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.

Consensus on an implicit bias and health disparities curriculum in neonatal medicine: a Delphi study.

OBJECTIVE: Despite longstanding and recurrent calls for effective implicit bias (IB) education in health professions education as one mechanism to reduce ongoing racism and health disparities, such curricula for neonatal-perinatal medicine (NPM) are limited. We aim to determine the key curricular elements for educating NPM fellows, advanced practice providers, and attending physicians in the critical topics of IB and health disparities. STUDY DESIGN: A modified Delphi study was performed with content experts in IB and health disparities who had educational relationships to those working and training in the neonatal intensive care unit. RESULT: Three Delphi rounds were conducted from May to November 2021. Experts reached consensus on a variety of items for inclusion in the curriculum, including educational goals, learning objectives, teaching strategies, and educator principles. CONCLUSION: Essential curricular components of an IB and health disparities curriculum for neonatal medicine were defined using rigorous consensus building methodology.

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.

Sintomatología musculoesquelética en trabajadores de postcosecha de un cultivo de flores de Cundinamarca / Musculoskeletal symptomatology in postharvest workers of a flower farm in Cundinamarca

Objetivos: Los síntomas musculoesquelético son una de las principales causas de perdida de la capacidad laboral y ausentismo en el mundo del trabajo. Los trabajadores de cultivo de flores están predispuestos a sufrirlas debido a la naturaleza de su trabajo. El Objetivo fue identificar la sintomatología musculoesquelética en los diferentes segmentos corporales. Material y Métodos: Estudio descriptivo con enfoque cuantitativo, la población fueron 135 trabajadores del área de postcosecha de un cultivo de flores ubicado en un municipio aledaño a la ciudad de Bogotá; se aplicaron 2 instrumentos, una encuesta de caracterización sociodemográfica y el cuestionario Nórdico Estandarizado. Resultados: Los segmentos corporales con presencia de síntomas fueron, la muñeca derecha 34%, espalda alta 32%, baja 27%, pies y tobillos 26%. El 99% de los trabajadores, atribuye su sintomatología músculo esquelética a la actividad laboral. Conclusión: Prevalencia significativa de síntomas músculo esqueléticos en los trabajadores en los últimos 12 meses. (AU)

Objetives: Musculoskeletal symptoms are one of the main causes of loss of work capacity and absenteeism in the world of work. Flower growing workers are predisposed to them due to the nature of their work. The objective was to identify the musculoskeletal symptomatology in the different body segments. Materials and Methods: Descriptive study with a quantitative approach, the population was 135 workers from the post-harvest area of a flower farm located in a municipality near the city of Bogotá, 2 instruments were applied, a sociodemographic characterization survey and the Standardized Nordic questionnaire. Results: The body segments with the presence of symptoms were the right wrist 34%, upper back 32%, lower back 27%, feet and ankles 26%. 99% of workers attribute their musculoskeletal symptoms to work activity. Conclusion: Significant prevalence of musculoskeletal symptoms in workers in the last 12 months. (AU)

Essentials of neonatal-perinatal medicine fellowship: scholarship perspective.

Neonatal-perinatal medicine fellows must achieve a meaningful accomplishment in scholarly activity as part of their training. Despite the requirement for scholarly training in fellowship, there is a vanishingly small number of MD-only physician-scientists pursuing a research-oriented career. Recent neonatal trainees have identified several factors that preclude their careers in research-focused academic neonatology, including lower pay in academic positions, inadequate training in research techniques, and the perception that individuals in research careers have a poor work-life balance. High competition for limited pediatric research funds also contributes to a diminishing pool of physician-scientists in neonatology. This small number of physician-scientists is threatened by a high rate of attrition among physicians who enter this career path. In order to prevent further declines in the number of neonatal physician-scientists, we need improvements in funding and strong intra- and cross-institutional mentorship to foster individuals interested in a career as a physician-scientist.

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.

