How Good is Good Enough?: Current-Day Pediatric Residency Program Directors' Challenges in Assessing and Achieving Resident Procedural Competency.

OBJECTIVE: Significant gaps exist in the pediatric resident (PR) procedural experience. Graduating PRs are not achieving competency in the 13 ACGME recommended procedures. It is unclear why PR are not able to achieve competency, or how existing gaps may be addressed. METHODS: We performed in-depth one-on-one semistructured interviews with 12 pediatric residency program directors (PPDs). The interviews were audio-recorded, and transcribed verbatim. Coding of the data using conventional content analysis led to generation of categories, which were validated through consensus development. RESULTS: We identified 4 main categories, including (1) programs struggle to ensure adequate training in procedural skills for PRs, with various barriers reported; (2) programs develop individualized strategies to address challenges in procedural skills training, and multiple options are necessary; (3) PPDs face challenges defining procedural competency and standardizing expectations; and (4) expectations for PR procedural training may require modification based upon current practice environments. Solutions include simulation, procedural boot camps, and procedural/subspecialty electives. CONCLUSIONS: Numerous methods to combat challenges in PR procedural training have been identified by participating PPDs, including simulation, tailoring electives, and developing institutional guidelines. However, accreditation bodies may need to update procedural expectations based on individual resident career goals and realities of current day practice.

Implementing Skills for Psychological Recovery at a Psychology Training Clinic During COVID-19.

The COVID-19 global pandemic has disrupted the routine provision of community mental health services, which is especially concerning given that emerging data suggest a rise in mental health concerns related to the COVID-19 crisis (Xiong et al., 2020). Thus, it seems imperative to provide trauma-informed services that are tailored to clients' coping with the pandemic and can be effectively delivered via telehealth. The goals of these important services would be to mitigate current distress, help prevent the onset of long-term mental health problems, and facilitate client safety during a public health crisis. The present article provides an overview of adoption and telehealth implementation of the Skills for Psychological Recovery (SPR) secondary prevention program within a psychology training clinic. Initial clinical outcome data supported the program's success in reducing mental health symptoms among individuals in psychological distress due to the COVID-19 crisis; however, the results were more striking for adults than for youths. The article concludes with recommendations for broader implementation and future directions for clinicians, supervisors, organizations, and researchers.

Figure and ground: how the visual cortex integrates local cues for global organization.

Inferring figure-ground organization in two-dimensional images may require different complementary strategies. For isolated objects, it has been shown that mechanisms in visual cortex exploit the overall distribution of contours, but in images of cluttered scenes where the grouping of contours is not obvious, that strategy would fail. However, natural scenes contain local features, specifically contour junctions, that may contribute to the definition of object regions. To study the role of local features in the assignment of border ownership, we recorded single-cell activity from visual cortex in awake behaving Macaca mulatta. We tested configurations perceived as two overlapping figures in which T- and L-junctions depend on the direction of overlap, whereas the overall distribution of contours provides no valid information. While recording responses to the occluding contour, we varied direction of overlap and variably masked some of the critical contour features to determine their influences and their interactions. On average, most features influenced the responses consistently, producing either enhancement or suppression depending on border ownership. Different feature types could have opposite effects even at the same location. Features far from the receptive field produced effects as strong as near features and with the same short latency. Summation was highly nonlinear: any single feature produced more than two-thirds of the effect of all features together. These findings reveal fast and highly specific organization mechanisms, supporting a previously proposed model in which "grouping cells" integrate widely distributed edge signals with specific end-stopped signals to modulate the original edge signals by feedback. NEW & NOTEWORTHY Seeing objects seems effortless, but defining objects in a scene requires sophisticated neural mechanisms. For isolated objects, the visual cortex groups contours based on overall distribution, but this strategy does not work for cluttered scenes. Here, we demonstrate mechanisms that integrate local contour features like T- and L-junctions to resolve clutter. The process is fast, evaluates widely distributed features, and gives any single feature a decisive influence on figure-ground representation.

Medical nutrition therapy in non-alcoholic fatty liver disease--a review of literature.

