Pediatric End-of-Life Simulation Workshop to Clinical Care: Lasting Implications on Clinical Practice.

Background: Simulations are an important modality for practicing high-acuity, low-frequency events. We implemented a deliberate practice simulation-based workshop to improve pediatric end-of-life care skills (PECS) competence. Purpose: To understand pediatric subspecialty fellows' perceptions about influences of a simulation-based workshop on PECS provided at the bedside several months following participation. Methods: Pediatric subspecialty fellows were recruited to voluntary focus groups during regular educational sessions six months following PECS workshop participation with aims to identify perceptions about their workshop participation and any implication on their clinical practice. Inductive qualitative content analysis of focus group interview data was performed adhering to the Standards for Reporting Qualitative Research. Results: Ten fellows participated in one of three focus groups. Researchers identified three major themes of fellow experience: burden, safe practice space, and self-efficacy. Fellows described practice implications from workshop participation, including incorporation of specific practices, improved anticipatory guidance, and increased team leader confidence. Conclusions: Targeted, deliberate simulation-based practice of PECS can help close the gap from learning to practice, contributing to provider self-efficacy and potentially improving clinical care for pediatric patients and families at end of life.

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.

Pediatric End-of-Life Care Skills Workshop: A Novel, Deliberate Practice Approach.

INTRODUCTION: Pediatric end of life (EOL) care skills are a high acuity, low occurrence skill set required by pediatric clinicians. Gaps in education and competence for this specialized care can lead to suboptimal patient care and clinician distress when caring for dying patients and their families. METHODS: A half-day workshop using a deliberate practice approach was designed by an inter-professional workgroup including bereaved parent consultants. Pediatric fellows (neonatal-perinatal medicine, critical care, hematology oncology, blood and marrow transplant) and advanced practice providers learned and practiced EOL skills in a safe simulation environment with instruction from interprofessional facilitators and standardized patients. Participant perceived competence (self-efficacy) was measured before, immediately-post, and 3 months post workshop. RESULTS: There were 28 first-time (of 34 total) participants in 4 pilot workshops. Participants reported significantly increased self-efficacy post-workshop for 6 of 9 ratings, which was sustained 3 months afterwards. Most (92%, n = 22 of 24 respondents) reported incorporating the workshop training into clinical practice at 3-month follow-up. CONCLUSIONS: With early success of the pilot workshops, future iterative work includes expanding workshops to earlier, interprofessional learners and collecting validity evidence for a competency-based performance checklist tool. A project website (https://z.umn.edu/PECS) was developed for local and collaborative efforts.

Early-Onset Neonatal Sepsis Caused by Vertical Transmission of Pasteurella multocida.

Early-onset neonatal sepsis contributes substantially to neonatal morbidity and mortality. Presenting signs and symptoms vary, and most causes are due to a limited number of common microbes. However, providers must be cognizant of unusual pathogens when treating early-onset sepsis (EOS). We report a case of a term neonate who presented with respiratory distress, lethargy, and hypoglycemia 5 hours after birth. He was treated for presumed EOS with blood culture, revealing an unusual pathogen, Pasteurella multocida . Sepsis from this pathogen is a rarely reported cause of early onset neonatal sepsis. Our report is one of few that implicate vertical transmission with molecular diagnostic confirmation of P . multocida , subspecies septica. The neonate was treated with antibiotics and supportive care and recovered without ongoing complications. Providers should maintain an index of suspicion for rare causes of neonatal EOS. For these unusual cases, precise microbial identification enables understanding to provide best clinical care and anticipation of complications.

Introducing Mass Communications Strategies to Medical Students: A Novel Short Session for Fourth-Year Students.