Adaptación a la realidad de Latinoamérica de la Guía Clínica NASPGHAN/ESPGHAN 2016 sobre Diagnóstico, Prevención y Tratamiento de Infección por Helicobacter pylori en Pediatría / Adaptation to the reality of Latin America of the NASPGHAN/ESPGHAN 2016 Guidelines on the Diagnosis, Prevention and Treatment of Helicobacter pylori Infection in Pediatrics

Resumen: Introducción: Las últimas guías clínicas conjuntas de NASPGHAN y ESPGHAN en relación a la infección por H. pylori publicadas el año 2016, contienen 20 afirmaciones que han sido cuestionadas en la práctica respecto a su aplicabilidad en Latinoamérica (LA); en particular en relación a la preven ción del cáncer gástrico. Métodos: Se realizó un análisis crítico de la literatura, con especial énfasis en datos de LA y se estableció el nivel de evidencia y nivel de recomendación de las afirmaciones mas controversiales de las Guías Conjuntas. Se realizaron 2 rondas de votación de acuerdo a la técnica Delfi de consenso y se utilizó escala de Likert (de 0 a 4) para establecer el "grado de acuerdo" entre un grupo de expertos de SLAGHNP. Resultados: Existen pocos estudios en relación a diagnóstico, efectividad de tratamiento y susceptibilidad a antibióticos de H. pylori en pacientes pediátricos de LA. En base a estos estudios, extrapolaciones de estudios de adultos y la experiencia clínica del panel de expertos participantes, se realizan las siguientes recomendaciones. Recomendamos la toma de biopsias para test rápido de ureasa e histología (y muestras para cultivo o técnicas moleculares, cuando estén disponibles) durante la endoscopia digestiva alta sólo si en caso de confirmar la infección por H. pylori, se indicará tratamiento de erradicación. Recomendamos que centros regionales seleccio nados realicen estudios de sensibilidad/resistencia antimicrobiana para H. pylori y así actúen como centros de referencia para toda LA. En caso de falla de erradicación de H. pylori con tratamiento de primera línea, recomendamos tratamiento empírico con terapia cuádruple con inhibidor de bomba de protones, amoxicilina, metronidazol y bismuto por 14 días. En caso de falla de erradicación con el esquema de segunda línea, se recomienda indicar un tratamiento individualizado considerando la edad del paciente, el esquema indicado previamente y la sensibilidad antibiótica de la cepa, lo que implica realizar una nueva endoscopía con extracción de muestra para cultivo y antibiograma o es tudio molecular de resistencia. En niños sintomáticos referidos a endoscopía que tengan antecedente de familiar de primer o segundo grado con cáncer gástrico, se recomienda considerar la búsqueda de H. pylori mediante técnica directa durante la endoscopia (y erradicarlo cuando es detectado). Con clusiones: La evidencia apoya mayoritariamente los conceptos generales de las Guías NASPGHAN/ ESPGHAN 2016, pero es necesario adaptarlas a la realidad de LA, con énfasis en el desarrollo de centros regionales para el estudio de sensibilidad a antibióticos y mejorar la correcta selección del tratamiento de erradicación. En niños sintomáticos con antecedente familiar de primer o segundo grado de cáncer gástrico, se debe considerar la búsqueda y erradicación de H. pylori.

Abstract: Introduction: The latest joint H. pylori NASPGHAN and ESPGHAN clinical guidelines published in 2016, contain 20 statements that have been questioned in practice regarding their applicability in Latin America (LA); in particular in relation to gastric cancer prevention. Methods: We conduc ted a critical analysis of the literature, with special emphasis on LA data and established the level of evidence and level of recommendation of the most controversial claims in the Joint Guidelines. Two rounds of voting were conducted according to the Delphi consensus technique and a Likert scale (from 0 to 4) was used to establish the "degree of agreement" among a panel of SLAGHNP ex perts. Results: There are few studies regarding diagnosis, treatment effectiveness and susceptibility to antibiotics of H. pylori in pediatric patients of LA. Based on these studies, extrapolations from adult studies, and the clinical experience of the participating expert panel, the following recom mendations are made. We recommend taking biopsies for rapid urease and histology testing (and samples for culture or molecular techniques, when available) during upper endoscopy only if in case of confirmed H. pylori infection, eradication treatment will be indicated. We recommend that selected regional centers conduct antimicrobial sensitivity/resistance studies for H. pylori and thus act as reference centers for all LA. In case of failure to eradicate H. pylori with first-line treatment, we recommend empirical treatment with quadruple therapy with proton pump inhibitor, amoxi cillin, metronidazole, and bismuth for 14 days. In case of eradication failure with the second line scheme, it is recommended to indicate an individualized treatment considering the age of the pa tient, the previously indicated scheme and the antibiotic sensitivity of the strain, which implies performing a new endoscopy with sample extraction for culture and antibiogram or molecular resistance study. In symptomatic children referred to endoscopy who have a history of first or se cond degree family members with gastric cancer, it is recommended to consider the search for H. pylori by direct technique during endoscopy (and eradicate it when detected). Conclusions: The evidence supports most of the general concepts of the NASPGHAN/ESPGHAN 2016 Guidelines, but it is necessary to adapt them to the reality of LA, with emphasis on the development of regional centers for the study of antibiotic sensitivity and to improve the correct selection of the eradication treatment. In symptomatic children with a family history of first or second degree gastric cancer, the search for and eradication of H. pylori should be considered.

