Preparing Patients for Oral Immunotherapy (PPOINT): International Delphi consensus for procedural preparation and consent.

BACKGROUND: Despite the promise of oral immunotherapy (OIT) to treat food allergies, this procedure is associated with potential risk. There is no current agreement about what elements should be included in the preparatory or consent process. OBJECTIVE: We developed consensus recommendations about the OIT process considerations and patient-specific factors that should be addressed before initiating OIT and developed a consensus OIT consent process and information form. METHODS: We convened a 36-member Preparing Patients for Oral Immunotherapy (PPOINT) panel of allergy experts to develop a consensus OIT patient preparation, informed consent process, and framework form. Consensus for themes and statements was reached using Delphi methodology, and the consent information form was developed. RESULTS: The expert panel reached consensus for 4 themes and 103 statements specific to OIT preparatory procedures, of which 76 statements reached consensus for inclusion specific to the following themes: general considerations for counseling patients about OIT; patient- and family-specific factors that should be addressed before initiating OIT and during OIT; indications for initiating OIT; and potential contraindications and precautions for OIT. The panel reached consensus on 9 OIT consent form themes: benefits, risks, outcomes, alternatives, risk mitigation, difficulties/challenges, discontinuation, office policies, and long-term management. From these themes, 219 statements were proposed, of which 189 reached consensus, and 71 were included on the consent information form. CONCLUSION: We developed consensus recommendations to prepare and counsel patients for safe and effective OIT in clinical practice with evidence-based risk mitigation. Adoption of these recommendations may help standardize clinical care and improve patient outcomes and quality of life.

Evaluating a Health Equity Podcast for Provider Practice Change: A Cross-sectional Study.

INTRODUCTION: Podcasts are effective tools for disseminating health education. This study aimed to disseminate a health equity curriculum on best practices. METHOD: A cross-sectional descriptive study was conducted as part of the Health Equity in Pediatrics podcast series between May and June 2023. Listeners were surveyed following each episode, and both quantitative and qualitative responses of voluntary respondents were analyzed. RESULTS: Episodes were downloaded 4,095 times. Survey respondents (n = 66) reported increased knowledge and intended practice change inspired by the podcast. Qualitative responses included themes surrounding knowledge, appreciation, and practice change. DISCUSSION: Podcasts are easily disseminated to wide audiences and can improve health equity knowledge while inspiring practice change. This style can help listeners identify practices that suggest implicit bias and implement more equitable best practices. Future research should examine implicit bias training and standardization of health equity education using podcasts.

Systematic online academic resource (SOAR) review: Pediatric respiratory infectious disease.

Background: Free open access medical education (FOAM) resources have become increasingly popular in graduate medical education. Despite their accessibility, the assessment of FOAM resources' quality is challenging due to their decentralized nature and the diverse qualifications of their authors and distribution platforms. In this first pediatric systematic online academic resource (SOAR) review, we utilized a systematic methodology to aggregate and assess the quality of FOAM resources on pediatric respiratory infectious disease topics. Methods: We searched 177 keywords using FOAMSearch, the top 50 FOAM websites on the Social Media Index, and seven additional pediatric emergency medicine-focused blogs. Following a basic initial screen, resources then underwent full-text quality assessment utilizing the revised Medical Education Translational Resources: Impact and Quality (rMETRIQ) tool. Results: The search yielded 44,897 resources. After 44,456 were excluded, 441 underwent quality assessment. A total of 36/441 posts (8% of posts) reached the high-quality threshold score (rMETRIQ ≥ 16). The most frequent topics overall were pneumonia and bronchiolitis. A total of 67/441 posts (15% of posts) were found to have a rMETRIQ score of less than or equal to 7, which may indicate poor quality. Conclusions: We systematically identified, described, and performed quality assessment on FOAM resources pertaining to the topic of pediatric respiratory infectious disease. We found that there is a paucity of high-quality posts on this topic. Despite this, the curated list of high-quality resources can help guide trainees and educators toward relevant educational information and suggest unmet needs for future FOAM resources.