PROBLEM: The World Health Organization calls on all with quality medical information to share it with the public and combat health misinformation; however, U.S. medical schools do not currently teach students effective communication with lay audiences about health. Most physicians have inadequate training in mass communication strategies. APPROACH: In August 2018, a novel 90-minute class at the University of Minnesota Medical School introduced fourth-year medical students to basic skills for communicating with lay audiences through mass media. Instructors were physicians with experience interacting with the general public via radio, op-ed articles, social media, print media, television, and community and legislative advocacy. After a 20-minute lecture and sharing of instructors' personal experiences, students completed two 30-minute small-group activities. They identified communications objectives and talking points for a health topic, drafting these as Tweets or an op-ed article outline, then presented talking points in a mock press conference with their peers, practicing skills just learned. Pre- and postsurveys documented students' previous engagement and comfort with future engagement with mass media messaging. OUTCOMES: Over 1 week, 142 students participated in 6 separate classes, and 127 completed both pre- and postsurveys. Before the course, only 6% (7/127) of students had comfortably engaged with social media and 14% (18/127) had engaged with traditional media in their professional roles. After the course, students self-reported an increase in their comfort, perceived ability, and likelihood of using specific communications skills to advocate for their patients (all P < .001). NEXT STEPS: The course will be expanded into a 5-session thread for third- and fourth-year medical students spread over 2 years. This thread will include meeting physicians who engage with lay audiences, identifying best practices for mass health communication, identifying bias and misinformation, "dos and don'ts" of social media, and communication skills for legislative advocacy.

Long-Term Outcomes after Early Neonatal Hyperglycemia in VLBW Infants: A Systematic Review.

INTRODUCTION: Long-term effects of early hyperglycemia in VLBW infants are poorly characterized. The objective of this study was to systematically review the effect of early hyperglycemia on growth, metabolic health, and neurodevelopment after neonatal intensive care unit discharge in VLBW infants. METHODS: The systematic review was conducted in accordance with the PRISMA guidelines. A study protocol was registered in PROSPERO (CRD42019123335). Data sources included Ovid MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus. Selected studies included infants with a blood glucose concentration >150 mg/dL (8.3 mmol/L) during the first 28 days of life, a gestational age (GA) <32 weeks, and/or a birth weight <1,500 g and longitudinal data on growth, metabolic health, or neurodevelopment outcomes. The GRADE system was used to assess quality of evidence. RESULTS: Eight studies (n = 987 infants) reported long-term outcomes from 4-month corrected GA to 7 years old. Most studies compared long-term outcomes of preterm infants with and without hyperglycemia. Two studies addressed outcomes related to interventions following early hyperglycemia. Some studies found differences in growth, metabolic health, and neurodevelopment outcomes between VLBW preterm infants with hyperglycemia and without hyperglycemia, while other studies found no differences between groups. The overall graded quality of evidence was low. CONCLUSIONS: Well-designed randomized controlled and prospective studies are necessary to determine the effect of early hyperglycemia and its treatment on later metabolic and neurodevelopmental outcomes in VLBW infants. Authors propose a potential study design for standardizing the assessment of long-term metabolic and neurodevelopmental outcomes following early hyperglycemia in preterm infants.

Building a Shared Mental Model of Competence Across the Continuum: Trainee Perceptions of Subinternships for Residency Preparation.

INTRODUCTION: Toward a vision of competency-based medical education (CBME) spanning the undergraduate to graduate medical education (GME) continuum, University of Minnesota Medical School (UMMS) developed the Subinternship in Critical Care (SICC) offered across specialties and sites. Explicit course objectives and assessments focus on internship preparedness, emphasizing direct observation of handovers (Core Entrustable Professional Activity, "EPA," 8) and cross-cover duties (EPA 10). METHODS: To evaluate students' perceptions of the SICC's and other clerkships' effectiveness toward internship preparedness, all 2016 and 2017 UMMS graduates in GME training (n = 440) were surveyed regarding skill development and assessment among Core EPAs 1, 4, 6, 8, 9, 10. Analysis included descriptive statistics plus chi-squared and Kappa agreement tests. RESULTS: Respondents (n = 147, response rate 33%) rated the SICC as a rotation during which they gained most competence among EPAs both more (#4, 57% rated important; #8, 75%; #10, 70%) and less explicit (#6, 53%; #9, 69%) per rotation objectives. Assessments of EPA 8 (80% rated important) and 10 (76%) were frequently perceived as important toward residency preparedness. Agreement between importance of EPA development and assessment was moderate (Kappa = 0.40-0.59, all surveyed EPAs). CONCLUSIONS: Graduates' perceptions support the SICC's educational utility and assessments. Based on this and other insight from the SICC, the authors propose implications toward collectively envisioning the continuum of physician competency.