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.

[Adaptation to the reality of Latin America of the NASPGHAN/ESPGHAN 2016 Guidelines on the Diagnosis, Prevention and Treatment of Helicobacter pylori Infection in Pediatrics]. / Adaptación a la realidad de Latinoamérica de la Guía Clínica NASPGHAN/ESPGHAN 2016 sobre Diagnóstico, Prevención y Tratamiento de Infección por Helicobacter pylori en Pediatría.

INTRODUCTION: The latest joint H. pylori NASPGHAN and ESPGHAN clinical guidelines published in 2016, contain 20 statements that have been questioned in practice regarding their applicability in Latin America (LA); in particular in relation to gastric cancer prevention. METHODS: We conduc ted a critical analysis of the literature, with special emphasis on LA data and established the level of evidence and level of recommendation of the most controversial claims in the Joint Guidelines. Two rounds of voting were conducted according to the Delphi consensus technique and a Likert scale (from 0 to 4) was used to establish the "degree of agreement" among a panel of SLAGHNP ex perts. RESULTS: There are few studies regarding diagnosis, treatment effectiveness and susceptibility to antibiotics of H. pylori in pediatric patients of LA. Based on these studies, extrapolations from adult studies, and the clinical experience of the participating expert panel, the following recom mendations are made. We recommend taking biopsies for rapid urease and histology testing (and samples for culture or molecular techniques, when available) during upper endoscopy only if in case of confirmed H. pylori infection, eradication treatment will be indicated. We recommend that selected regional centers conduct antimicrobial sensitivity/resistance studies for H. pylori and thus act as reference centers for all LA. In case of failure to eradicate H. pylori with first-line treatment, we recommend empirical treatment with quadruple therapy with proton pump inhibitor, amoxi cillin, metronidazole, and bismuth for 14 days. In case of eradication failure with the second line scheme, it is recommended to indicate an individualized treatment considering the age of the pa tient, the previously indicated scheme and the antibiotic sensitivity of the strain, which implies performing a new endoscopy with sample extraction for culture and antibiogram or molecular resistance study. In symptomatic children referred to endoscopy who have a history of first or se cond degree family members with gastric cancer, it is recommended to consider the search for H. pylori by direct technique during endoscopy (and eradicate it when detected). CONCLUSIONS: The evidence supports most of the general concepts of the NASPGHAN/ESPGHAN 2016 Guidelines, but it is necessary to adapt them to the reality of LA, with emphasis on the development of regional centers for the study of antibiotic sensitivity and to improve the correct selection of the eradication treatment. In symptomatic children with a family history of first or second degree gastric cancer, the search for and eradication of H. pylori should be considered.

