Best Practices and Educator Strategies for Facilitating a Flipped Classroom in Graduate Medical Education.

OBJECTIVE: Effective flipped classroom (FC) education fosters learner engagement, promoting higher-level cognitive skills. FC learning in graduate medical education (GME) has increased, but few educators have significant experience with FC facilitation. There are no evidence-based practices to support professional development of FC facilitation skills in GME. The objective of this study is to identify best practices for effective FC facilitation in GME. STUDY DESIGN: We conducted a mixed-methods, cross-sectional study of faculty educators who participated in a randomized controlled trial (RCT) using FC for physiology education in neonatal-perinatal medicine. Educators completed a 25-question survey about effective strategies for FC facilitation. A subset of educators participated in interviews to share their FC facilitation experiences and strategies to maximize learner engagement. Quantitative survey data were analyzed with descriptive statistics. Qualitative survey and interview data were coded and analyzed inductively to identify themes. RESULTS: Seventy-five educators completed the survey (75/136, 55% response rate), and 11 participated in semistructured interviews. While educators facilitated a median of two FC sessions (interquartile range: 1, 5) during the RCT, 43 (57%) had not received prior training in FC facilitation. Qualitative data analyses generated five themes that aligned with quantitative survey results: (1) educator preferences, (2) unique FC facilitation skills, (3) learning environment optimization, (4) subject matter expertise, and (5) learner behavior management. Sixty-two educators (83%) felt they were well prepared to lead FC sessions. Thirty-six educators (48%) reported that unprepared learners disrupt the learning environment, and the provision of clear expectations and adequate time to prepare for FCs improves learner preparation. Strategies to facilitate effective FC sessions included creating a safe learning environment and engaging learners in critical thinking. CONCLUSION: Educators highlighted faculty development needs, strategies, and actions to promote effective FC facilitation. Further exploration through learner interviews will provide additional evidence for the development of best practices and resources for FC facilitation. KEY POINTS: · Educators prefer the FC educational modality over traditional didactic lectures.. · Prior experiences in simulation debriefing provide foundational skills for new FC facilitators.. · Setting learner expectations and ensuring safe space in the classroom encourage learner engagement.. · Educator and learner preparation for FC is essential to optimize the learning experience.. · Unique approaches in facilitation are required to support all types of learners..

A new era of assessment for neonatal-perinatal medicine trainees: milestones 2.0.

To optimize post-graduate competency-based assessment for medical trainees, the Accreditation Council for Graduate Medical Education initiated a sub-specialty-specific revision of the existing Milestones 1.0 assessment framework in 2016. This effort was intended to increase both the effectiveness and accessibility of the assessment tools by incorporating specialty-specific performance expectations for medical knowledge and patient care competencies; decreasing item length and complexity; minimizing inconsistencies across specialties through the development of common "harmonized" milestones; and providing supplemental materials, including examples of expected behaviors at each developmental level, suggested assessment strategies, and relevant resources. This manuscript describes the efforts of the Neonatal-Perinatal Medicine Milestones 2.0 Working Group, outlines the overall intent of Milestones 2.0, compares the novel Milestones to the original version, and details the materials contained in the novel supplemental guide. This new tool should enhance NPM fellow assessment and professional development while maintaining consistent performance expectations across specialties.

Flipping the Teachers: Impact of a Standardized Physiology Curriculum on Neonatology Medical Educators.

