What is the Evidence for Over the Counter Laxatives to Treat Childhood Constipation?

PURPOSE OF REVIEW: Functional constipation is a common pediatric GI disorder that is responsible for a significant portion of pediatric office visits each year. It presents a significant stressor for patients, their families, and providers alike. There are a variety of over the counter agents available for treatment of pediatric constipation. RECENT FINDINGS: Osmotic laxatives, such as polyethylene glycol 3350 (PEG 3350) and lactulose, remain the most effective and safe therapy for both long and short term treatment of pediatric functional constipation. Stimulant laxatives, like Senna and Bisacodyl, probiotics, fiber preparations, enemas, and suppositories make excellent choices for adjunct therapies in specific clinical scenarios. There are multiple over the counter pharmacologic agents with various mechanisms of action that have demonstrated efficacy in pediatric functional constipation. These therapies are generally safe and well tolerated by patients.

Investigating First Year Surgery Residents' Expectations of Demand, Control, and Support During Training.

OBJECTIVE: To provide a more granular understanding of the expectations of general surgery interns regarding workplace demand, control, and support prior to starting training. SUMMARY/BACKGROUND DATA: General surgery (GS) interns are at highest risk for burnout and attrition. Maslach frames burnout as resulting from a mismatch between workplace expectations and reality. Occupational science demonstrates workplace demand, control, and support (DCS) as strong influencers of job strain. GS interns' realistic expectations of demands are associated with decreased likelihood of attrition, but their expectations regarding this factor are poorly understood. METHODS: Semi-structured interviews were conducted with 14 incoming surgical residents at UCSF: University of California, San Francisco (57% women, 71% non-White), exploring expectations regarding workplace DCS. Transcripts were uploaded to analytic software and coded in dyads using an iterative approach to consensus. Transcripts were thematically analyzed using inductive and deductive reasoning, applying job-demand-resource theory frameworks, and following a published 6-step approach. RESULTS: Four main themes emerged: past experiences, expected rewards, anticipated challenges, and the desire to belong. Past experiences describes the expectation to successfully cope with future stressors via self-reliance. Rewards such as professional mastery, personal growth, and sense of meaning were expected outcomes seen as balancing anticipated challenges. Anticipated challenges included low control, toxic cultural elements, and discrimination. Desire to belong (i.e., earned recognition as a peer, inclusion in an elite culture) emerged as a powerful motivator, with survival connotations for women and non-Whites. CONCLUSION: Our results suggest incoming interns overestimate the efficacy of self-reliance for coping; count on specific rewards; express realistic expectations regarding challenges; and see inclusion among surgeons as an aspiration that off-sets prolonged effort. Further study is warranted to understand expectation-reality mismatch and potential interventions to target dissonance. MINI-ABSTRACT: In this institutional study of general surgery interns, we provide a more granular understanding of the expectations of general surgery interns regarding workplace demand, control, and support prior to starting training, and how we might target "expectations-reality" mismatch and the "desire to belong" as a means of mitigating burnout and minimizing attrition from training.

A mindful approach to complications: Brief review of the literature and practical guide for the surgeon.

Patient complications and adverse outcomes are inherent to surgical practice and training. In addition to the impact on patients, there are profound and well-documented impacts of complications on surgeons, surgical trainees, and surgical teams. This manuscript reviews the literature regarding mindfulness-based practices and the associated mitigation of the adverse impact of complications. These mindfulness-based practices prepare surgeons for complications by improving mental and cognitive resilience facilitating more effective management of complications that avoids undue psychological and emotional stress. Practical recommendations are provided for the practicing surgeon from providers experienced in mindfulness-based training and preparation.

Identifying Novel Inhibitors of Workplace Support and the Importance of Value Congruence and Feeling Valued in General Surgery Residency Training.

OBJECTIVE: To explore residents' perceptions of workplace support inhibitors and their relationship to resident wellbeing. We aim to provide evidence-based targets to inform future work operationalizing support in surgical training. DESIGN: This is a 2-part mixed-methods cross-sectional study. Part 1 analyzed qualitative data from focus groups (April 2021-May 2022). Part 2 comprised an online survey (informed by findings in Part 1, May 2022) to assess the association between perceived workplace support (e.g. feeling valued and value congruence) and poor individual global wellbeing (e.g. languishing). SETTING: National multi-center study including 16 ACGME-accredited academic programs. PARTICIPANTS: General surgery residents at all training levels, both clinical and research years. RESULTS: 28 residents participated in the focus groups which revealed three major themes around perceived inhibitors of workplace support: lack of trust in residency program (e.g. ulterior motives), poor communication from leadership (e.g. lack of transparency, ineffective dialogue), and unfair systems in residency training (e.g. exploitation of residents, paternal leave policies). These themes emphasized the importance of feeling valued and value congruence, with the latter reflected in the form of trust and communication with leadership, a key element of worker-workplace alignment. 251 residents responded to the survey (response rate 31%, 50.6% women) which revealed that a lower sense of feeling valued and lower perceived value congruence were significantly associated with languishing. CONCLUSIONS: Our findings suggest feeling valued and value congruence (specifically, having trust and communication with leadership) are important targets for increasing workplace support in surgical training, offering evidence-based targets for future work to operationalize support in surgical training.

