Implementation of a Children's Hospital Acute Care Behavior Response Team.

BACKGROUND: Pediatric patients with behavioral needs are frequently admitted to the hospital for medical care; when behavioral crises occur, patients and staff are at risk for injury. Our aim was to implement a behavior response team (BRT) to increase the days between employee injury due to aggressive patient interactions on the inpatient medical units from 99 to 150 over 1 year. METHODS: A multidisciplinary team used quality improvement methods to design and implement the BRT system that includes 2 options: huddle to proactively plan for patients exhibiting early signs of escalation and STAT for immediate help for patients with imminent risk of harm to self or others. Using run and statistical process control charts, we tracked events per month, days between Occupational Safety & Health Administration-recordable events, and violent restraint use over time for 1 year after implementation. Staff pre and postimplementation surveys were compared to assess staff perception of safety and support provided by the BRT intervention. RESULTS: The BRT was implemented across the inpatient system in July 2020, with an average number of 13 events per month. Days between Occupational Safety & Health Administration-recordable events remained stable with a maximum of 134 days. Restraint use remained stable at 0.74 per 1000 patient days. The perception of behavioral support available to staff increased significantly pre to postsurvey. CONCLUSIONS: The implementation of a BRT can improve staff perception of support and confidence in safely caring for patients with behavior needs on the inpatient medical unit, although additional provider- and system-level improvements are needed to prevent employee injuries.

Eplerenone for the Treatment of Chronic Recurrent Chorioretinopathy Centralis Serosa. / Eplerenon zur Behandlung der chronisch rezidivierenden Chorioretinopathia centralis serosa.

BACKGROUND: Chorioretinopathy centralis serosa (CCS) is a common disease that leads to the loss of retinal ion/fluid homeostasis due to decompensation of the retinal pigment epithelium, resulting in fluid accumulation with detachment of the neurosensory retina and/or retinal pigment epithelium. We investigated the effect of eplerenone, a mineralocorticoid receptor inhibitor, on chronic recurrent CCS (cr-CCS). METHODS: A retrospective study with data analysis of 17 eyes (12 patients) between 2014 - 2021 with cr-CCS in whom other methods were not effective, not applicable, or not desired, was performed. Duration of CCS was at least 12 months with at least one recurrence. Each patient received 25 mg (1st week) and 50 mg (from the 2nd week) for at least 3 months. In each case, best-corrected visual acuity and central and peripheral retinal thickness were measured by spectral-domain optical coherence tomography. Side effects were rated by the patients as "none", "mild" (noticeable but not affecting), "tolerable" (affecting but acceptable because of good effect), and "not tolerable" (then discontinuation of therapy). RESULTS: There was no significant reduction in central or peripheral retinal thickness. A complete reduction of subretinal fluid was achieved in 5 of 17 eyes (29.4%). In 12 eyes, no effect of eplerenone could be detected, so other therapies were required. Visual acuity change was mainly dependent on the duration of CCS and the degree of photoreceptor damage. Side effects were reported by 11 patients as "none" and 1 patient as "mild" (arterial hypotension). No other side effects were observed. CONCLUSION: The response rates of therapy with eplerenone were relatively low, and no significant effect could be demonstrated. Eplerenone should not (no longer) be routinely used in the therapy of cr-CCS.

Impact of a Remote Virtual Reality Curriculum Pilot on Clinician Conflict Communication Skills.