BACKGROUND AND AIM: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide, with a prevalence of 20%-40% in Western populations. The purpose of this article is to review data related to lifestyle changes in patients with NAFLD. METHOD: We searched a public domain database (PubMed) with the following categories: disease (NAFLD, fatty liver, and non-alcoholic steatohepatitis [NASH]) and intervention (lifestyle intervention, diet, nutrition) with each possible combination through 25 September 2014, for relevant articles. Review of articles was restricted to those published in English. We selected the studies involving adult patients only. CONCLUSION: There is no consensus as to what diet or lifestyle approach is the best for NAFLD patients. However, patients with NAFLD may benefit from a moderate- to low-carbohydrate (40%-45% of total calories) diet, coupled with increased dietary MUFA and n-3 PUFAs, reduced SFAs. More CRT are needed to clarify the specific effects of different diets and dietary components on the health of NAFLD patients. ABBREVIATIONS: NAFL = Non-alcoholic fatty liver, NAFLD = non-alcoholic fatty liver disease, NASH = non-alcoholic steatohepatitis, HCC = hepatocarcinoma, BEE = basal energy expenditure, CRT = A small clinical randomized trial showed that short-term carbohydrate restriction is more efficacious in reducing intrahepatic triglyceride, IHT = intrahepatic triglyceride, VLCD = Very low calorie diets, AST = aspartate aminotransferases, SFAs = saturated fatty acids.

Statistical platform to discern spatial and temporal coordination of endothelial sprouting.

Many biological processes, including angiogenesis, involve intercellular feedback and temporal coordination, but inference of these relations is often drowned in low sample sizes or noisy population data. To address this issue, a methodology was developed to statistically study spatial lateral inhibition and temporal synchronization in one specific biological process, endothelial sprouting mediated by Notch signaling. Notch plays an essential role in the development of organized vasculature, but the effects of Notch on the temporal characteristics of angiogenesis are not well understood. Results from this study showed that Notch lateral inhibition operates at distances less than 31 µm. Furthermore, combining time lapse microscopy with an intraclass correlation model typically used to analyze family data showed intrinsic temporal synchronization among endothelial sprouts originating from the same microcarrier. Such synchronization was reduced with Notch inhibitors, but was enhanced with the addition of Notch ligands. These results indicate that Notch plays a critical role in the temporal regulation of angiogenesis, as well as spatial control, and this method of analysis will be of significant utility in studies of a variety of other biological processes.

Mimicking nature by codelivery of stimulant and inhibitor to create temporally stable and spatially restricted angiogenic zones.

Nature frequently utilizes opposing factors to create a stable activator gradient to robustly control pattern formation. This study employs a biomimicry approach, by delivery of both angiogenic and antiangiogenic factors from spatially restricted zones of a synthetic polymer to achieve temporally stable and spatially restricted angiogenic zones in vivo. The simultaneous release of the two spatially separated agents leads to a spatially sharp angiogenic region that is sustained over 3 wk. Further, the contradictory action of the two agents leads to a stable level of proangiogenic stimulation in this region, in spite of significant variations in the individual release rates over time. The resulting spatially restrictive and temporally sustained profiles of active signaling allow the creation of a spatially heterogeneous and functional vasculature.

Analysis of the context integration mechanisms underlying figure-ground organization in the visual cortex.

Most neurons in visual cortex respond to contrast borders and are orientation selective, and some are also selective for which side of a border is figure and which side is ground ("border ownership coding"). These neurons are influenced by the image context far beyond the classical receptive field (CRF) and as early as 25 ms after the onset of activity in the cortex. The nature of the fast context integration mechanism is not well understood. What parts of a figure contribute to the context effect? What is the structure of the "extraclassical surround"? Is the context information propagated through horizontal fibers within cortex or through reciprocal connections via higher-level areas? To address these questions, we studied border ownership modulation with fragmented figures. Neurons were recorded in areas V1 and V2 of Macaca mulatta under behaviorally induced fixation. Test figures were fragmented rectangles. While one edge was centered on the CRF, the presence of the fragments outside the CRF was varied. The surround fragments produced facilitation on the preferred border ownership side as well as suppression on the nonpreferred side, with approximately 80% of the locations contributing on average. Fragments far from the CRF influenced the responses even in the absence of fragments closer to the CRF, and without the extra delay that would incur from propagation through horizontal fibers. Three principally different models are discussed. The results support a model in which the antagonistic surround influences are produced by reentrant signals from a higher-level area.