Investigating Workplace Support and the Importance of Psychological Safety in General Surgery Residency Training.

OBJECTIVE: Workplace interventions that increase support can mitigate burnout, improve workplace satisfaction, and increase well-being. Our aim is to provide evidence-based targets to inform future work for operationalizing support in general surgery residency. DESIGN: This is a 2-part mixed-methods cross-sectional study. Part 1 analyzed qualitative data from focus groups (April 2021-May 2022). Part 2 comprised an online survey (informed by findings in Part 1) in May 2022 to assess the association between perceived psychological safety (PS) and flourishing, as well as PS and languishing. SETTING: National multi-center study including 16 ACGME-accredited academic programs. PARTICIPANTS: General surgery residents at various training levels, in both clinical and research. RESULTS: A total of 28 residents participated in the focus groups which revealed both enhancers and inhibitors of support pertaining to PS in the workplace. Enhancers of support included those currently implemented (i.e., allyship of mentors) and those proposed by residents (i.e., nonpunitive analysis of mistakes). Inhibitors of support included both systems (i.e., wellness initiatives as a 'band-aid' for systems issues) and culture (i.e., indefatigability, stoicism). About 251 residents (31%) responded to the survey which revealed higher perception of PS was significantly associated with flourishing at the level of residency program and departmental leadership. Lower perception of PS was significantly associated with languishing at the level of residency program leadership only. CONCLUSION: Our findings highlight the promotion of PS, such as expansion of mentorship to include advocacy (advocating on a resident's behalf, recognition when mistreated) and affirmation (i.e., soliciting opinions on controversial social matters/events, recognizing different life experiences), cultural acceptance of asking for help (without being perceived as weak), formal help navigating interpersonal dynamics (i.e., guidance from senior residents), and leadership presentations and modeling to destigmatize asking for help, as a means of operationalizing workplace support to increase flourishing and decrease languishing.

Operationalizing the Culture of Burnout and Well-Being: Multicenter Study of Value Congruence and Flourishing in General Surgery Residency.

BACKGROUND: Value congruence (VC) is the degree of alignment between worker and workplace values and is strongly associated with reduced job strain and retention. Within general surgery residency, the impact of VC and how to operationalize it to improve workplace well-being remain unclear. STUDY DESIGN: This 2-part mixed-methods study comprised 2 surveys of US general surgery residents and qualitative interviews with program directors. In Part 1, January 2021, mixed-level surgical residents from 16 ACGME-accredited general surgery residency programs participated in survey #1. This survey was used to identify shared or conflicting perspectives on VC concerning well-being initiatives and resources. In April 2021, interviews from 8 institutions were conducted with 9 program directors or their proxies. In Part 2, May to June 2022, a similar cohort of surgical residents participated in survey #2. Unadjusted logistic and linear regression models were used in this survey to assess the association between VC and individual-level global well-being (ie flourishing), respectively. RESULTS: In survey #1 (N = 300, 34% response rate), lack of VC was an emergent theme with subthemes of inaccessibility, inconsiderateness, inauthenticity, and insufficiency regarding well-being resources. Program directors expressed variable awareness of and alignment with these perceptions. In survey #2 (N = 251, 31% response rate), higher VC was significantly associated with flourishing (odds ratio 1.91, 95% CI 1.44 to 2.52, p < 0.001). CONCLUSIONS: Exploring the perceived lack of VC within general surgery residency reveals an important cultural variable for optimizing well-being and suggests open dialogue as a first step toward positive change. Future work to identify where and how institutional actions diminish perceived VC is warranted.

The effect of a simulation-based training intervention on the performance of established critical care unit teams.

OBJECTIVE: We evaluated the effectiveness of a simulation-based intervention on improving teamwork in multidisciplinary critical care teams managing airway and cardiac crises and compared simulation-based learning and case-based learning on scores for performance. DESIGN: Self-controlled randomized crossover study design with blinded assessors. SETTING: A simulated critical care ward, using a high-fidelity patient simulator, in a university simulation center. SUBJECTS: Forty teams from critical care units within the region comprising one doctor and three nurses. INTERVENTION: At the beginning and end of the 10-hr study day, each team undertook two preintervention and two postintervention assessment simulations (one airway, one cardiac on both occasions). The study day included presentations and discussions on human factors and crisis management, and airway and cardiac skills stations. For the intervention, teams were randomized to case-based learning or simulation-based learning for cardiac or airway scenarios. MEASUREMENTS AND MAIN RESULTS: Each simulation was recorded and independently rated by three blinded expert assessors using a structured rating tool with technical and behavioral components. Participants were surveyed 3 months later. We demonstrated significant improvements in scores for overall teamwork (p ≤ .002) and the two behavioral factors, "Leadership and Team Coordination" (p ≤ .002) and "Verbalizing Situational Information" (p ≤ .02). Scores for clinical management also improved significantly (p ≤ .003). We found no significant difference between simulation-based learning and case-based learning in the context of this study. Survey data supported the effectiveness of study day with responders reporting retention of learning and changes made to patient management. CONCLUSIONS: A simulation-based study day can improve teamwork in multidisciplinary critical care unit teams as measured in pre- and postcourse simulations with some evidence of subsequent changes to patient management. In the context of a full-day course, using a mix of simulation-based learning and case-based learnings seems to be an effective teaching strategy.