OBJECTIVES: Conflict management skills are essential for interprofessional team functioning, however existing trainings are time and resource intensive. We hypothesized that a curriculum incorporating virtual reality (VR) simulations would enhance providers' interprofessional conflict communication skills and increase self-efficacy. METHODS: We conducted a randomized controlled pilot study of the Conflict Instruction through Virtual Immersive Cases (CIVIC) curriculum among inpatient clinicians at a pediatric satellite campus. Participants viewed a 30-minute didactic presentation on conflict management and subsequently completed CIVIC (intervention group) or an alternative VR curriculum on vaccine counseling (control group), both of which allowed for verbal interactions with screen-based avatars. Three months following VR training, all clinicians participated in a unique VR simulation focused on conflict management that was recorded and scored using a rubric of observable conflict management behaviors and a Global Entrustment Scale (GES). Differences between groups were evaluated using generalized linear models. Self-efficacy was also assessed immediately pre, post, and 3 months postcurriculum. Differences within and between groups were assessed with paired independent and 2-sample t-tests, respectively. RESULTS: Forty of 51 participants (78%) completed this study. The intervention group (n = 17) demonstrated better performance on the GES (P = .003) and specific evidence-based conflict management behaviors, including summarizing team member's concerns (P = .02) and checking for acceptance of the plan (P = .02), as well as statistical improvements in 5 self-efficacy measures compared with controls. CONCLUSIONS: Participants exposed to CIVIC demonstrated enhanced conflict communication skills and reported increased self-efficacy compared with controls. VR may be an effective method of conflict communication training.

Real world data on IO-based therapy for metastatic renal cell carcinoma.

PURPOSE: Immune-based (IO)-combinations are the backbone in the systemic therapy of metastatic renal cell carcinoma (mRCC). Despite phase III clinical trial data, real world data are of special importance to reflect clinical practice. METHODS: This retrospective study included 201 mRCC patients receiving first-line systemic therapy from January 2006. Clinicopathological and treatment-related data were recorded. Progression-free (PFS) and overall survival (OS) were analyzed using descriptive statistics and Kaplan-Meier analysis. RESULTS: Over the years, IO-based therapies have increased significantly. The collective comprises 76 patients with first-line IO-based therapy (IO-IO:55, TKI-IO:21) and 125 patients with TKI-monotherapy. PFS was significantly improved with TKI-IO combinations if compared to both TKI-monotherapy (23.9 vs. 10.3 months, HR 0.48, p = 0.034) and IO-IO combination (23.9 vs. 6.1 months, HR 0.37, p = 0.012). OS for TKI-IO treated patients was longer compared to TKI-monotherapy (HR 0.37, p = 0.050) at median follow-up of 24.1 versus 29.9 months. In a subanalysis of nivolumab treated patients, starting from second-line (n = 40), PFS was 5.5 months. The addition of nivolumab either in second-or later lines improved OS compared to repeated TKI- or mTOR-therapies alone (6.13 vs. 2.61 years, HR 0.46, p = 0.003). CONCLUSION: Both first-line IO-based combinations and nivolumab after first-line TKI-monotherapy prolong OS in a real-world setting.

Development and evaluation of a pediatric hospital medicine board review course.

BACKGROUND: The American Board of Medical Specialties recognized Pediatric Hospital Medicine (PHM) for subspecialty certification in 2016, with the first certification exam in 2019. To address the need for exam preparatory materials, we designed and evaluated a novel PHM board review course that was offered both in-person and online. METHODS: Course content was based on the American Board of Pediatrics (ABP) PHM certifying exam outline. Course objectives were developed from published PHM core competencies and the 2012 ABP general pediatrics content objectives. National experts served as faculty, presenting didactic sessions, and contributing to a question bank for high-yield review. For program evaluation, we applied the Kirkpatrick Model, evaluating estimated exam pass rates (Level 4), participant learning (Level 2) via post-presentation practice questions, and participants' ratings of presenters (via five-point Likert scale) and satisfaction (Level 1). RESULTS: There were 112 in-person and 144 online participants with estimated pass rates of 89 and 93%, respectively. The mean correct response for the post-presentation knowledge questions was 84%. Faculty effectiveness ratings ranged from 3.81 to 4.96 (median score 4.60). Strengths included the pace of the course, question bank, and printed syllabus. Suggestions for improvement included question bank expansion, focus on "testable" points rather than general information, and challenges with long days of didactic presentations. CONCLUSIONS: This novel PHM board review course demonstrated effectiveness. Hospitalists preferred focused "testable" information, an active learning environment, and a robust question bank. Future preparatory courses should consider including more opportunities for practice questions, focused content review, and learner engagement.

