and providers confirmed prior published studies highlighting patient barriers and generated new ideas by co-creating solutions. Common themes of proposed interventions included (1) prioritizing more equitable systems of offering technology, (2) using visual and hands-on approaches to increase accessibility of technology and education, (3) including peer and family support systems more, and (4) assisting with insurance navigation and social needs. Discussion: Our study furthers the field by providing stakeholder-endorsed intervention ideas that propose feasible changes at the patient, provider, and system levels to reduce inequity in diabetes technology use in type 1 diabetes. Multidisciplinary stakeholder engagement in disparities research offers unique insight that is impactful and acceptable to the target population.

Generation of a Universal Human Complement Source by Large-Scale Depletion of IgG and IgM from Pooled Human Plasma.

Complement is a key component of functional immunological assays used to evaluate vaccine-mediated immunity to a range of bacterial and viral pathogens. However, standardization of these assays is complicated due to the availability of a human complement source that lacks existing antibodies acquired either through vaccination or natural circulation of the pathogen of interest. We have developed a method for depleting both IgG and IgM in 200 mL batches from pooled hirudin-derived human plasma by sequential affinity chromatography using a Protein G Sepharose column followed by POROS™ CaptureSelect™ IgM Affinity resin. The production of large IgG- and IgM-depleted batches of human plasma that retains total hemolytic and alternative pathway activities allows for improved assay standardization and comparison of immune responses in large clinical trials.

mRNA vaccination in people over 80 years of age induces strong humoral immune responses against SARS-CoV-2 with cross neutralization of P.1 Brazilian variant.

Age is the major risk factor for mortality after SARS-CoV-2 infection and older people have received priority consideration for COVID-19 vaccination. However, vaccine responses are often suboptimal in this age group and few people over the age of 80 years were included in vaccine registration trials. We determined the serological and cellular response to spike protein in 100 people aged 80-96 years at 2 weeks after the second vaccination with the Pfizer BNT162b2 mRNA vaccine. Antibody responses were seen in every donor with high titers in 98%. Spike-specific cellular immune responses were detectable in only 63% and correlated with humoral response. Previous SARS-CoV-2 infection substantially increased antibody responses after one vaccine and antibody and cellular responses remained 28-fold and 3-fold higher, respectively, after dual vaccination. Post-vaccine sera mediated strong neutralization of live Victoria infection and although neutralization titers were reduced 14-fold against the P.1 variant first discovered in Brazil they remained largely effective. These data demonstrate that the mRNA vaccine platform delivers strong humoral immunity in people up to 96 years of age and retains broad efficacy against the P.1 variant of concern.