Epibulbar Nodular Fasciitis.

PURPOSE: To report a case of epibulbar nodular fasciitis in a 32-year-old female and provide context by reviewing the current literature. RESULTS: Using excisional biopsy, the patient was successfully diagnosed and treated for epibulbar nodular fasciitis. Upon follow-up, there has been no recurrence, consistent with the typical course for nodular fasciitis. CONCLUSIONS: Epibulbar nodular fasciitis is a rare process that can be successfully treated by surgical resection. While two cases of trauma-associated epibulbar nodular fasciitis have been present in the literature, our case did not have such a history. The etiology of nodular fasciitis remains unclear.

Genetic Risk for Inflammatory Bowel Disease Is a Determinant of Crohn's Disease Development in Chronic Granulomatous Disease.

BACKGROUND: Approximately, one-third to one-half of children with chronic granulomatous disease (CGD) develop gastrointestinal inflammation characteristic of idiopathic inflammatory bowel disease (IBD), usually Crohn's disease. We hypothesized that the overall IBD genetic risk, determined by IBD genetic risk score (GRS), might in part determine IBD development in CGD. METHODS: We reviewed medical records to establish IBD diagnoses in CGD subjects seen at NIAID. IBD risk single nucleotide polymorphism genotypes were determined using the Immunochip, and GRS were estimated by Mangrove. RESULTS: Among 157 white patients with CGD, 55 were confirmed, 78 excluded, and 24 were uncertain for IBD. Two hundred one established, independent European IBD risk single nucleotide polymorphisms passed quality control. After sample quality control and removing non-IBD CGD patients with perianal disease, mean GRS for 40 unrelated patients with CGD-IBD was higher than 53 CGD non-IBD patients (in log2-scale 0.08 ± 1.62 versus -0.67 ± 1.64, P = 0.026) but lower than 239 IBD Genetics Consortium (IBDGC) young-onset Crohn's disease cases (0.76 ± 1.60, P = 0.025). GRS for non-IBD CGD was similar to 609 IBDGC controls (-0.69 ± 1.60, P = 0.95). Seven established IBD single nucleotide polymorphisms were nominally significant among CGD-IBD versus CGD non-IBD, including those near LACC1 (P = 0.005), CXCL14 (P = 0.007), and TNFSF15 (P = 0.016). CONCLUSIONS: The weight of the common IBD risk alleles are significant determinants of IBD in CGD. However, IBD risk gene burden among CGD children with IBD is significantly lower than that in nonsyndromic pediatric Crohn's disease, congruent with the concept that defective superoxide production in CGD is also a major IBD risk factor. Individual IBD genes might interact with the CGD defect to cause IBD in CGD.

Evaluation of an instrument to measure teamwork in multidisciplinary critical care teams.

INTRODUCTION: Teamwork failures contribute to adverse events causing harm to patients. Establishing and maintaining a team and managing the tasks are active processes. Medical education largely ignores teamwork skills. However, lack of robust instruments to measure teamwork limits evaluation of interventions to improve it. The authors aimed to develop and validate an instrument to measure teamwork behaviours. METHODS: From existing literature, the authors developed an instrument, gaining rater consensus that the final 23 items were comprehensive, comprehensible and observable. Data on the instrument were obtained from three expert raters who scored videotaped simulations of 40 critical care teams (one doctor, three nurses) participating in four simulated emergencies. Exploratory Factor Analysis, Generalisability Analysis and rater interviews on assessor performance provided information on the properties of the instrument. RESULTS: Exploratory Factor Analysis found items clustered into three factors: Leadership and Team Coordination; Mutual Performance Monitoring; and Verbalising Situational Information. Internal consistencies (Cronbach's α) for these factors were 0.917, 0.915 and 0.893, respectively. The Generalisability coefficient for overall team behaviour was 0.78 and the G coefficients for the three factors were 0.85, 0.4 and 0.37, respectively. Variance Components and interview data provided insight into individual item performance. Significantly improved performance with time and seniority supported construct validity. DISCUSSION: The instrument performed well as an overall measure of team behaviour and reflected three dimensions of teamwork. Triangulation of information on the instrument, the factors and individual items will allow a methodical and informed approach to further development of the instrument. The ultimate goal is an instrument that can robustly evaluate interventions to improve team function in healthcare.