OBJECTIVE: Academic physicians must teach elements in an Accreditation Council for Graduate Medical Education (ACGME)-mandated curriculum while balancing career development and clinical workload. Exploring educator perceptions on the learning environment and comparing two instructional methods (traditional didactics [TD] vs. flipped classroom [FC]) in one pediatric subspecialty may elucidate current challenges, barriers, and strategies to optimize learning and educator satisfaction. STUDY DESIGN: A randomized trial comparing effectiveness and learner preference for FC versus TD physiology teaching was conducted in ACGME-accredited neonatal-perinatal medicine (NPM) fellowship programs in 2018 to 2019. Educator preferences were elicited through online surveys pre- and postintervention. Free-text comments were provided for questions exploring strengths, challenges, and opportunities in fellowship education. Statistical analysis included comparisons of demographics and pre-post-intervention educator responses between groups. Thematic analysis of text responses was conducted to identify common subthemes. RESULTS: From 61 participating programs, 114 FC educators and 130 TD educators completed surveys. At baseline, all educators experienced professional satisfaction from teaching fellows, but noted challenges with time available to create and/or deliver educational content, limited content expertise amongst faculty, colleagues' limited enthusiasm toward educating fellows, and lack of perceived value of education by institutions given limited protected time or credit toward promotion. Postintervention, educators in both groups noted a preference to teach physiology using FC due to interactivity, learner enthusiasm, and learner-centeredness. FC educators had a 17% increase in preference to teach using FC (p = 0.001). Challenges with FC included ensuring adequate trainee preparation, protecting educational time, and providing educators with opportunities to develop facilitation skills. CONCLUSION: Overall, NPM educators in a trial evaluating a standardized, peer-reviewed curriculum report professional satisfaction from teaching, but described logistical challenges with developing/delivering content. Educators preferred instruction using FC, but identified challenges with learner preparedness and ensuring adequate educator time and skill. Future efforts should be dedicated to addressing these barriers. KEY POINTS: · Many challenges exist for educators teaching neonatal-perinatal medicine fellows, including time, support, and recognition.. · Many educators preferred using flipped classroom methodology with a standardized curriculum due to interactivity and learner-centeredness.. · Benefits of a standardized, peer-reviewed curriculum include reduced preparation time, adaptability of content, and learning environment enhancement..

Comparison of knowledge acquisition and retention following traditional didactic vs. flipped classroom education utilizing a standardized national curriculum: a randomized controlled trial.

OBJECTIVE: Measure the effectiveness of and preference for a standardized, national curriculum utilizing flipped classrooms (FC) in neonatal-perinatal medicine (NPM) fellowships. STUDY DESIGN: Multicentered equivalence, cluster randomized controlled trial of NPM fellowship programs randomized to receive standardized physiology education as in-class lectures (traditional didactic, TD arm) or as pre-class online videos followed by in-class discussions (FC arm). Four multiple-choice question quizzes and three surveys were administered to measure knowledge acquisition, retention, and educational preferences. RESULTS: 530 fellows from 61 NPM fellowships participated. Quiz performance was comparable between groups at all time points (p = NS, TD vs FC at 4 time points). Post intervention, more fellows in both groups preferred group discussions (pre/post FC 42% vs. 58%, P = 0.002; pre/post TD 43% vs. 60%, P = < 0.001). FC fellows were more likely to rate classroom effectiveness positively (FC/TD, 70% vs. 36%, P < 0.001). CONCLUSIONS: FCs promote knowledge acquisition and retention equivalent to TD and FC modalities are preferred by fellows.

Value, Strengths, and Challenges of e-Learning Modules Paired with the Flipped Classroom for Graduate Medical Education: A Survey from the National Neonatology Curriculum.

OBJECTIVE: This study aimed to determine the value, strengths, and challenges of implementing an e-learning based flipped classroom (FC) educational modality as part of the standardized physiology National Neonatology Curriculum (NNC), created for neonatal-perinatal medicine (NPM) fellow learners and faculty educators. STUDY DESIGN: This is a cross-sectional study of NPM fellows and faculty educators who utilized at least one of the e-learning based NNC FC respiratory physiology programs between May and September 2018. Participants were surveyed anonymously regarding their experiences participating in the NNC, including measures of preparation time. A combination of descriptive statistics and proportion comparisons were used for data analysis. RESULTS: Among 172 respondents, the majority of fellow and faculty respondents reported positive attitudes toward the educational content and case discussions, and the majority supported national standardization of NPM physiology education (92%). Fellows reported greater preclass preparation for their FC compared with previous didactic lectures (30-60 vs. 0-15 minutes, p < 0.01). Faculty facilitators reported less preparation time before facilitating a FC compared with the time required for creating a new didactic lecture (median: 60 vs. 240 minutes, p < 0.01). Both fellows and faculty respondents preferred the FC approach to traditional didactics, with fellows showing a greater degree of preference than faculty (68 vs. 52%, respectively, p = 0.04). CONCLUSION: Fellows and faculty educators supported the FC learning, reporting peer-to-peer learning, and the establishment of a learning community which promotes adult learning and critical thinking skills. A national physiology curriculum creates equitable and engaging educational experiences for all NPM fellows while reducing individual program burden of content creation. Our findings further supported the development of an NNC using a flipped classroom modality.