Altered alpha and theta oscillations correlate with sequential working memory in Parkinson's disease.

Daily activities such as preparing a meal rely on the ability to arrange thoughts and actions in the right order. Patients with Parkinson's disease have difficulties in sequencing tasks. Their deficits in sequential working memory have been associated with basal ganglia dysfunction. Here we demonstrate that altered parietal alpha and theta oscillations correlate with sequential working memory in Parkinson's disease. We included 15 patients with Parkinson's disease (6 women, mean age: 66.0 years), 24 healthy young (14 women, mean age: 24.1 years), and 16 older participants (7 women, mean age: 68.6 years). All participants completed a picture ordering task with scalp electroencephalogram (EEG) recording, where they arranged five pictures in a specific order and memorized them over a delay. When encoding and maintaining picture sequences, patients with Parkinson's disease showed a lower baseline alpha peak frequency with higher alpha power than healthy young and older participants. Patients with a higher baseline alpha power responded more slowly for ordered trials. When manipulating picture sequences, patients with Parkinson's disease showed a lower frequency of maximal power change for random versus ordered trials than healthy young and older participants. Healthy older participants showed a higher frequency of maximal power change than healthy young participants. Compared with patients with frequency of maximal power change in the alpha band (8-15 Hz), patients with frequency of maximal power change in the theta band (4-7 Hz) showed a higher ordering-related accuracy cost (random versus ordered) in the main task and tended to respond more slowly and less accurately in an independent working memory test. In conclusion, altered baseline alpha oscillations and task-dependent modulation of alpha and theta oscillations may be neural markers of poor sequential working memory in Parkinson's disease.

Role of the Systemic Immune-Inflammation Index in Patients with Metastatic Renal Cell Carcinoma Treated with First-Line Ipilimumab plus Nivolumab.

Background: The aim of this study was to evaluate the predictive and prognostic value of the systemic immune-inflammation index (SII) in patients with metastatic renal cell carcinoma (mRCC) treated with first-line ipilimumab plus nivolumab. Methods: This retrospective study included forty-nine mRCC patients treated with first-line ipilimumab plus nivolumab at the Department of Urology of the University of Tuebingen, Germany. SII was assessed before starting ipilimumab plus nivolumab therapy at the time of first imaging and at tumor progression. Optimal SII cut-off was stratified by ROC-analysis. Univariable and multivariable Cox regression analyses were used to evaluate the predictive and prognostic value of SII. Results: Optimal SII cut-off was 788. Twenty-nine/forty-nine patients had high SII (≥788) before initiation of ipilimumab plus nivolumab. High SII was an independent prognostic factor for worse progression-free (HR 2.70, p = 0.014) and overall survival (HR 10.53, p = 0.025). The clinical benefit rate was higher for patients with low SII if compared to high SII (80% vs. 32.1%). An increase in SII > 20% from baseline after twelve weeks of therapy was associated with progression at first imaging (p = 0.003). Conclusions: SII is both prognostic and predictive and could refine decision making in patients with unclear imaging on therapy with ipilimumab plus nivolumab.

Prognostic impact of complete metastasectomy in metastatic renal cell carcinoma in the era of immuno-oncology-based combination therapies.

