Vascular Endothelial Growth Factor and Soluble Vascular Endothelial Growth Factor Receptor as Novel Biomarkers for Poor Outcomes in Children With Severe Sepsis and Septic Shock.

Vascular endothelial growth factor (VEGF) and its receptor, soluble fms-like tyrosine kinase (sFLT), are biomarkers of endothelial activation. Vascular endothelial growth factor and sFLT have been associated with sepsis severity among adults, but pediatric data are lacking. The goal of this study was to assess VEGF and sFLT as predictors of outcome for children with sepsis. METHODS: Biomarkers measured for each patient at time of presentation to the emergency department were compared in children with septic shock versus children with sepsis without shock. For children with septic shock, the associations between biomarker levels and clinical outcome measures, including intensive care unit and hospital length of stay, vasoactive inotrope score, and measures of organ dysfunction, were assessed. RESULTS: Soluble fms-like tyrosine kinase and VEGF were elevated in children with septic shock (n = 73) compared with those with sepsis (n = 93). Elevated sFLT but not VEGF was associated with longer intensive care unit length of stay (P = 0.003), longer time requiring vasoactive agents (P < 0.001), higher maximum vasoactive inotrope score (P < 0.001), and higher maximum pediatric logistic organ dysfunction score (P < 0.001). CONCLUSIONS: Vascular endothelial growth factor and sFLT measured in the emergency department are elevated in children with septic shock, and elevated sFLT but not VEGF is associated with worse clinical outcomes.

Customized head molds reduce motion during resting state fMRI scans.

Head motion causes artifacts in functional magnetic resonance imaging (fMRI) scans, a problem especially relevant for task-free resting state paradigms and for developmental, aging, and clinical populations. In a cohort spanning 7-28 years old (mean age 15) we produced customized head-anatomy-specific Styrofoam molds for each subject that inserted into an MRI head coil. We scanned these subjects under two conditions: using our standard procedure of packing the head coil with foam padding about the head to reduce head motion, and using the customized molds to reduce head motion. In 12 of 13 subjects, the molds reduced head motion throughout the scan and reduced the fraction of a scan with substantial motion (i.e., volumes with motion notably above baseline levels of motion). Motion was reduced in all 6 head position estimates, especially in rotational, left-right, and superior-inferior directions. Motion was reduced throughout the full age range studied, including children, adolescents, and young adults. In terms of the fMRI data itself, quality indices improved with the head mold on, scrubbing analyses detected less distance-dependent artifact in scans with the head mold on, and distant-dependent artifact was less evident in both the entire scan and also during only low-motion volumes. Subjects found the molds comfortable. Head molds are thus effective tools for reducing head motion, and motion artifacts, during fMRI scans.

Advance Care Planning and Parent-Reported End-of-Life Outcomes in Children, Adolescents, and Young Adults With Complex Chronic Conditions.

OBJECTIVES: For children, adolescents, and young adults with complex chronic conditions advance care planning may be a vital component of optimal care. Advance care planning outcomes research has previously focused on seriously ill adults and adolescents with cancer where it is correlated with high-quality end-of-life care. The impact of advance care planning on end-of-life outcomes for children, adolescents, and young adults with complex chronic conditions is unknown, thus we sought to evaluate parental preferences for advance care planning and to determine whether advance care planning and assessment of specific family considerations during advance care planning were associated with differences in parent-reported end-of-life outcomes. DESIGN: Cross-sectional survey. SETTING: Large, tertiary care children's hospital. SUBJECTS: Bereaved parents of children, adolescents, and young adults with complex chronic conditions who died between 2006 and 2015. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: One-hundred fourteen parents were enrolled (54% response rate) and all parents reported that advance care planning was important, with a majority (70%) endorsing that discussions should occur early in the illness course. Parents who reported advance care planning (65%) were more likely to be prepared for their child's last days of life (adjusted odds ratio, 3.78; 95% CI, 1.33-10.77), to have the ability to plan their child's location of death (adjusted odds ratio, 2.93; 95% CI, 1.06-8.07), and to rate their child's quality of life during end-of-life as good to excellent (adjusted odds ratio, 3.59; 95% CI, 1.23-10.37). Notably, advance care planning which included specific assessment of family goals was associated with a decrease in reported child suffering at end-of-life (adjusted odds ratio, 0.23; 95% CI, 0.06-0.86) and parental decisional regret (adjusted odds ratio, 0.42; 95% CI, 0.02-0.87). CONCLUSIONS: Parents of children, adolescents, and young adults with complex chronic conditions highly value advance care planning, early in the illness course. Importantly, advance care planning is associated with improved parent-reported end-of-life outcomes for this population including superior quality of life. Further studies should evaluate strategies to ensure high-quality advance care planning including specific assessment of family goals.