Factores de riesgo psicosocial que afectan a los profesionales en enfermería / Psychosocial risk factors that affect nursing professionals / Fatores de risco psicossociais que afetam os profissionais de enfermagem

Objetivo: revisar la evidencia científica sobre los factores de riesgo psicosocial que afectan a los profesionales en enfermería que laboran en servicios asistenciales: exigencias cuantitativas, ritmo de trabajo, doble presencia y demandas emocionales. Metodo: se realizó una revisión de artículos científicos publicados entre el 2007 y el 2018 en las bases de datos Medline, PubMed, Scien - ceDirect, Scopus, OVID Nursing, Springer, Taylor and Francis y otros recursos electrónicos como SciELO y Lilacs, mediante los descriptores: enfermería, salud laboral, condiciones de trabajo, estrés laboral y carga de trabajo. Se seleccionaron 74 artículos que cumplieron con los criterios de inclusión. Resultados: las exigencias cuantitativas y la intensificación del ritmo de trabajo aumentan la sobrecarga laboral, por la atención a un gran número de pacientes y la realización de funciones ajenas al ejercicio del cuidado directo. Las demandas emocionales se originan en la acción del cuidado y en la permanente confrontación con el sufrimiento, el dolor y la muerte. La compaginación entre el trabajo asalariado y el doméstico, así como el desempeño en dos o más empleos y el trabajo por turnos son frecuentes en la profesión. Conclusiones: el profesional en enfermería se expone en gran medida a los factores de riesgo psicosocial: exigencias cuantitativas, ritmo de trabajo, doble presencia y demandas emocionales. Estos pueden afectar negativamente su salud física y mental, así como la calidad del cuidado otorgado.

Objective: Review the scientific evidence on psychosocial risk factors: quantitative, work rate, double presence and emotional demands on nursing professionals in healthcare services. Mate - rial and method: A review of scientific articles was carried out from 2007 to 2018 in Medline, PubMed, ScienceDirect, Scopus, OVID Nursing, Springer, Taylor and Francis and other electronic databases such as SciELO and Lilacs, through the descriptors: nursing, occupational health, working conditions, work stress, and workload. We selected 74 articles that met the inclusion criteria. Results: Quantitative demands and the intensifica - tion of the rhythm of work increase the nurse's work overload due large quantity of patients and functions unrelated to the exercise of direct care. The emotional demands originate during caretaking actions and in the permanent confrontation with suffering, pain and death. The combination of salaried and domestic work, as well as undertaking two or more jobs and shift work, are frequent aspects in nursing professionals. Conclusions: The nursing professional is exposed to psycho - social risk factors: quantitative, work pace, double presence and emotional demands, which can negatively affect their physical and mental health, as well as the quality of the care provided.

Objetivo: revisar as evidências científicas sobre fatores de risco psicossocial: exigências quantitativas, ritmo de trabalho, dupla presença e demandas emocionais em profissionais de enfer - magem de serviços de saúde. Material e método: uma revisão de artigos científicos foi realizada de 2007 a 2018 nas bases de dados: Medline, PubMed, ScienceDirect, Scopus, OVID Nursing, Springer, Taylor and Francis e outros recursos eletrônicos como SciELO e Lilacs, através dos descritores: enfermagem, saúde ocupacional, condições de trabalho, estresse laboral e carga de trabalho. Foram selecionados 74 artigos que atenderam aos critérios de inclusão. Resultados: as demandas quantitativas e a intensificação do ritmo de trabalho aumentam a sobrecarga de trabalho, por causa da atenção a um grande número de pacientes e funções não relacionadas ao exercício do cuidado direto. As demandas emocionais se originam na ação do cuidado e no confronto permanente com o sofrimento, a dor e a morte. A conciliação entre trabalho assalariado e doméstico, bem como o desempenho em dois ou mais postos de trabalho e turnos de trabalho, são aspectos frequentes nos profissionais de enfermagem. Conclusão: o profissional de enfermagem é exposto em grande parte a fatores de risco psicossocial: quantitativo, ritmo de trabalho, presença dupla e demandas emocionais, o que pode afetar negativamente sua saúde física e mental, bem como a qualidade do cuidado concedido.

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.

Conducting Quantitative Medical Education Research: From Design to Dissemination.