Just-in-Time, Just-in-Place Virtual Training in the Pediatric Emergency Department: A Novel Approach to Impact the Perfusion Exam.

Background: Early identification of shock is vital in decreasing morbidity and mortality in the pediatric population. Although residents are taught the perfusion portion of the rapid cardiopulmonary assessment at our institution, they perform it at the bedside with 8.4% completing 1 part of the assessment and 9.7% verbalizing their findings. Newer technologies, including virtual reality (VR), offer immersive training to close this clinical gap. Objective: To assess senior pediatric residents' performance of a perfusion exam and verbalization of their perfusion assessment following VR-based Just-in-Time/Just-in-Place (JITP) training compared to video-based JITP training. We hypothesized that JITP media training was feasible, and VR JITP was more effective than video-based training. Methods: Residents were randomized to VR or video-based training during shifts in the emergency department. Clinical performance was assessed by review of a video-recorded patient encounter using a standardized assessment tool and by an in-person, two question shock assessment. Residents completed a survey assessing attitudes toward their intervention at the time of training. Results: Eighty-five senior pediatric residents were enrolled; 84 completed training. Sixty-four (76%) residents had a patient encounter available for video review (VR 33; Video 31). Fourteen residents in the VR group (42.4%, 95% CI 25.5% to 60.8%) and 13 residents in the video group (41.9%, 95% CI 24.6% to 60.9%) completed a perfusion exam AND verbalized an assessment during their next clinical encounter (X2 p-value 1.00). Fifty-one of 64 residents (79.7%) completed the two-step shock assessment; 50 (98%) agreed with supervising physician's assessment. VR was rated more effective than reading, low-fidelity manikin, standardized patient encounters, traditional didactic teaching, and online learning. Video was rated more effective than online learning, traditional didactic teaching, and reading. Conclusion: Novel video and VR JITP perfusion exam and assessment trainings are impactful and well-received by senior pediatric residents.

Going viral: A scoping review of the current state and impact of online research dissemination in emergency medicine.

BACKGROUND: The use of free open-access medical education (FOAM) and other online knowledge dissemination methods has increased over the past decade. However, the role and impact of these tools in the knowledge translation continuum are poorly understood, potentially limiting the ability of knowledge generators to fully harness and exploit their potential. Here, we aim to comprehensively map and synthesize the literature describing the use of online tools for the dissemination of emergency medicine research. METHODS: Using scoping review methodology, we searched the traditional literature via PubMed, CINAHL, EMBASE, ERIC, SCOPUS, and the gray literature for publications exploring online methods to disseminate new research findings. We synthesized the results and constructed a conceptual model of current research dissemination methods. RESULTS: We included 79 out of 655 unique abstracts and articles identified in our search, 62 of which were from the traditional literature. We describe six primary domains: integration with traditional literature, measurement of dissemination, online organizations and communities of practice, professional development, quality assurance tools and techniques, and advantages and disadvantages of FOAM. For each domain we present an exemplar article and prevailing gaps in knowledge. Finally, we propose a current conceptual framework for dissemination of new research findings that describes both traditional and novel methods of dissemination. CONCLUSIONS: This comprehensive review of the literature and current dissemination framework will empower researchers, research networks, and granting organizations to maximize their use of FOAM and other online methods to disseminate new knowledge as well as provide clinicians a better understanding of the tools and methods by which to access and implement new research findings.

Anaphylaxis knowledge gaps and future research priorities: A consensus report.