PURPOSE: Complete metastasectomy of renal cell carcinoma (RCC) is receding into the past due to the progress of immuno-oncology-based combinations (IO) in systemic therapy. The prognostic impact of curative intended complete metastasectomy vs. immediate IO-based therapy or tyrosine kinase inhibition (TKI) on progression-free survival (PFS) and cancer-specific survival (CSS) was investigated in the first-line setting. METHODS: 205 patients with synchronous or metachronous metastasis received complete metastasectomy (n = 80) or systemic therapy (n = 125, TKI: 87, TKI-IO: 13, IO-IO: 25) as first-line therapy. The prognostic impact of these therapies was assessed using Cox regression and Kaplan-Meier analyses. RESULTS: First-line complete metastasectomy significantly improved CSS compared to both TKI monotherapy (6.1 vs. 2.6 years, HR 0.45, p < 0.001) and IO-based combination therapy (IO-IO/TKI-IO, 6.1 vs. 3.5 years, HR 0.28, p = 0.007). Repetitive complete metastasectomy without ever receiving systemic therapy vs. systemic therapy in first-line significantly prolonged CSS (11.3 vs. 3.1 years, HR 0.34, p = 0.002). First-line complete metastasectomy and subsequent systemic therapy at tumor progression was associated with a significant CSS benefit vs. systemic therapy (5.8 vs. 3.1 years, HR 0.53, p = 0.003), also compared to IO-based combinations (5.8 vs. 3.5 years, HR 0.30, p = 0.017). Median PFS was improved by IO-based therapy compared to TKI monotherapy in the first-line setting (HR 0.61, p = 0.05), with maximal benefit of the TKI-IO combination vs. TKI monotherapy (HR 0.27, p = 0.01), as well as compared to PFS of complete metastasectomy (HR 0.34, p = 0.035). CONCLUSION: Despite the progress of IO-based combination therapies in first line, complete metastasectomy remains an integral part of the multimodality treatment of metastatic RCC.

Qualitative Analysis of a Virtual Near-Peer Pediatric Boot Camp Elective.

Objective: To explore fourth-year medical students' experience with a virtual, near-peer facilitated pediatric boot camp through the lens of self-determination theory (SDT). Methods: We developed a virtual pediatric boot camp elective for fourth-year medical students pursuing pediatric residency using Kern's six steps of curriculum development. The two-week virtual elective consisted of facilitated video conferences and small group discussions led by two senior pediatric residents. Semi-structured focus groups were conducted after elective completion. Using SDT as our conceptual framework, we explored participants' experience with the near-peer facilitation of the boot camp. Focus group recordings were transcribed and thematically analyzed using deductive coding for SDT, with inductive coding for themes outside the theory's scope. Saturation was reached after three focus groups. The codebook was iteratively revised through peer debriefing between coders and reviewed by other authors. Credibility was established through member checking. Results: Ninety-two percent of eligible medical students (n = 23/25) participated in the boot camp with attendance ranging from 18-21 students per session. Twelve students (52%) participated in three focus groups. Qualitative analysis identified five major themes. Four themes consistent with SDT emerged: competence, autonomy, relatedness to near-peers, and relatedness to specialty/institution. The learning environment, including the virtual setting, emerged as an additional, non-SDT-related theme. Conclusions: Medical students' experience with our virtual boot camp closely aligned with SDT. Near-peer relatedness emerged as a unique theme which could be further investigated in other aspects of medical student education. Future research could evaluate higher-level learning outcomes from near-peer educational opportunities. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-021-01466-w.

Coaching the Fundamentals: Exploring the Applicability and Usefulness of a Novel Skills-Based Feedback Modality.

OBJECTIVE: Receiving and integrating feedback is a key to medical trainee development. To assist trainees seeking improvement through daily formative feedback and deliberate practice, the authors created a new skills-based framework called microskills, derived from the Accreditation Council for Graduate Medical Education (ACMGE) milestones and entrustable professional activities. The authors then explored pediatric resident perceptions around the applicability and usefulness of microskills. METHODS: The authors conducted 4 qualitative semistructured focus groups of 28 pediatric residents. Focus group prompts asked participants to reflect on microskills as a new feedback modality and microskills in relation to existing feedback and assessment approaches. Focus group transcripts were analyzed through inductive thematic analysis through an iterative process until theoretical saturation was reached. RESULTS: Participants felt microskills could facilitate skill-building and improvement, allow for consistent, targeted feedback, and establish a practice of coaching. Participants also perceived microskills' future success to be dependent on how the modality is adopted and utilized alongside existing assessment tools. CONCLUSIONS: Trainees found microskills to be a granular, context-based, coaching tool that could improve skill-building and the feedback process. Microskills' emphasis on feedback and their delineation of clinical skills that can be repeatedly practiced has the potential to provide a roadmap for trainee growth. Though microskills could fill a current need in the medical training landscape, they are not a substitute for existing assessment frameworks.