Nonresectional repair of the barlow mitral valve: importance of dynamic annular evaluation.

BACKGROUND: The most extensive form of myxomatous degeneration of the mitral valve causing severe mitral regurgitation is "Barlow disease." Surgical repair of this condition has been considered difficult because of the extent and magnitude of annular, leaflet, and chordal abnormalities and has usually involved partial resection of one or both mitral leaflets. METHODS: A surgical approach has been developed which does not involve leaflet resection. Instead, by means of precise dynamic annular sizing, a predetermined zone of leaflet apposition is achieved. The leaflets are positioned so that their large area is contained within the left ventricle. Normal annular, leaflet, and papillary muscle dynamic function is restored. RESULTS: This procedure was performed in 61 patients. The repair rate was 100%. The mean age was 57.6 +/- 12.7 years. They were 67.2% male. The preoperative anteroposterior annular dimension was 52.1 +/- 4.3 mm. The full, flexible complete ring size was 33.4 +/- 1.9 mm. There was no perioperative mortality. There was no systolic anterior leaflet motion. All patients were discharged with no or mild mitral regurgitation. At a follow-up interval of 1.2 +/- 2.1 years one patient had developed recurrent mitral regurgitation, secondary to marked remodeling to normal left ventricular function. CONCLUSIONS: Initial experience with a nonresectional approach for Barlow disease has produced good early results.

Feasibility and intermediate term outcome of repair of prolapsing anterior mitral leaflets with artificial chordal replacement in 152 patients.

BACKGROUND: Mitral valve repair of the anterior leaflet has been more difficult than at other sites. METHODS: Between February 1983 and June 2004, 607 mitral valve repairs were performed on one service. Of these, 410 patients had leaflet repair procedures: 152 were anterior leaflet repairs; isolated in 94, and combined with posterior repair in 58 patients. The results in these patients were compared with the results of posterior leaflet repair in 258 patients. All patients received flexible ring annuloplasty. RESULTS: Age and sex of the anterior leaflet and posterior leaflet patients were similar: mean age 62.5 +/- 14.3, 62.9 +/- 14.9 years; males, 50.6%, p = not significant (NS). Preoperative ejection fraction was for anterior repairs 52.6 +/- 12.8%; posterior repair, 58.2 +/- 11.8%, p = NS. Coronary artery bypass was more frequently performed with anterior leaflet repair in 18 patients (19.1%) versus 45 (6.6%) for posterior leaflet repair (p = NS). The median number of chordae was similar in the anterior leaflet and posterior leaflet patients 4 (2-8), 4 (2-6), p = NS. Perioperative mortality was similar: anterior leaflet patients, 3.3% (2/94); posterior leaflet patients, 1.1% (2/258), p = NS. Hospital stay was for anterior leaflet patients and posterior leaflet patients: 12.86 +/- 13.3 vs 11.0 +/- 12.3, p = NS. Kaplan-Meier estimates of freedom from reoperation at 3 years were: for anterior leaflet patients, 91.9%: for posterior leaflet patients, 90.7%, p = 0.77. No structural polytetrafluoroethylene (PTFE) chordal failures were observed. Late echocardiographic data were obtained in 136 patients on 222 occasions at a mean of 3.2 +/- 3.34 years. Severe mitral regurgitation was present in 10 patients (7.3%). CONCLUSIONS: Repair of the anterior leaflet is facilitated by the use of PTFE replacement. Anterior leaflet repair can be performed reproducibly with the same results as posterior leaflet repair.

Participant recruitment and motivation for participation in optical technology for cervical cancer screening research trials.