BACKGROUND: Despite a better understanding of the epidemiology, pathogenesis, and management of patients with anaphylaxis, there remain knowledge gaps. Enumerating and prioritizing these gaps would allow limited scientific resources to be directed more effectively. OBJECTIVE: We sought to systematically describe and appraise anaphylaxis knowledge gaps and future research priorities based on their potential impact and feasibility. METHODS: We convened a 25-member multidisciplinary panel of anaphylaxis experts. Panelists formulated knowledge gaps/research priority statements in an anonymous electronic survey. Four anaphylaxis themed writing groups were formed to refine statements: (1) Population Science, (2) Basic and Translational Sciences, (3) Emergency Department Care/Acute Management, and (4) Long-Term Management Strategies and Prevention. Revised statements were incorporated into an anonymous electronic survey, and panelists were asked to rate the impact and feasibility of addressing statements on a continuous 0 to 100 scale. RESULTS: The panel generated 98 statements across the 4 anaphylaxis themes: Population Science (29), Basic and Translational Sciences (27), Emergency Department Care/Acute Management (24), and Long-Term Management Strategies and Prevention (18). Median scores for impact and feasibility ranged from 50.0 to 95.0 and from 40.0 to 90.0, respectively. Key statements based on median rating for impact/feasibility included the need to refine anaphylaxis diagnostic criteria, identify reliable diagnostic, predictive, and prognostic anaphylaxis bioassays, develop clinical prediction models to standardize postanaphylaxis observation periods and hospitalization criteria, and determine immunotherapy best practices. CONCLUSIONS: We identified and systematically appraised anaphylaxis knowledge gaps and future research priorities. This study reinforces the need to harmonize scientific pursuits to optimize the outcomes of patients with and at risk of anaphylaxis.

Pediatric emergency medicine fellowship point-of-care ultrasound training in 2020.

OBJECTIVES: The primary objective was to survey pediatric emergency medicine (PEM) leaders and fellows regarding point-of-care ultrasound (POCUS) training in PEM fellowship programs, including teaching methods, training requirements, and applications taught. Secondary objectives were to compare fellows' and program leaders' perceptions of fellow POCUS competency and training barriers. METHODS: This was a cross-sectional survey of U.S. PEM fellows and fellowship program leaders of the 78 fellowship programs using two online group-specific surveys exploring five domains: program demographics; training strategies and requirements; perceived competency; barriers, strengths, and weaknesses of POCUS training; and POCUS satisfaction. RESULTS: Eighty-three percent (65/78) of programs and 53% (298/558) of fellows responded. All participating PEM fellowship programs included POCUS training in their curriculum. Among the 65 programs, 97% of programs and 92% of programs utilized didactics and supervised scanning shifts as educational techniques, respectively. Sixty percent of programs integrated numerical benchmarks and 49% of programs incorporated real-time, hands-on demonstration as training requirements. Of the 19 POCUS applications deemed in the literature as core requirements for fellows, at least 75% of the 298 fellows reported training in 13 of those applications. Although less than half of fellows endorsed competency for identifying intussusception, ultrasound-guided pericardiocentesis, and transvaginal pregnancy evaluation, a higher proportion of leaders reported fellows as competent for these applications (40% vs. 68%, p ≤ 0.001; 21% vs. 39%, p = 0.003; and 21% vs. 43%, p ≤ 0.001). Forty-six percent of fellows endorsed a lack of PEM POCUS evidence as a training barrier compared to 31% of leaders (p = 0.02), and 39% of leaders endorsed a lack of local financial support as a training barrier compared to 23% of fellows (p = 0.01). CONCLUSIONS: Although most PEM fellowship programs provide POCUS training, there is variation in content and requirements. Training does conform to many of the expert recommended guidelines; however, there are some discrepancies and perceived barriers to POCUS training remain.

A Descriptive Analysis of the Cumulative Experiences of Emergency Medicine Residents in the Pediatric Emergency Department.

OBJECTIVES: Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine. METHODS: Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition. RESULTS: Twenty-five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses. CONCLUSIONS: Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

Evidence-based Standardization of Constipation Management in the Emergency Department: A Quality Improvement Study.