Relationships between Early Nutrition, Illness, and Later Outcomes among Infants Born Preterm with Hyperglycemia.

OBJECTIVE: To evaluate the effects of hyperglycemia on body composition and neurodevelopment, and how early nutrition and illness modify these relationships in infants born preterm. STUDY DESIGN: Prospective data were collected from infants born <32 weeks of gestational age (N = 97), including inpatient days of hyperglycemia (blood glucose >150 mg/dL) and nutrient intake. Body composition was measured at discharge and 4 months' postmenstrual age (PMA). Bayley Scales of Infant Development III (BSID-III) were administered at 12 months' PMA. Linear regression analysis was performed, adjusting for birth gestational age. Associations between hyperglycemia, body composition, and BSID-III were analyzed in models accounting for first-week nutrition and early illness severity via Score for Neonatal Acute Physiology-II. RESULTS: Mean birth gestational age was 27.8 (SD 2.4) weeks. Hyperglycemia occurred in 48.5% of infants. Hyperglycemia for ≥5 days was negatively associated with fat mass and fat free mass z scores at discharge, and fat free mass z score at 4 months' PMA (P < .05 all). Hyperglycemia for ≥5 days was negatively associated with cognition, language, and motor scores on the BSDI at 12 months (P ≤ .01 all). Associations with body composition and BSID-III were diminished when models included first week nutrition yet remained unchanged when illness severity was included. CONCLUSIONS: In infants <32 weeks, ≥5 days of hyperglycemia is associated with decreased lean mass at 4 months' PMA and poorer neurodevelopmental outcome at 12 months' PMA. These associations may be mediated by decreased first week nutrition, potentially related to reduced glucose infusion rate for management of hyperglycemia.

Medical Student Workshop Improves Student Confidence in Working With Trained Medical Interpreters.

INTRODUCTION: Many physicians care for patients whose primary spoken language is not English, and these interactions present challenges in physician-patient communication. These challenges contribute to the significant health disparities experienced by populations with limited English proficiency (LEP). Using trained medical interpreters is an important step in addressing this problem, as it improves communication outcomes. Despite this, many medical education programs have little formal instruction on how to work effectively with interpreters. METHODS: To address this gap, we created an interactive workshop led by professional trained interpreters and faculty facilitators for medical students in their clinical years. Students were asked to evaluate the session based on relevance to their clinical experiences and helpfulness in preparing them for interactions with patients with LEP. RESULTS: Immediately after the session, students reported that the clinical scenarios presented were similar those seen on their clinical clerkships. They also reported increased confidence in their ability to work with interpreters. On later follow-up, students reported that the instruction helped prepare them for subsequent patient interactions that involved interpreters. CONCLUSION: A workshop is an effective method for improving medical student comfort and confidence when working with interpreters for populations with LEP.

Body composition and cognition in preschool-age children with congenital gastrointestinal anomalies.