In order to improve recruitment for cervical cancer screening trials, it is necessary to analyze the effectiveness of recruitment strategies used in current trials. A trial to test optical spectroscopy for the diagnosis of cervical neoplasia recruited 1000 women from the community; the trial evaluated the emerging technology against Pap smears and colposcopically directed biopsies for cervical dysplasia. We have examined women's reasons for participating as well as the effectiveness and efficiency for each recruitment strategy. Reasons for participation were identified and compared between trials. The recruitment method that resulted in the most contacts was newspaper reportorial coverage and advertising, followed by family and friends, then television news coverage. The most cost-effective method for finding eligible women who attend the research appointment is word of mouth from a family member or friend. Recommendations are given for maximizing the efficiency of recruitment for cervical cancer screening trials.

Effects of exam-room computing on clinician-patient communication: a longitudinal qualitative study.

OBJECTIVE: To evaluate the impact of exam-room computers on communication between clinicians and patients. DESIGN AND METHODS: Longitudinal, qualitative study using videotapes of regularly scheduled visits from 3 points in time: 1 month before, 1 month after, and 7 months after introduction of computers into the exam room. SETTING: Primary care medical clinic in a large integrated delivery system. PARTICIPANTS: Nine clinicians (6 physicians, 2 physician assistants, and 1 nurse practitioner) and 54 patients. RESULTS: The introduction of computers into the exam room affected the visual, verbal, and postural connection between clinicians and patients. There were variations across the visits in the magnitude and direction of the computer's effect. We identified 4 domains in which exam-room computing affected clinician-patient communication: visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the exam room. We observed a range of facilitating and inhibiting effects on clinician-patient communication in all 4 domains. For 2 domains, visit organization and verbal and nonverbal behavior, facilitating and inhibiting behaviors observed prior to the introduction of the computer appeared to be amplified when exam-room computing occurred. Likewise, exam-room computing involving navigation and mastery skills and spatial organization of the exam-room created communication challenges and opportunities. In all 4 domains, there was little change observed in exam-room computing behaviors from the point of introduction to 7-month follow-up. CONCLUSIONS: Effective use of computers in the outpatient exam room may be dependent upon clinicians' baseline skills that are carried forward and are amplified, positively or negatively, in their effects on clinician-patient communication. Computer use behaviors do not appear to change much over the first 7 months. Administrators and educators interested in improving exam-room computer use by clinicians need to better understand clinician skills and previous work habits associated with electronic medical records. More study of the effects of new technologies on the clinical relationship is also needed.

Long-term results of coronary artery bypass grafting in patients with ischemic cardiomyopathy: the impact of renal insufficiency and noncardiac vascular disease.

BACKGROUND: We examined outcomes of patients with ischemic cardiomyopathy (ICMP), defined by left ventricular ejection fraction (LVEF) <35%, compared with patients with better-preserved LVEF, undergoing coronary bypass graft surgery (CABG). In addition, we examined the relative impact of a reduced LVEF in comparison with other comorbidities on long-term mortality in these patients. METHODS AND RESULTS: We evaluated 1381 patients (114 with ICMP, 1267 with better-preserved LVEF) who underwent isolated CABG at a tertiary Veterans Administration (VA) hospital between 1990 and 2000 using data from the VA Continuous Improvement in Cardiac Surgery Program and other VA databases. The 5-year survival was 74.0% in patients with ICMP and 84.4% in the group with better-preserved LVEF ( p = .005). LVEF <35% remained a significant predictor of long-term mortality in multivariable models (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.02-2.35). However, the presence of comorbidities, especially renal insufficiency, peripheral vascular disease, and cerebrovascular disease, had a similar or greater impact on long-term mortality. Renal insufficiency (serum creatinine >1.5 mg/dL) was associated with the highest risk of long-term mortality (HR 2.02, 95% CI 1.46-2.80). The use of a left internal thoracic artery graft reduced the risk of long-term mortality (HR 0.72, 95% CI 0.54-0.98). CONCLUSION: Even though severely depressed LVEF is associated with an increased risk of long-term mortality, the presence of comorbid factors, especially renal dysfunction and noncardiac vascular disease, increase the risk of long-term mortality by a similar or even larger magnitude. These comorbid factors should be given important consideration when evaluating the risks and benefits of CABG.