Characterization of Genetic Heterogeneity in Recurrent Metastases of Renal Cell Carcinoma.

Metastatic renal cell carcinoma (RCC) exhibits poor prognosis. Better knowledge of distant metastases is crucial to foster personalized treatment strategies. Here, we aimed to investigate the genetic landscape of metastases, including synchronous and/or recurrent metastases to elucidate potential drug target genes and clinically relevant mutations in a real-world setting of patients. We assessed 81 metastases from 56 RCC patients, including synchronous and/or recurrent metastases of 19 patients. Samples were analysed through next-generation sequencing with a high coverage (~1000× mean coverage). We therefore established a novel sequencing panel comprising 32 genes with impact on RCC development. We observed a high frequency of mutations in known RCC driver genes (e.g., >40% carriers of VHL and PBRM1 mutations) in metastases irrespective of the metastatic site. The somatic mutational composition was significantly associated with cancer-specific survival (p(logrank) = 0.03). Moreover, we identified in 34 patients at least one drug target gene as well as clinically relevant mutations listed in the VICC Meta-Knowledgebase in 7%. In addition to significantly higher mutational burden in recurrent metastases compared to earlier ones, synchronous and/or recurrent metastases of individual patients, even after a time-period >2 yrs, shared a high proportion of somatic events. Our data demonstrate the importance of somatic profiling in metastases for precision medicine in RCC.

Synthetic Material Abdominal Swabs Reduce Activation of Platelets and Leukocytes Compared to Cotton Materials.

During surgical procedures, cotton abdominal swabs with their high absorptive capacity and malleability are used to retain organs and absorb blood or other body fluids. Such properties of the natural material cotton are advantageous for most operations, but in cardiopulmonary bypass (CPB) surgery, a high blood volume can accumulate in the thoracic cavity that is quickly retransfused via the heart-lung machine (HLM). This common practice is supposed to be safe due to the high anticoagulation. However, in vitro analyses showed that blood cells and plasma proteins were activated despite a high anticoagulation, which can propagate especially an inflammatory response in the patient. Thus, we investigated patients' blood during CPB surgery for inflammatory and coagulation-associated activation after contact to the HLM and either cotton or synthetic abdominal swabs. Contact with cotton significantly increased thrombocyte and neutrophil activation measured as ß-thromboglobulin and PMN-elastase secretion, respectively, compared to synthetic abdominal swabs. Both inflammatory cytokines, interleukin (IL) 1ß and IL6, were also significantly increased in the cotton over the synthetic patient group, while SDF-1α was significantly lower in the synthetic group. Our data show for the first time that cotton materials can activate platelets and leukocytes despite a high anticoagulation and that this activation is lower with synthetic materials. This additional activation due to the material on top of the activation exerted by the tissue contact that blood is exposed to during CPB surgery can propagate further reactions in patients after surgery, which poses a risk for this already vulnerable patient group.

Building a doctor, one skill at a time: Rethinking clinical training through a new skills-based feedback modality.