Systemic Angiopoietin-1/2 Dysregulation in Pediatric Sepsis and Septic Shock.

Background: Angiopoietin-1 and -2 are vascular growth factors that exert opposing effects on endothelial activation and dysfunction. The aim of this study was to assess the association of these biomarkers with outcomes in children with sepsis. Methods: Biomarkers were assayed from the blood collected in an emergency department prior to any intervention. Predictor variables were Ang-1 and Ang-2 levels and the Ang-2/Ang-1 ratio. Outcomes included mortality, length of time on vasopressors, and ICU and hospital lengths of stay. The Pediatric RISk of Mortality III Score was calculated. A vasoactive inotrope score was calculated every 12 hours. Results: Forty-five children with sepsis and 49 with septic shock were analyzed. The median Ang-2 was higher in septic shock. The Ang-2/Ang-1 ratio was approximately 2-fold greater in those with septic shock. The Ang-2/Ang-1 ratio was associated with higher doses of vasoactive agents at 12 hours and longer ICU length of stay. In septic shock, for every 0.35 unit increase in the Ang-2/Ang-1 ratio, the PRISM III score increased by 1. Conclusions: The Ang-2/Ang-1 ratio was higher in children with septic shock. Ang-2/Ang-1 was associated with higher vasoactive agents, longer ICU length of stay, and correlated with the severity of illness score.

A Pilot Study of the Association of Amino-Terminal Pro-B-Type Natriuretic Peptide and Severity of Illness in Pediatric Septic Shock.

OBJECTIVES: Biomarkers that can measure illness severity and predict the risk of delayed recovery may be useful in guiding pediatric septic shock. Amino-terminal pro-B-type natriuretic peptide has not been assessed in pediatric septic patients at the time of presentation to the emergency department prior to any interventions. The primary aim was to assess if emergency department amino-terminal pro-B-type natriuretic peptide is associated with worse outcomes and severity of illness. DESIGN: Prospective observational pilot study. SETTINGS: Tertiary free-standing children's hospital. PATIENTS: Children 0-17 years old with a diagnosis of septic shock were enrolled. Patients with preexisting cardiac and renal dysfunction were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Amino-terminal pro-B-type natriuretic peptide analysis was performed on samples obtained in the emergency department prior to any intervention. The association between biomarkers and clinical outcomes and illness severity using Pediatric RISk of Mortality 3 were assessed. Eighty-two patients with septic shock underwent analysis. The median (interquartile range) amino-terminal pro-B-type natriuretic peptide levels was 394 pg/mL (102-1,392 pg/mL). Each decile change increase in amino-terminal pro-B-type natriuretic peptide was associated with a change in ICU length of stay by 8.7%, (95% CI, 2.4-15.5), hospital length of stay by 5.7% (95% CI, 0.4-11.2), organ dysfunction by 5.1% (95% CI, 1.8-8.5), a higher inotropic score at 12, 24, and 36 hours, and longer time requiring vasoactive agents. There was a significant correlation between baseline amino-terminal pro-B-type natriuretic peptide and the Pediatric RISk of Mortality 3 score (Spearman rho = 0.247; p = 0.029). CONCLUSIONS: This pilot study shows an association between emergency department amino-terminal pro-B-type natriuretic peptide on presentation and worse septic shock outcomes and amino-terminal pro-B-type natriuretic peptide levels correlates with an ICU severity score.

Self-regulation via neural simulation.

Can taking the perspective of other people modify our own affective responses to stimuli? To address this question, we examined the neurobiological mechanisms supporting the ability to take another person's perspective and thereby emotionally experience the world as they would. We measured participants' neural activity as they attempted to predict the emotional responses of two individuals that differed in terms of their proneness to experience negative affect. Results showed that behavioral and neural signatures of negative affect (amygdala activity and a distributed multivoxel pattern reflecting affective negativity) simulated the presumed affective state of the target person. Furthermore, the anterior medial prefrontal cortex (mPFC)-a region implicated in mental state inference-exhibited a perspective-dependent pattern of connectivity with the amygdala, and the multivoxel pattern of activity within the mPFC differentiated between the two targets. We discuss the implications of these findings for research on perspective-taking and self-regulation.