Oxygen and mechanical ventilation impede the functional properties of resident lung mesenchymal stromal cells.

Resident/endogenous mesenchymal stromal cells function to promote the normal development, growth, and repair of tissues. Following premature birth, the effects of routine neonatal care (e.g. oxygen support and mechanical ventilation) on the biological properties of lung endogenous mesenchymal stromal cells is (L-MSCs) is poorly understood. New Zealand white preterm rabbits were randomized into the following groups: (i) sacrificed at birth (Fetal), (ii) spontaneously breathing with 50% O2 for 4 hours (SB), or (iii) mechanical ventilation with 50% O2 for 4h (MV). At time of necropsy, L-MSCs were isolated, characterized, and compared. L-MSCs isolated from the MV group had decreased differentiation capacity, ability to form stem cell colonies, and expressed less vascular endothelial growth factor mRNA. Compared to Fetal L-MSCs, 98 and 458 genes were differentially expressed in the L-MSCs derived from the SB and MV groups, respectively. Gene ontology analysis revealed these genes were involved in key regulatory processes including cell cycle, cell division, and angiogenesis. Furthermore, the L-MSCs from the SB and MV groups had smaller mitochondria, nuclear changes, and distended endoplasmic reticula. Short-term hyperoxia/mechanical ventilation after birth alters the biological properties of L-MSCs and stimulates genomic changes that may impact their reparative potential.

Flipping the classroom: a national pilot curriculum for physiology in neonatal-perinatal medicine.

OBJECTIVE: To explore interest, feasibility, perceived effectiveness, and acceptability of a standardized, national physiology curriculum for neonatal-perinatal medicine (NPM) fellows using online videos for knowledge acquisition paired with flipped classrooms (FCs) for knowledge application. STUDY DESIGN: Two educational programs pairing online videos with FCs were developed and peer-reviewed. These programs were piloted at five institutions. Fellows completed surveys, and fellows and educators participated in focus groups after their FC experiences. RESULTS: Thirty-five fellows responded to the survey. Forty-one fellows and six educators participated in focus groups. Fellows and educators preferred online videos paired with FCs over didactic teaching and perceived them to be effective for knowledge acquisition and application. CONCLUSION: Fellows and educators preferred FC learning over traditional didactics and reported that FCs facilitated creation of a learning community, fostering active learning. The favorable response toward this pilot project and the feasibility of its use supports further development of a standardized NPM physiology curriculum for fellowship training.

NewB for newbies: a randomized control trial training housestaff to perform neonatal intubation with direct and videolaryngoscopy.

BACKGROUND: Competency rates in neonatal intubation among pediatric residents are low and currently not meeting ACGME/AAP standards. AIMS: The aim of this study was to compare standard bedside teaching of neonatal endotracheal intubation to a computer module, as well as introduce residents to the emerging technology of videolaryngoscopy. METHODS: The study population consisted of The University of Texas Health Science Center at San Antonio Pediatric interns/residents and PGY-1 Anesthesia interns rotating through the NICU. Prior to participating in the study, the residents completed a survey addressing past experiences with intubation, comfort level, and prior use of direct and videolaryngoscopy. Participants then performed timed trials of both direct and videolaryngoscopy on the SimNewB(®). They had up to three attempts to successfully intubate, with up to 30 s on each attempt. After randomization, participants received one of the following teaching interventions: standard, computer module, or both. This was followed by a second intubation trial and survey completion. RESULTS: Thirty residents were enrolled in the study. There was significant improvement in time to successful intubation in both methods after any teaching intervention (direct 22.0 ± 13.4 s vs 14.7 ± 5.9 s, P = 0.002 and videolaryngoscopy 42.2 ± 29.3 s vs 26.8 ± 18.6 s, P = 0.003). No differences were found between the types of teaching. Residents were faster at intubating with direct laryngoscopy compared to videolaryngoscopy before and after teaching. By the end of the study, only 33% of residents preferred using videolaryngoscopy over direct laryngoscopy, but 76% felt videolaryngoscopy was better to teach intubation. CONCLUSIONS: Both standard teaching and computer module teaching of neonatal intubation on a mannequin model results in improved time to successful intubation and overall improved resident confidence with intubation equipment and technique. Although intubation times were lower with direct laryngoscopy compared to videolaryngoscopy, the participating residents felt that videolaryngoscopy is an important educational tool.