The Accreditation Council for Graduate Medical Education milestones and entrustable professional activities (EPAs) are important assessment approaches but may lack specificity for learners seeking improvement through daily feedback. As in other professions, clinicians grow best when they engage in deliberate practice of well-defined skills in familiar contexts. This growth is augmented by specific, actionable coaching from supervisors. This article proposes a new feedback modality called microskills, which are derived from the psychology, negotiation, and business literature, and are unique in their ability to elicit targeted feedback for trainee development. These microskills are grounded in both clinical and situational contexts, thereby mirroring learners' cognitive schemas and allowing for more natural skill selection and adoption. When taken as a whole, microskills are granular actions that map to larger milestones, competencies, and EPAs. This article outlines the theoretical justification for this new skills-based feedback modality, the methodology behind the creation of clinical microskills, and provides a worked example of microskills for a pediatric resident on a hospital medicine rotation. Ultimately, microskills have the potential to complement milestones and EPAs and inform feedback that is specific, actionable, and relevant to medical learners.

Nurse/Resident Reciprocal Shadowing to Improve Interprofessional Communication.

OBJECTIVES: Poor communication is a major contributor to sentinel events in hospitals. Suboptimal communication between physicians and nurses may be due to poor understanding of team members' roles. We sought to evaluate the impact of a shadowing experience on nurse-resident interprofessional collaboration, bidirectional communication, and role perceptions. METHODS: This mixed-methods study took place at 2 large academic children's hospitals with pediatric residency programs during the 2018-2019 academic year. First-year residents and nurses participated in a reciprocal, structured 4-hour shadowing experience. Participants were surveyed before, immediately after, and 6 months after their shadowing experience by using an anonymous web-based platform containing the 20-item Interprofessional Collaborative Competency Attainment Survey, as well as open-ended qualitative questions. Quantitative data were analyzed via linear mixed models. Qualitative data were thematically analyzed. RESULTS: Participants included 33 nurses and 53 residents from the 2 study sites. The immediate postshadowing survey results revealed statistically significant improvements in 12 Interprofessional Collaborative Competency Attainment Survey question responses for nurses and 19 for residents (P ≤ .01). Subsequently, 6 questions for nurses and 17 for residents revealed sustained improvements 6 months after the intervention. Qualitative analysis identified 5 major themes related to optimal nurse-resident engagement: effective communication, collaboration, role understanding, team process, and patient-centered. CONCLUSIONS: The reciprocal shadowing experience was associated with an increase in participant understanding of contributions from all interprofessional team members. This improved awareness may improve patient care. Future work may be conducted to assess the impact of spread to different clinical areas and elucidate patient outcomes that may be associated with this intervention.

Pathways to Publication in Pediatric Hospital Medicine Educational Research.

OBJECTIVES: Dissemination of rigorous, innovative educational research is key to inform best practices among the global medical education community. Although abstract presentation at professional conferences is often the first step, journal publication maximizes impact. The current state of pediatric hospital medicine (PHM) educational scholarship dissemination via journal publication has not been well described. To describe educational research dissemination after PHM conference abstract submission, we identified the publication rate, median time to publication, and median publishing journal impact factor of abstracts submitted over 4 years. METHODS: Abstract data were obtained from the 2014-2017 PHM conferences and organized by presentation type (oral, poster, rejected). PubMed, MedEdPORTAL, and Google Scholar were queried for abstract publication evidence. We used logistic regression models, Kaplan-Meier survival curves and Kruskal-Wallis tests to determine the association of presentation type with the odds of publication, time to publication, and publishing journal impact factors. RESULTS: Of 173 submitted educational research abstracts, 56 (32%) were published. Oral abstracts had threefold greater and fivefold greater odds of publication compared to poster and rejected abstracts, respectively (odds ratio 3.2; 95% confidence interval 1.3-8.0; P = .011; odds ratio 5.2; 95% confidence interval 1.6-16.7; P = .003). Median time to publication did not differ between presentation types. The median journal impact factor was >2 times higher for published oral and poster abstracts than published rejected abstracts. CONCLUSIONS: Because abstract acceptance and presentation type may be early indicators of publication success, abstract submission to the PHM conference is a reasonable first step in disseminating educational scholarship.