Patterns of Care at the End of Life for Children and Young Adults with Life-Threatening Complex Chronic Conditions.

OBJECTIVE: To characterize patterns of care at the end of life for children and young adults with life-threatening complex chronic conditions (LT-CCCs) and to compare them by LT-CCC type. STUDY DESIGN: Cross-sectional survey of bereaved parents (n = 114; response rate of 54%) of children with noncancer, noncardiac LT-CCCs who received care at a quaternary care children's hospital and medical record abstraction. RESULTS: The majority of children with LT-CCCs died in the hospital (62.7%) with more than one-half (53.3%) dying in the intensive care unit. Those with static encephalopathy (AOR, 0.19; 95% CI, 0.04-0.98), congenital and chromosomal disorders (AOR, 0.28; 95% CI, 0.09-0.91), and pulmonary disorders (AOR, 0.08; 95% CI, 0.01-0.77) were significantly less likely to die at home compared with those with progressive central nervous system (CNS) disorders. Almost 50% of patients died after withdrawal or withholding of life-sustaining therapies, 17.5% died during active resuscitation, and 36% died while receiving comfort care only. The mode of death varied widely across LT-CCCs, with no patients with pulmonary disorders dying receiving comfort care only compared with 66.7% of those with CNS progressive disorders. A majority of patients had palliative care involvement (79.3%); however, in multivariable analyses, there was distinct variation in receipt of palliative care across LT-CCCs, with patients having CNS static encephalopathy (AOR, 0.07; 95% CI, 0.01-0.68) and pulmonary disorders (AOR, 0.07; 95% CI, 0.01-.09) significantly less likely to have palliative care involvement than those with CNS progressive disorders. CONCLUSIONS: Significant differences in patterns of care at the end of life exist depending on LT-CCC type. Attention to these patterns is important to ensure equal access to palliative care and targeted improvements in end-of-life care for these populations.

Medication Reconciliation Failures in Children and Young Adults With Chronic Disease During Intensive and Intermediate Care.

OBJECTIVES: Although medication reconciliation has become standard during hospital admission, rates of unintentional medication discrepancies during intensive care of pediatric patients with chronic disease are unknown. Such discrepancies are an important cause of adverse drug events in adults with chronic illness and are associated with unintentional discontinuation of chronic medications. We sought to determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease. DESIGN: Prospective observational cohort study. SETTING: Patients discharged from the intensive and intermediate care units at a tertiary care children's hospital from September 2013 to May 2014. PATIENTS: Consecutive sample of 308 patients less than 25 years old with chronic disease defined by prescription of at least one predetermined class of chronic medication prior to hospitalization. MEASUREMENTS AND MAIN RESULTS: The number of unintentional medication discrepancies with the potential for harm, as well as patient and medication-related factors predisposing patients to these errors were assessed. Two thousand seven hundred thirty-nine medication discrepancies were identified; 284 (10%) were unintentional and had the potential for harm (0.9/patient). Of these, 128 (45%) were due to errors in taking the preadmission medication history, whereas 156 (55%) were due to errors reconciling the medication history with orders. Most events occurred at admission (66%) and were dosing errors (45%). In multivariable negative binomial regression analyses (adjusted rate ratios [95% CI]), each additional preadmission medication (1.07 [1.04-1.10]), chronic respiratory medications (1.51 [1.01-2.28]), and chronic noninvasive ventilation (1.53 [1.07-2.19]) were associated with increased risk of a discrepancy. CONCLUSIONS: Unintentional medication discrepancies with the potential for harm are common among children and young adults with chronic disease during critical care admission due to both failure to obtain an accurate medication history and errors in reconciling the history with patient orders. The use of current medication reconciliation processes is insufficient to prevent errors in this high-risk population.

When Is an Adolescent an Adult? Assessing Cognitive Control in Emotional and Nonemotional Contexts.

An individual is typically considered an adult at age 18, although the age of adulthood varies for different legal and social policies. A key question is how cognitive capacities relevant to these policies change with development. The current study used an emotional go/no-go paradigm and functional neuroimaging to assess cognitive control under sustained states of negative and positive arousal in a community sample of one hundred ten 13- to 25-year-olds from New York City and Los Angeles. The results showed diminished cognitive performance under brief and prolonged negative emotional arousal in 18- to 21-year-olds relative to adults over 21. This reduction in performance was paralleled by decreased activity in fronto-parietal circuitry, implicated in cognitive control, and increased sustained activity in the ventromedial prefrontal cortex, involved in emotional processes. The findings suggest a developmental shift in cognitive capacity in emotional situations that coincides with dynamic changes in prefrontal circuitry. These findings may inform age-related social policies.