TGF-ß2, a protective intestinal cytokine, is abundant in maternal human milk and human-derived fortifiers but not in donor human milk.

OBJECTIVE: This study compared cytokines (in particular transforming growth factor [TGF]-ß2) and lactoferrin in maternal human milk (MHM), human-derived milk fortifier (HDMF), and donor human milk (DHM). MATERIALS AND METHODS: MHM was randomly collected from breastfeeding mothers who had no infectious illness at the time of milk expression. HDMF and DHM were products derived from human milk processed by Holder pasteurization. MHM samples were collected at different times (early/late) and gestations (preterm/term). Lactoferrin was analyzed by western blotting, and cytokines were quantified using commercial enzyme-linked immunosorbent assays. Significance was determined using analysis of variance. RESULTS: In the 164 samples analyzed, TGF-ß2 concentrations in HDMF and preterm MHM (at all collection times) were fivefold higher than in DHM (p<0.05). Early preterm MHM had levels of interleukin (IL)-10 and IL-18, 11-fold higher than DHM (p<0.05). IL-6 in DHM was 0.3% of the content found in MHM. IL-18 was fourfold higher in early MHM versus late MHM regardless of gestational age (p<0.05). Lactoferrin concentration in DHM was 6% of that found in MHM. CONCLUSIONS: Pasteurization decreases concentrations of most cytokines and lactoferrin in DHM. TGF-ß2, a protective intestinal cytokine, has comparable concentrations in HDMF to MHM despite pasteurization.

Neonatal chlamydial pneumonia induces altered respiratory structure and function lasting into adult life.

Respiratory dysfunction in adults has been correlated with neonatal Chlamydia trachomatis pneumonia in several studies, but a causal association has not been clearly demonstrated. In this study, we examined radial alveolar counts (RACs) by microscopy, and airway and parenchymal lung function using a small animal ventilator in juvenile (5 weeks age) and adult (8 weeks age) BALB/c mice challenged as neonates with Chlamydia muridarum (C. mur) on day 1 or day 7 after birth, representing saccular (human pre-term neonates) and alveolar (human term neonates) stages of lung development, respectively. Pups challenged with C. mur on either day 1 or 7 after birth demonstrated significantly enhanced airway hyperreactivity and lung compliance, both as juveniles (5 weeks age) and adults (8 weeks age), compared with mock-challenged mice. Moreover, mice challenged neonatally with Chlamydia displayed significantly reduced RACs, suggesting emphysematous changes. Antimicrobial treatment during the neonatal infection induced early bacterial clearance and partially ameliorated the Chlamydia-induced lung dysfunction as adults. These results suggest that neonatal chlamydial pneumonia, especially in pre-term neonates, is a cause of respiratory dysfunction continuing into adulthood, and that antimicrobial administration may be partially effective in preventing the adverse respiratory sequelae in adulthood. The results of our studies also emphasize the importance of prenatal screening and treatment of pregnant women for C. trachomatis in order to prevent the infection of neonates.

Regulation of epithelial Na+ channel (ENaC) in the salivary cell line SMG-C6.