BACKGROUND: Children with congenital gastrointestinal anomalies (CGIAs) experience multiple stressors while hospitalized in neonatal intensive care units during an essential time of growth and development. Early stress and inadequate nutrition are linked to altered growth patterns and later neurodevelopmental delays. In other at-risk populations, improved fat-free mass (FFM) accretion is associated with improved cognitive outcomes. OBJECTIVE: To determine if body composition is associated with cognitive function in preschool-age children with CGIAs. STUDY DESIGN: An observational study examined body composition and cognition in 34 preschool-age children with CGIAs. Anthropometric measurements and body composition testing via air displacement plethysmography were obtained. Measurements were compared with a reference group of healthy, term-born children. Cognition was measured with the NIH Toolbox Early Childhood Cognition Battery. Linear regression was used to test the association of body composition with cognitive function. RESULTS: Compared with the reference group, children with CGIAs had similar anthropometric measurements (weight, height, and body mass index z-scores) and body composition at preschool-age. Processing speed scores were lower than standardized means (p = 0.001). Increased FFM was associated with higher receptive vocabulary scores (p = 0.001), cognitive flexibility scores (p = 0.005), and general cognitive function scores (p = 0.05). CONCLUSIONS: At preschool-age, children with CGIAs have similar growth and body composition to their peers. In children with CGIAs, higher FFM was associated with higher cognitive scores. Closer tracking of body composition and interventions aimed at increasing FFM may improve long-term outcomes in this population.

Body Composition Changes from Infancy to 4 Years and Associations with Early Childhood Cognition in Preterm and Full-Term Children.

BACKGROUND: Infants born prematurely are at risk for neurodevelopmental complications. Early growth is associated with improved later cognition. The relationship of early proportionality and body composition with later cognition is not well established. OBJECTIVES: To assess differences in fat-free mass and adiposity (fat mass, percent body fat) changes in preterm and full-term infants through preschool age and examine associations with early childhood cognition. METHODS: This is a prospective, observational study in an appropriate for gestational age cohort of 71 patients (20 preterm and 51 full-term) from infancy through preschool age. Anthropometric and body composition measurements via air displacement plethysmography were obtained during infancy at term and 3-4 months (preterm corrected ages), and at 4 years. Cognitive testing occurred at 4 years. Associations of body composition changes between visits with cognitive function were tested using linear regression. RESULTS: In the preterm group, higher term to 4-month corrected age percent body fat gains were associated with lower working memory performance (p = 0.01), and higher 4-month corrected age to 4-year fat-free mass gains were associated with higher full-scale IQ (p = 0.03) and speed of processing performance (p ≤ 0.02). In the full-term group, higher 4-month to 4-year fat mass gains were associated with lower full-scale IQ (p = 0.03). CONCLUSIONS: Body composition gains during different time periods are associated with varying areas of cognitive function. These findings may inform interventions aimed at optimal growth.

Body Composition Trajectories From Infancy to Preschool in Children Born Premature Versus Full-term.

OBJECTIVES: The aim of the study was to longitudinally characterize infancy to preschool body composition trajectories and the association of early fat and fat-free mass gains with preschool age body composition in children born premature versus full-term. METHODS: A cohort of appropriate-for-gestational age preterm (n = 20) and term (n = 51) infants were followed at 3 visits: "neonatal" visit 1 at 2 weeks of age for term and near term corrected age for preterm; "infancy" visit 2 at 3 to 4 months (preterm corrected age); "preschool" visit 3 at 4 years. Body composition via air displacement plethysmography and anthropometrics were measured at all visits. Tracking of infancy weight and body composition with preschool measurements was tested using Pearson partial correlation coefficients. Associations between serial body composition measurements were assessed using multiple linear regression. RESULTS: Early differences in body composition between premature (mean gestational age 31.9 weeks, mean birth weight 1843 g) and full-term (mean gestational age 39.8 weeks) infants were not present at preschool age. Visit 1 body composition was not correlated with preschool measurements in the preterm infants. Visit 2 measurements were correlated with preschool measures. Fat-free mass accretion from visit 1 to visit 2 was positively associated with preschool lean mass (ß = 0.038, P = 0.049) in preterm children, whereas fat accretion was not associated with preschool body composition. CONCLUSIONS: Children born prematurely and full-term have similar body composition at preschool age. For preterms infancy fat-free mass gains, and not adiposity gains, are positively associated with preschool fat-free mass; this may be associated with lower risk of later obesity and adverse metabolic outcomes.