Tight glycemic control after pediatric cardiac surgery in high-risk patient populations: a secondary analysis of the safe pediatric euglycemia after cardiac surgery trial.

BACKGROUND: Our previous randomized, clinical trial showed that postoperative tight glycemic control (TGC) for children undergoing cardiac surgery did not reduce the rate of health care-associated infections compared with standard care (STD). Heterogeneity of treatment effect may exist within this population. METHODS AND RESULTS: We performed a post hoc exploratory analysis of 980 children from birth to 36 months of age at the time of cardiac surgery who were randomized to postoperative TGC or STD in the intensive care unit. Significant interactions were observed between treatment group and both neonate (age ≤30 days; P=0.03) and intraoperative glucocorticoid exposure (P=0.03) on the risk of infection. The rate and incidence of infections in subjects ≤60 days old were significantly increased in the TGC compared with the STD group (rate: 13.5 versus 3.7 infections per 1000 cardiac intensive care unit days, P=0.01; incidence: 13% versus 4%, P=0.02), whereas infections among those >60 days of age were significantly reduced in the TGC compared with the STD group (rate: 5.0 versus 14.1 infections per 1000 cardiac intensive care unit days, P=0.02; incidence: 2% versus 5%, P=0.03); the interaction of treatment group by age subgroup was highly significant (P=0.001). Multivariable logistic regression controlling for the main effects revealed that previous cardiac surgery, chromosomal anomaly, and delayed sternal closure were independently associated with increased risk of infection. CONCLUSIONS: This exploratory analysis demonstrated that TGC may lower the risk of infection in children >60 days of age at the time of cardiac surgery compared with children receiving STD. Meta-analyses of past and ongoing clinical trials are necessary to confirm these findings before clinical practice is altered. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00443599.

Parental Factors That Confer Risk and Resilience for Remote Learning Outcomes During the COVID-19 Pandemic Among Children With and Without Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: To test whether parental factors including internalizing symptoms, parenting style, and confidence in assisting with remote learning conferred risk/resilience for children with/without ADHD's learning and emotional outcomes during the COVID-19 pandemic. METHOD: 291 parents of children (ages 6-13; n = 180 males) with (n = 148) and without ADHD completed questionnaires online (April-July 2020). RESULTS: Structural equation modeling identified parental risk/resilience factors. Across groups, risk predicted greater difficulties with learning, internalizing and externalizing symptoms, while parent confidence in educating their child predicted better outcomes. A positive association was observed between parental involvement and child difficulties, which was stronger in families of children with ADHD. Children with/without ADHD did not differ in remote learning difficulties. CONCLUSION: Parent factors impacted child emotional and learning outcomes during the pandemic. With increases in remote learning practices, there is a need for improved understanding of how parent factors impact outcomes of children with/without ADHD.

Measuring Emotion Dysregulation in Children With Attention-Deficit/Hyperactivity Disorder: Revisiting the Factor Structure of the Emotion Regulation Checklist.

Emotion dysregulation (ED) is prevalent among youth with Attention-Deficit/Hyperactivity Disorder (ADHD) and significantly impacts functioning. Nuanced measurement of ED is central to understanding its role in this disorder and informing treatment approaches. The present study examined the factor structure of the Emotion Regulation Checklist (ERC) among children with ADHD with and without Oppositional Defiant Disorder (ODD). Exploratory factor analysis (EFA) conducted in a sample of 328 youth (mean age = 6.08) with ADHD indicated a four-factor solution, comprised of the following factors: Negative Emotion Lability, Positive Emotion Lability, Socially Appropriate Affect, and Socially Incongruent Affect. The Negative and Positive Emotion Lability subscales assess the reactivity of negatively and positively valenced emotions, respectively. The Socially Appropriate and Socially Incongruent Affect subscales provide an assessment of social-emotional functioning. All subscales discriminated between children with ADHD only and ADHD with co-morbid ODD, such that children with ODD had greater emotional lability and social-emotional difficulties. This revised factor structure of the ERC facilitates a uniquely brief, yet multifaceted and specific, assessment of emotional difficulties in children with ADHD that can inform treatment planning and operationalize emotional reactivity and social-emotional functioning in future research efforts.

Adolescent-Specific Motivation Deficits in Autism Versus Typical Development.