Mitral valve repair in patients with low left ventricular ejection fractions: early and late results.

STUDY OBJECTIVES: This retrospective study was performed to examine the outcome of mitral valve repair (ie, mitral valvuloplasty [MVP]) in relation to preoperative low left ventricular ejection fraction (LVEF). DESIGN AND SETTINGS: From our series of 338 consecutive patients who underwent MVP between 1983 and 2001, we compared the course of 302 patients with preoperative LVEF of > 35% (group I) to that of 36 patients with LVEF of

Appetite is not influenced by a unique milk peptide: caseinomacropeptide (CMP).

The milk protein, caseinomacropeptide (CMP), is a predominant breakdown product of casein in the human stomach, and may aid in the regulation of food intake. Using a human feeding study design, this project assessed the effects of CMP on satiety and satiation by measuring the amount of food consumed at meal times and through subjective motivation to eat questionnaires. The following beverage treatments were prepared: 0.4% CMP solution, 2.0% CMP solution, vehicle alone, and water containing colorant and clouding agent. Twenty male and 32 female adults were enrolled into the study using a Latin Square randomization. Treatment beverages and ad libitum lunches were consumed on four separate occasions at the Study Center. After lunch, subjects left the Study Center, and completed a standardized questionnaire every hour throughout the afternoon and evening to assess hunger and stomach fullness, and kept track of all food and beverages consumed. Under these experimental conditions, CMP had no effect on energy intake or weight of food consumed at lunch or for the remainder of the day. CMP also had no effect on subjective indicators of satiety. Intake of CMP before a midday meal has no effect on regulation of food intake over a short-term period.

Low irradiances affect abscisic acid, indole-3-acidic acid, and cytokinin levels of wheat (Triticum aestivum L.) tissues.

Wheat (Triticum aestivum L.) plants were grown under four irradiance levels: 1,400, 400, 200, and 100 micromol m-2 s-1. Leaves and roots were sampled before, during, and after the boot stage, and levels of abscisic acid (ABA), indole-3-acetic acid (IAA), zeatin, zeatin riboside, dihydrozeatin, dihydrozeatin riboside, isopentenyl adenine, and isopentenyl adenosine were quantified using noncompetitive indirect ELISA systems. Levels of IAA in leaves and roots of plants exposed to 100 micromol m-2 s-1 of irradiance were 0.7 and 2.9 micromol kg-1 dry mass (DM), respectively. These levels were 0.2 and 1.0 micromol kg-1 DM, respectively, when plants were exposed to 1,400 micromol m-2 s-1. Levels of ABA in leaves and roots of plants exposed to 100 micromol m-2 s-1 were 0.65 and 0.55 micromol kg-1 DM, respectively. They were 0.24 micromol kg-1 DM (both leaves and roots) when plants were exposed to 1,400 micromol m-2 s-1. Levels of isopentenyl adenosine in leaves (24.3 nmol kg-1 DM) and roots (29.9 nmol kg-1 DM) were not affected by differences in the irradiance regime. Similar values were obtained in a second experiment. Other cytokinins could not be detected (<10 nmol kg 1 DM) in either experiment with the sample sizes used (150-600 mg DM for roots and shoots, respectively).

Studies on flower initiation of Super-Dwarf wheat under stress conditions simulating those on the Space Station, Mir.

Super-Dwarf wheat plants were grown in growth chambers under 12 treatments with three photoperiods (18 h, 21 h, 24 h) and four carbon dioxide (CO2) levels (360, 1,200, 3,000 and 7,000 micromoles mol-1). Carbon dioxide concentrations affected flower initiation rates of Super-Dwarf wheat. The optimum CO2 level for flower initiation and development was 1,200 micromoles mol-1. Super-optimum CO2 levels delayed flower initiation, but did not decrease final flower bud number per head. Longer photoperiods not only accelerated flower initiation rates, but also decreased deleterious effects of super-optimum CO2. Flower bud size and head length at the same developmental stage were larger under longer photoperiods, but final flower bud number was not affected by photoperiod.