Constipation is a common problem in pediatric patients. Abdominal radiographs (AXRs) are frequently obtained in the pediatric emergency department for diagnosis despite their poor reliability to rule out underlying pathology or prognostic ability to determine the degree of constipation. The goal of this quality improvement (QI) initiative was to standardize the diagnosis and management of constipation in the pediatric emergency department and urgent care in patients ages 6 months to 21 years and decrease AXR use by 20% and sustain this reduction for 12 months. METHODS: This prospective QI project involved a multidisciplinary team at a large urban pediatric tertiary care center. The study team constructed a key driver diagram and identified interventions, such as creating a standardized evaluation and management algorithm for constipation, using free open-access medical education platforms, incorporating the electronic medical record interface, and expanding educational conferences to include standardized approach and discharge instructions for patients with constipation across all acuity levels. The primary measure of AXR utilization was tracked overtime on a statistical process control chart to evaluate the impact of interventions. RESULTS: The percentage of visits for constipation that included an AXR decreased from a baseline of 49.6%-37.1%, a 25% reduction. Length-of-stay, return visits within 7 days, and inpatient admissions remained unchanged by the interventions. CONCLUSIONS: QI methodology successfully decreased AXR utilization in the evaluation of constipation across a broad spectrum of acuity levels. Further interventions may help to decrease the length of stay and further decrease AXR utilization.

The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department.

ABSTRACT: Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.

The Girl With the Bleeding Earlobe Mass.

ABSTRACT: Pilomatrixomas, also known as epithelioma calcificans, are benign tumors of hair follicle matrix cells that are often mistaken for other lesions, especially cutaneous abscesses. We report an illustrative case in which a teenage girl developed a red, swollen earlobe that required multiple care visits and interventions until definitive diagnosis and treatment were provided. Although the lesion was initially treated as an abscess, it continued to progress in size and discomfort. The correct diagnosis was established after imaging and complete excision with pathologic examination. Ultimately, our patient was subjected to avoidable procedures that carried the risk of potentially negative cosmetic sequelae before the proper intervention. Although abscesses are common, it is important for clinicians to avoid incision and drainage of lesions, unless the diagnosis is certain.

Use of Resident-Sensitive Quality Measure Data in Entrustment Decision Making: A Qualitative Study of Clinical Competency Committee Members at One Pediatric Residency.

PURPOSE: Resident-sensitive quality measures (RSQMs) are quality measures that are likely performed by an individual resident and are important to care quality for a given illness of interest. This study sought to explore how individual clinical competency committee (CCC) members interpret, use, and prioritize RSQMs alongside traditional assessment data when making a summative entrustment decision. METHOD: In this constructivist grounded theory study, 19 members of the pediatric residency CCC at Cincinnati Children's Hospital Medical Center were purposively and theoretically sampled between February and July 2019. Participants were provided a deidentified resident assessment portfolio with traditional assessment data (milestone and/or entrustable professional activity ratings as well as narrative comments from 5 rotations) and RSQM performance data for 3 acute, common diagnoses in the pediatric emergency department (asthma, bronchiolitis, and closed head injury) from the emergency medicine rotation. Data collection consisted of 2 phases: (1) observation and think out loud while participants reviewed the portfolio and (2) semistructured interviews to probe participants' reviews. Analysis moved from close readings to coding and theme development, followed by the creation of a model illustrating theme interaction. Data collection and analysis were iterative. RESULTS: Five dimensions for how participants interpret, use, and prioritize RSQMs were identified: (1) ability to orient to RSQMs: confusing to self-explanatory, (2) propensity to use RSQMs: reluctant to enthusiastic, (3) RSQM interpretation: requires contextualization to self-evident, (4) RSQMs for assessment decisions: not sticky to sticky, and (5) expectations for residents: potentially unfair to fair to use RSQMs. The interactions among these dimensions generated 3 RSQM data user profiles: eager incorporation, willing incorporation, and disinclined incorporation. CONCLUSIONS: Participants used RSQMs to varying extents in their review of resident data and found such data helpful to varying degrees, supporting the inclusion of RSQMs as resident assessment data for CCC review.

Resident-Sensitive Quality Measures in the Pediatric Emergency Department: Exploring Relationships With Supervisor Entrustment and Patient Acuity and Complexity.