Rigorous medical education research is critical to effectively develop and evaluate the training we provide our learners. Yet many clinical medical educators lack the training and skills needed to conduct high-quality medical education research. We offer guidance on conducting sound quantitative medical education research. Our aim is to equip readers with the key skills and strategies necessary to conduct successful research projects, highlighting new concepts and controversies in the field. We utilize Glassick's criteria for scholarship as a framework to discuss strategies to ensure that the research question of interest is worthy of further study and how to use existing literature and conceptual frameworks to strengthen a research study. Through discussions of the strengths and limitations of commonly used study designs, we expose the reader to particular nuances of these decisions in medical education research and discuss outcomes generally focused on, as well as strategies for determining the significance of consequent findings. We conclude with information on critiquing research findings and preparing results for dissemination to a broad audience. Practical planning worksheets and comprehensive tables illustrating key concepts are provided in order to guide researchers through each step of the process. Medical education research provides wonderful opportunities to improve how we teach our learners, to satisfy our own intellectual curiosity, and ultimately to enhance the care provided to patients.

Estudio multicéntrico sobre la epidemiologia de la Esofagitis Eosinofílica Pediátrica en América Latina / Multicenter study on the epidemiology of pediatric eosinophilic esophagitis in latinamerica

Objetivo: Evaluar las características epidemiológicas de un grupo de pacientes pediátricos con esofagitis eosinofílica (EEo) y las modalidades de tratamiento empleadas en Latinoamérica. Pacientes y métodos: Estudio multicéntrico, observacional, transversal. Se aplicó una encuesta a 36 Centros de Gastroenterología y Endoscopia Pediátrica de 10 países latinoamericanos con la finalidad de obtener información socio-demográfica y datos sobre el tratamiento utilizado para el manejo de los casos evaluados durante el periodo 2014-2016. Resultados: 372 casos de EEo pediátrica fueron evaluados durante el periodo 2014-2016 y 108 casos (29%) correspondieron al trimestre Abril-Junio 2016. 46,72% de los casos pertenecían al grupo de edad escolar y 71,8% consultaron por disfagia. 87,2% de los pacientes fueron manejados con dieta, 55,3% esteroides deglutidos (12,8% en monoterapia) y 6% recibió montelukast. No hubo reporte de pacientes en terapia con agentes biológicos. Conclusiones: los resultados sugieren un predominio del sexo masculino con una mayor incidencia de la enfermedad en la edad escolar y la adolescencia. Las manifestaciones clínicas más frecuentes son disfagia, vómitos y síntomas de reflujo gastroesofágico. El tratamiento más indicado por los especialistas en América Latina es la dieta seguido del uso de esteroides deglutidos. Los IBP también son ampliamente utilizados como terapia coadyuvante. Un estudio de prevalencia a nivel continental es necesario para evaluar el comportamiento de la enfermedad en diferentes regiones de América Latina.

Aims: To evaluate epidemiological features of pediatric patients with eosinophilic esophagitis in Latinamerica and therapeutical options indicated by pediatric gastroenterologists in our continent. Patients and methods: multicenter, observational, transversal study. 36 Centers of Pediatric Gastroenterology and Endoscopy from 10 latinamerican countries participated giving clinical and sociodemographic information about pediatric patients with EoE diagnosed and treated during the last two years (study period). Results: 372 cases of pediatric EoE were evaluated during period 2014-2016 (108 cases were evaluated during trimester April-June 2016). 46,72% of cases were school age children, with dysphagia been the main clinical symptom in 71,8% of patients. 87,2% of patients received diet as a main indication of treatment, 55,3% received swallowed steroids (12,8% as monotherapy) and 6% were treated with montelukast among others. There were no reports of patients under treatment with biological drugs. Conclusions: epidemiological features of our study group suggest a higher prevalence of pediatric EoE in male school age children and adolescents. Most frecuent clinical symptoms are dysphagia, vomiting and gastroesophageal reflux symptoms. Treatment is based mainly on diet and swallowed steroids. A continental prevalence study is necessary to evaluate the behavior of the disease in different regions of Latinamerica.

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.