Differences in motivation during adolescence relative to childhood and adulthood in autism was tested in a cross-sectional study. 156 Typically developing individuals and 79 individuals with autism ages 10-30 years of age completed a go/nogo task with social and non-social cues. To assess age effects, linear and quadratic models were used. Consistent with prior studies, typically developing adolescents and young adults demonstrated more false alarms for positive relative to neutral social cues. In autism, there were no changes in attention across age for social or non-social cues. Findings suggest reduced orienting to motivating cues during late adolescence and early adulthood in autism. The findings provide a unique perspective to explain the challenges for adolescents with autism transitioning to adulthood.

Detection of eye contact with deep neural networks is as accurate as human experts.

Eye contact is among the most primary means of social communication used by humans. Quantification of eye contact is valuable as a part of the analysis of social roles and communication skills, and for clinical screening. Estimating a subject's looking direction is a challenging task, but eye contact can be effectively captured by a wearable point-of-view camera which provides a unique viewpoint. While moments of eye contact from this viewpoint can be hand-coded, such a process tends to be laborious and subjective. In this work, we develop a deep neural network model to automatically detect eye contact in egocentric video. It is the first to achieve accuracy equivalent to that of human experts. We train a deep convolutional network using a dataset of 4,339,879 annotated images, consisting of 103 subjects with diverse demographic backgrounds. 57 subjects have a diagnosis of Autism Spectrum Disorder. The network achieves overall precision of 0.936 and recall of 0.943 on 18 validation subjects, and its performance is on par with 10 trained human coders with a mean precision 0.918 and recall 0.946. Our method will be instrumental in gaze behavior analysis by serving as a scalable, objective, and accessible tool for clinicians and researchers.

Rigidity coincides with reduced cognitive control to affective cues in children with autism.

The present study tested whether salient affective cues would negatively influence cognitive control in children with and without autism spectrum disorder (ASD). One hundred children aged 6-12 years who were either typically developing or had ASD performed a novel go/no-go task to cues of their interest versus cues of noninterest. Linear mixed-effects (LME) models for hit rate, false alarms, and the sensitivity index d' were used to test for group differences. Caregivers completed the Repetitive Behavior Scale-Revised to test associations between repetitive behaviors and task performance. Children with ASD had reduced cognitive control toward their interests compared with typically developing children. Further, children with ASD showed reduced cognitive control to interests compared with noninterests, a pattern not observed in typically developing children. Decreased cognitive control toward interests was associated with higher insistence on sameness behavior in ASD, but there was no association between sameness behavior and cognitive control for noninterests. Together, children with ASD demonstrated decreased cognitive flexibility in the context of increased affective salience related to interests. These results provide a mechanism for how salient affective cues, such as interests, interfere with daily functioning and social communication in ASD. Further, the findings have broader clinical implications for understanding how affective cues can drive interactions between restricted patterns of behavior and cognitive control. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

How effective is LENA in detecting speech vocalizations and language produced by children and adolescents with ASD in different contexts?

The LENA system was designed and validated to provide information about the language environment in children 0 to 4 years of age and its use has been expanded to populations with a number of communication profiles. Its utility in children 5 years of age and older is not yet known. The present study used acoustic data from two samples of children with autism spectrum disorders (ASD) to evaluate the reliability of LENA automated analyses for detecting speech utterances in older, school age children, and adolescents with ASD, in clinic and home environments. Participants between 5 and 18 years old who were minimally verbal (study 1) or had a range of verbal abilities (study 2) completed standardized assessments in the clinic (study 1 and 2) and in the home (study 2) while speech was recorded from a LENA device. We compared LENA segment labels with manual ground truth coding by human transcribers using two different methods. We found that the automated LENA algorithms were not successful (<50% reliable) in detecting vocalizations from older children and adolescents with ASD, and that the proportion of speaker misclassifications by the automated system increased significantly with the target-child's age. The findings in children and adolescents with ASD suggest possibly misleading results when expanding the use of LENA beyond the age ranges for which it was developed and highlight the need to develop novel automated methods that are more appropriate for older children. Autism Research 2019, 12: 628-635. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Current commercially available speech detection algorithms (LENA system) were previously validated in toddlers and children up to 48 months of age, and it is not known whether they are reliable in older children and adolescents. Our data suggest that LENA does not adequately capture speech in school age children and adolescents with autism and highlights the need to develop new automated methods for older children.

A Study of Global Health Elective Outcomes: A Pediatric Residency Experience.