PURPOSE: This study explores the associations between resident-sensitive quality measures (RSQMs) and supervisor entrustment as well as between RSQMs and patient acuity and complexity for encounters in the pediatric emergency department (PED) in which residents are caring for patients. METHOD: Pediatric residents rotating through Cincinnati Children's Hospital Medical Center PED as well as supervising pediatric emergency medicine faculty and fellows were recruited during the 2017-2018 academic year for the purpose of collecting the following data from the residents' patient encounters for 3 illnesses (acute asthma exacerbation, bronchiolitis, and closed head injury [CHI]): supervisor entrustment decision rating, RSQMs relevant to the care provided, and supervisor patient acuity and complexity ratings. To measure the association of RSQM composite scores with the other variables of interest, mixed models were used. RESULTS: A total of 83 residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with CHI. Entrustment decision ratings were positively associated with asthma RSQM composite scores (beta coefficient = 0.03; P < .001). There was no significant association between RSQM composite scores and entrustment decision ratings for bronchiolitis or CHI. RSQM composite scores were significantly higher when acuity was also higher and significantly lower when acuity was also lower for both asthma (P < .001) and bronchiolitis (P = .01). However, RSQM composite scores were almost identical between levels of acuity for CHI (P = .94). There were no significant differences in RSQM composite scores when complexity varied. CONCLUSION: This study found limited associations between RSQM composite scores and entrustment decision ratings but offers insight into how RSQMs could be used for the purposes of resident assessment and feedback.

Emergency Management of an Eyelid Zipper Injury in a Child.

BACKGROUND: Zipper injuries are rare in the pediatric emergency department, with most reported cases involving the penile and scrotal skin. Knowledge of appropriate zipper release techniques is important to ensure safe and immediate removal of entrapped tissue to prevent complications. CASE REPORT: This case report describes a unique presentation of a zipper injury involving entrapment of the upper eyelid. We describe the successful removal of the zipper with gentle manipulation aided by mineral oil lubrication and by cutting fabric from the zipper system to release tension. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: While zipper injuries are rare, an emergency physician must be prepared to provide urgent intervention to prevent complications. This unique case report presents 1 example of successful zipper release in the case of a zipper injury to the eyelid in a child. We review other approaches for emergent zipper removal and discuss postprocedure care.

Initial Implementation of Resident-Sensitive Quality Measures in the Pediatric Emergency Department: A Wide Range of Performance.

PURPOSE: A lack of quality measures aligned with residents' work led to the development of resident-sensitive quality measures (RSQMs). This study sought to describe how often residents complete RSQMs, both individually and collectively, when they are implemented in the clinical environment. METHOD: During academic year 2017-2018, categorical pediatric residents in the Cincinnati Children's Hospital Medical Center pediatric emergency department were assessed using RSQMs for acute asthma exacerbation (21 RSQMs), bronchiolitis (23 RSQMs), and closed head injury (19 RSQMs). Following eligible patient encounters, all individual RSQMs for the illnesses of interest were extracted from the health record. Frequencies of 3 performance classifications (opportunity and met, opportunity and not met, or no opportunity) were detailed for each RSQM. A composite score for each encounter was calculated by determining the proportion of individual RSQMs performed out of the total possible RSQMs that could have been performed. RESULTS: Eighty-three residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with closed head injury during the study period. Residents had the opportunity to meet the RSQMs in most encounters, but exceptions existed. There was a wide range in the frequency of residents meeting RSQMs in encounters in which the opportunity existed. One closed head injury measure was met in all encounters in which the opportunity existed. Across illnesses, some RSQMs were met in almost all encounters, while others were met in far fewer encounters. RSQM composite scores demonstrated significant range and variation as well-asthma: mean = 0.81 (standard deviation [SD] = 0.11) and range = 0.47-1.00, bronchiolitis: mean = 0.62 (SD = 0.12) and range = 0.35-0.91, and closed head injury: mean = 0.63 (SD = 0.10) and range = 0.44-0.89. CONCLUSIONS: Individually and collectively, RSQMs can distinguish variations in the tasks residents perform across patient encounters.