Glucocorticoids and mineralocorticoids modulate Na+ transport via epithelial Na+ channels (ENaC). The rat submandibular epithelial cell line, SMG-C6, expresses alpha-ENaC mRNA and protein and exhibits amiloride-sensitive Na+ transport when grown in low-serum (2.5%) defined medium, therefore, we examined the effects of altering the composition of the SMG-C6 cell growth medium on ENaC expression and function. No differences in basal or amiloride-sensitive short-circuit current (Isc) were measured across SMG-C6 monolayers grown in the absence of thyroid hormone, insulin, transferrin, or EGF. In the absence of hydrocortisone, basal and amiloride-sensitive Isc significantly decreased. Similarly, monolayers grown in 10% serum-supplemented medium had lower basal Isc and no response to amiloride. Adding hydrocortisone (1.1 microM) to either the low or 10% serum medium increased basal and amiloride-sensitive Isc, which was blocked by RU486, the glucocorticoid and progesterone receptor antagonist. Aldosterone also induced an increase in alpha-ENaC expression and Na+ transport, which was also blocked by RU486 but not by the mineralocorticoid receptor antagonist spironolactone. Thus, in the SMG-C6 cell line, hydrocortisone and aldosterone increased ENaC expression and basal epithelial Na+ transport. The absence of endogenous ENaC expression in culture conditions devoid of steroids makes the properties of this cell line an excellent model for investigating pathways regulating ENaC expression and Na+ transport.

Induction of serum- and glucocorticoid-induced kinase-1 (SGK1) by cAMP regulates increases in alpha-ENaC.

Alpha-ENaC expression and activity is regulated by a variety of hormones including beta-adrenergic agonists via the second messenger cAMP. We evaluated the early intermediate pathways involved in the up-regulation of SGK1 by DbcAMP and whether SGK1 is a prerequisite for induction of alpha-ENaC expression. Submandibular gland epithelial (SMG-C6) cells treated with DbcAMP (1 mM) induced both SGK1 mRNA and protein expression. DbcAMP-stimulated SGK1 mRNA expression was decreased by actinomycin D and mRNA and protein expressions were attenuated by PKA inhibitors (H-89 and KT5720). Inhibition of PI3-K with either LY294002 or dominant negative PI3-K reduced DbcAMP-stimulated SGK1 protein and mRNA levels, attenuated the phosphorylation of CREB (a cAMP-activated transcription factor) and decreased alpha-ENaC protein levels and Na(+) transport. In addition, the combination of PKA inhibitors with dominant negative PI3-K synergistically inhibited DbcAMP-induced Na(+) transport. Inhibition of SGK1 expression by siRNA decreased but did not obliterate DbcAMP-induced alpha-ENaC expression. Thus, in a cell line which endogenously exhibits minimal alpha-ENaC expression, induction of SGK1 by DbcAMP occurs via the PI3-K and PKA pathways. Increased alpha-ENaC levels and function are partly dependent upon the early induction of SGK1 expression.

El secuestro: su repercusion en las creencias y en la estructura de relaciones en un grupo de familias antioqueñas / Kidnap and effects in Antioquia's family

Se investigó en forma multidimensional el secuestro, acto sociopolítico del conflicto armado interno en Colombia, y su impacto en las relaciones y paradigmas de 32 familias de Antioquia, departamento que ocupa el primer puesto en el país y en el mundo con respecto a esta situación. Tales relaciones y paradigmas se evaluaron en un periodo supuestamente critico, cuatro a nueve meses después de la liberación. El objetivo fue describir las interacciones y las creencias de familias afectadas con un secuestro y su asociación con la alteración del equilibrio y la necesidad terapéutica individual y familiar. Los instrumentos aplicados fueron entrevista colaborativa-reflexiva, escala de visión del mundo y genograma. Los resultados señalaron que las familias definieron la unión como esencial a su identidad y como creencia proyectada a dos pilares culturales, el dinero y la religiosidad. La estructura de relaciones era muy cercana y después del cautiverio la pareja fue más simétrica, el padre se unió a los hijos y la jerarquía fue democrática. Lo religioso-práctico y la habilidad negociadora se fortalecieron. Por último, la credibilidad en el Estado disminuyó, pues sintieron que éste los abandonó. La mayoría enfrentó exitosamente el secuestro, pero el 85 por ciento lo connotó de manera negativa. El 28 por ciento presentó algún subsistema tensionado: pérdidas, explosión de vulnerabilidades y encierro. Se dieron dos asociaciones significativas: las relaciones con conflicto o distanciamiento y el tratamiento familiar y un escaso compromiso con la vida y el individual