Background and Objectives: To identify the effects of global health electives over a decade in a pediatric residency program. Methods: This was an anonymous email survey of the Boston Combined Residency alumni funded for global health electives from 2002 to 2011. A test for trend in binomial proportions and logistic regression were used to document associations between elective and participant characteristics and the effects of the electives. Qualitative data were also analyzed. Results: Of the 104 alumni with available email addresses, 69 (66%) responded, describing 94 electives. Elective products included 27 curricula developed, 11 conference presentations, and 7 academic publications. Thirty-two (46%) alumni continued global health work. Previous experience, previous travel to the site, number of global electives, and cumulative global elective time were associated with postresidency work in global health or with the underserved. Conclusions: Resident global electives resulted in significant scholarship and teaching and contributed to long-term career trajectories.

Neural correlates of preferred activities: development of an interest-specific go/nogo task.

The activities we choose to spend our leisure time with are intrinsically motivating and vary across individuals. Yet it is unknown how impulse control or neural activity changes when processing a preferred stimulus related to a hobby or interest. Developing a task that assesses the response to preferred interests is of importance as it would be relevant to a range of psychiatric disorders that have hyper- or hypo-arousal to such cues. During functional Magnetic Resonance Imaging (fMRI), 39 healthy adults completed a novel task to test approach behavior and cognitive control to cues that were personalized to the participants' interests compared to stimuli the participants identified as being of non-interest and colored shapes. fMRI results showed that cues of one's interest elicited activation in the anterior insula compared to colored shapes. Interests did not change inhibition compared to non-interests and colored shapes and all stimuli equally engaged a frontostriatal circuit. Together the results suggest that adults were sensitive to their interests but were effective at regulating their impulses towards these cues, a skill that is critical for navigating the temptations and distractions in our daily environment.

Patients with bulimia nervosa do not show typical neurodevelopment of cognitive control under emotional influences.

Bulimia nervosa (BN) emerges in the late teen years and is characterized by binge eating and related compensatory behaviors. These behaviors often co-occur with periods of negative affect suggesting an association between emotions and control over eating behavior. In the current study, we examined how cognitive control and neural processes change under emotional states of arousal in 46 participants with (n=19) and without (n=27) BN from the ages of 18-33 years. Participants performed a go/nogo task consisting of brief negative, positive and neutral emotional cues and sustained negative, positive and neutral emotional states of arousal during functional magnetic resonance imaging (fMRI). Overall task performance improved with age for healthy participants, but not for patients with BN. These age-dependent behavioral effects were paralleled by diminished recruitment of prefrontal control circuitry in patients with BN with age. Although patients with BN showed no difference in performance on the experimental manipulations of negative emotions, sustained positive emotions related to improved performance among patients with BN. Together the findings highlight a neurodevelopmental approach towards understanding markers of psychopathology and suggest that sustained positive affect may have potential therapeutic effects on maintaining behavioral control in BN.

Perspectives of host faculty and trainees on international visiting faculty to paediatric academic departments in East Africa.

BACKGROUND: Investments in faculty exchanges to build physician workforce capacity are increasing. Little attention has been paid to the expectations of host institution faculty and trainees. This prospective qualitative research study explored faculty and resident perspectives about guest faculty in paediatric departments in East Africa, asking (1) What are the benefits and challenges of hosting guest faculty, (2) What factors influence the effectiveness of faculty visits and (3) How do host institutions prepare for faculty visits? METHODS: We recruited 36 faculty members and residents from among four paediatric departments in East Africa to participate in semistructured interviews which were audio recorded and transcribed. Data were qualitatively analysed using principles of open coding and thematic analysis. We achieved saturation of themes. RESULTS: Benefits of faculty visits varied based on the size and needs of host institutions. Emergent themes included the importance of guest faculty time commitment, and mutual preparation to ensure that visit goals and scheduling met host needs. We documented conflicts that developed around guest emotional responses and ethical approaches to clinical resource limitations, which some hosts tried to prepare for and mitigate. Imbalance in resources led to power differentials; some hosts sought partnerships to re-establish control over the process of having guests. CONCLUSIONS: We identified that guest faculty can assist paediatric institutions in building capacity; however, effective visits require: (1) mutually agreed on goals with appropriate scheduling, visit length and commitment to ensure that the visits meet the host's needs, (2) careful selection and preparation of guest faculty to meet the host's goals, (3) emotional preparation by prospective guests along with host orientation to clinical work in the host's setting and (4) attention to funding sources for the visit and mitigation of resulting power differentials.