Resident Performance of the Rapid Cardiopulmonary Assessment in the Emergency Department.

OBJECTIVES: The rapid cardiopulmonary assessment (RCPA) is an essential first step in effective resuscitation of critically ill children. Pediatric residents may not be achieving competency with resuscitative skills, including RCPA. Our objective was to determine how often pediatric residents complete the RCPA for actual patients. METHODS: This was an observational, cross-sectional study of senior residents (≥postgraduate year 2) performing the RCPA in the resuscitation area of a high-volume pediatric emergency department (PED), where pediatric residents are expected to perform the bedside examination and assessment for all medical (nontrauma) patients. Data were collected primarily by video review on a standard form. The primary outcome was completion of the RCPA, defined as both examination and verbalized assessment of the airway, breathing, and circulation. We explored the association between RCPA completion and both residency year and number of previous PED rotations. RESULTS: Complete data were collected from one randomly selected patient for 71 (95%) of 75 of eligible senior residents who rotated in the PED between January and June 2013. Two residents (3%) performed a complete RCPA. Verbalized assessment of circulation was especially rare (7/71; 10%). There was no association between RCPA completion and year of training or previous PED experience (P > 0.05). CONCLUSIONS: Senior pediatric resident performance of the RCPA in the resuscitation area of a high-volume PED was poor. There was no association between RCPA completion and greater resident experience, including in the PED. These findings add to a growing body of literature suggesting that pediatric residents are not achieving competency with the RCPA and resuscitation skills.

Objective Assessment of Resident Teaching Competency Through a Longitudinal, Clinically Integrated, Resident-as-Teacher Curriculum.

OBJECTIVE: Competency-based training should be paired with objective assessments. To date, there has been limited objective assessment of resident-as-teacher curricula (RATC). We sought to assess the impact of a longitudinal RATC on postgraduate year-1 (PGY1) resident teaching competency using Observed Structured Teaching Encounters (OSTEs) for the skills of 1) brief didactic teaching [DT], 2) feedback [FB], and 3) precepting [PR]. METHODS: A controlled, prospective, educational study was conducted from May 2015 to June 2016. The RATC consisted of a workshop series with reinforcement of key skills (DT, FB) during clinical rotations. Intervention residents participated in the RATC and completed OSTEs at the beginning and end of the academic year. A control group, PGY1 residents that matriculated the year previously, completed the OSTEs before starting their PGY2 year. OSTEs were reviewed by 2 blinded study personnel. We assessed reliability between raters via intraclass correlation coefficients and differences in OSTE scores via least squared mean differences (LSMD). RESULTS: In total, 92.5% (n = 37) of eligible control and 100% (n = 41) of eligible intervention residents participated. The OSTEs demonstrated excellent agreement between reviewers (DT: 0.99, FB: 0.89, PR: 0.98). A significant pre-post difference was demonstrated in the intervention group for DT (LSMD [95% confidence interval], 3.14 [2.49-3.79], P < .0001), FB (0.93 [0.49-1.37], P < .0001), and PR (0.64 [0.09-1.18], P < .022). A significant difference between the control and intervention groups was demonstrated for DT (3.00 [2.05-3.96], P < .0001). CONCLUSIONS: Skill-based OSTEs can be used to detect changes in residents' teaching competency and may represent a potential component of programmatic evaluation of resident-as-teacher curricula.

A Newborn With Abdominal Pain.

A previously healthy 3-week-old boy presented with 5 hours of marked fussiness, abdominal distention, and poor feeding. He was afebrile and well perfused. His examination was remarkable for localized abdominal tenderness and distention. He was referred to the emergency department in which an abdominal radiograph revealed gaseous distention of the bowel with a paucity of gas in the pelvis. Complete blood cell count and urinalysis were unremarkable. His ongoing fussiness and abnormal physical examination prompted consultation with surgery and radiology. Our combined efforts ultimately established an unexpected diagnosis.