Alimentación del paciente con diarrea aguda

El manejo nutricional es un aspecto importante del tratamiento del niño con diarrea aguda. Se ha demostrado que: el ayuno, la desnutrición y la alteración de la microbiota intestinal, disminuyen: masa intestinal, actividad enzimática y tasa de recambio celular. Los objetivos fundamentales están dirigidos a evitar mayor deterioro de la salud y la evolución de la enfermedad hacia la cronicidad. Está demostrado lo beneficioso de continuar la alimentación durante el proceso diarreico, unida a la terapia de rehidratación oral, ya que disminuye el déficit de proteína y energía, evita el catabolismo, estimula la función intestinal y permite el mantenimiento de enzimas digestivas, ejerciendo efecto trófico sobre la mucosa del intestino delgado para reducir las pérdidas fecales y disminuir la hipotrofia funcional y anatómica asociada con el "reposo del intestino". La realimentación debe ser gradual, oportuna, precoz, completa y adecuada, a fin de ofrecer el aporte necesario de calorías, proteínas, lípidos y carbohidratos. El niño debe continuar con lactancia materna, en caso de recibir fórmula láctea, no se requiere su dilución ni el uso de fórmulas especiales. Se recomiendan: alimentos absorbentes o astringentes que contienen polisacáridos con propiedades coloidales como pectina y dextrina que disminuyen número de deposiciones y aumentan su consistencia; evitar consumo de alimentos ricos en fibra insoluble; consumir fuente proteica de alto valor biológico e hipoalergénica; administrar los vegetales y frutas en sopas espesas, puré, jugos o compotas naturales, y fortificarlos con harina de maíz o arroz sin agregado de azúcar.

Nutritional management is an important aspect of the treatment of children with acute diarrhea. It has been shown that fasting, malnutrition, and alteration of the intestinal microbiota, decrease: intestinal mass, enzyme activity and cell turnover rate. The fundamental objectives are directed to avoid further deterioration of the health and the progression of the disease towards chronicity. Benefits of continuation of feeding during diarrhoea, coupled with oral rehydration therapy has been demonstrated, since it decreases the deficit of protein and energy, prevents catabolism, stimulates intestinal function and allows the maintenance of digestive enzymes exerting trophic effect on the mucosa of the small intestine, which in turn reduces fecal losses, functional and anatomical hypotrophy associated with the "rest of the intestine". Refeeding should be gradual, timely, early, complete and adequate, in order to provide the necessary contribution of calories, proteins, lipids and carbohydrates. The child should continue breastfeeding. In case of receiving milk formula, this requires no dilution or special formulas. Recommended: absorbent or astringent foods that contain polysaccharide with colloidal properties such as pectin and dextrin which decrease number of bowel movements and increase its consistency; avoid consumption of foods high in insoluble fibre; protein source of high biological value and hypoallergenic type; preparation of vegetables and fruit as thick soups, puree, juice or natural jams, and fortify them with corn or rice flours without added sugar.

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.

Smad7 inhibits autocrine expression of TGF-ß2 in intestinal epithelial cells in baboon necrotizing enterocolitis.

Preterm infants may be at risk of necrotizing enterocolitis (NEC) due to deficiency of transforming growth factor-ß 2 (TGF-ß(2)) in the developing intestine. We hypothesized that low epithelial TGF-ß(2) expression in preterm intestine and during NEC results from diminished autocrine induction of TGF-ß(2) in these cells. Premature baboons delivered at 67% gestation were treated per current norms for human preterm infants. NEC was diagnosed by clinical and radiological findings. Inflammatory cytokines, TGF-ß(2), Smad7, Ski, and strawberry notch N (SnoN)/Ski-like oncoprotein (SKIL) was measured using quantitative reverse transcriptase-polymerase chain reaction, immunoblots, and immunohistochemistry. Smad7 effects were examined in transfected IEC6 intestinal epithelial cells in vitro. Findings were validated in archived human tissue samples of NEC. NEC was recorded in seven premature baboons. Consistent with existing human data, premature baboon intestine expressed less TGF-ß(2) than term intestine. TGF-ß(2) expression was regulated in epithelial cells in an autocrine fashion, which was interrupted in the premature intestine and during NEC due to increased expression of Smad7. LPS increased Smad7 binding to the TGF-ß(2) promoter and was associated with dimethylation of the lysine H3K9, a marker of transcriptional silencing, on the nucleosome of TGF-ß(2). Increased Smad7 expression in preterm intestine was correlated with the deficiency of SnoN/SKIL, a repressor of the Smad7 promoter. Smad7 inhibits autocrine expression of TGF-ß(2) in intestinal epithelial cells in the normal premature intestine and during NEC. Increased Smad7 expression in the developing intestine may be due to a developmental deficiency of the SnoN/SKIL oncoprotein.