Development and Implementation of a Quick Response (QR) Code System to Streamline the Process for Fellows' Evaluation in the Pediatric Intensive Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU) at a Large Academic Center.

BACKGROUND/OBJECTIVE: Useful feedback and evaluation are critical to a medical trainee's development. While most academic physicians understand that giving feedback to learners is essential, many do not consider the components of feedback to be truly useful, and there are barriers to implementation. We sought to use a quick reader (QR) system to solicit feedback for trainees in two pediatric subspecialties (pediatric critical care and neonatal-perinatal medicine) at one institution to increase the quality and quantity of feedback received. METHODS: New valuations were modified from the existing evaluations and imported into online systems with QR code capability. Each fellow was given a QR code linking to evaluations and encouraged to solicit feedback and evaluations in a variety of clinical settings and scenarios. Evaluation numbers and quality of evaluations were assessed and compared both pre- and post-intervention. RESULTS: There were increases in the number of evaluations completed for both the pediatric critical care fellows and the neonatal-perinatal medicine fellows. There was no overall change in the quality of written evaluations received. Satisfaction with the evaluation system improved for both faculty and fellows of both training programs. CONCLUSION: In our critical care units, we were successfully able to implement a QR code-driven evaluation for our fellows that improved access for the faculty and offered the ability of the learner to solicit evaluations, without compromising the number or quality of evaluations. What's new: Quick reader (QR) codes can be used by learners to solicit evaluations and feedback from faculty. They can increase the quantity of written evaluations received without affecting their quality.

Understanding the Factors that Determine a Fellow's Choice in Neonatal-Perinatal Medicine and How They Establish Their Rank List.

OBJECTIVE: Little is known about why neonatology fellows pick the fellowship program they do. Understanding why fellows choose neonatology and rank their programs would be of benefit to program leadership and to other applicants. STUDY DESIGN: This was a survey study sent to current neonatology fellows in the United States between September 2020 and October 2020, and were asked to rank their choices on a Likert scale. Respondents were also able to give free text responses to open-ended questions. RESULTS: The most important factor fellows state for choosing their program was location, with multiple reasons given. There were significant differences in how certain subgroups ranked programs. CONCLUSION: Location of the fellowship program is the most important factor for fellows. There are differences within subgroups of fellows on how they rank their fellowship program. Fellowship directors can use this information to better inform selections on who to interview and how to rank fellows. KEY POINTS: · Patient population appears to be the most important reason why fellows choose neonatology.. · Program location is the most important reason why fellows choose their specific training program.. · Fellowships can continue to highlight fellow camaraderie, scholarship, and clinical opportunities..

Part 5: Essentials of Neonatal-Perinatal Medicine Fellowship: evaluation of competence and proficiency using Milestones.

The Accreditation Council for Graduate Medical Education (ACGME) Pediatric Subspecialty Milestone Project competencies are used for Neonatal-Perinatal Medicine (NPM) fellows. Milestones are longitudinal markers that range from novice to expert (levels 1-5). There is no standard approach to the required biannual evaluation of fellows by fellowship programs, resulting in significant variability among programs regarding procedural experience and exposure to pathology during clinical training. In this paper, we discuss the opportunities that Milestones provide, potential strategies to address challenges, and future directions.

Vitamin D has no impact on outcomes after HSCT in children-A retrospective study.

Vitamin D not only plays an important role in bone metabolism but is also involved in multiple immune-mediated processes in the body which may be adversely affected in those with low levels. Most pediatric studies evaluating the association of vitamin D in patients undergoing allogeneic HSCT are single-center studies. We present the results of retrospective study at 5 centers across the United States in pediatric patients undergoing allogeneic HSCT. (VDD) and (VDI) were defined by vitamin D levels of <20 ng/ml and 21-30 ng/ml, respectively. The mean vitamin D levels pre-HSCT, day +30, and +100 were suggestive of VDI, but normalized thereafter. We compared the transplant characteristics and outcomes in 233 patients with VDD and VDI and those with normal levels and found no statistical difference in neutrophil or platelet engraftment, infections (viral, bacterial, or fungal) post-HSCT, length of hospital stay during HSCT, graft failure, acute or chronic GvHD, survival at day +100 and 1 year, or relapse of primary malignancy. We conclude that VDI or deficiency does not affect any of the common transplant variables after allogeneic HSCT in children. There is a need of a large multicenter prospective study to evaluate its role further.

Creation and Validation of Tool to Assess Resident Competence in Neonatal Resuscitation.

BACKGROUND: The American Board of Pediatrics requires that pediatricians be able to initiate stabilization of a newborn. After residency, 45% of general pediatricians routinely attend deliveries. However, there is no standard approach or tool to measure resident proficiency in newborn resuscitation across training programs. In a national survey, we found a large variability in faculty assessment of the amount of supervision trainees need for various resuscitation scenarios. Objective documentation of trainee performance would permit competency-based decisions on the level of supervision required and facilitate feedback on trainee performance. METHODS: A simplified tool was created following the Neonatal Resuscitation Program (NRP) algorithm, with emphasis on communication, leadership, knowledge of equipment, and initial stabilization. To achieve content validity, the tool was evaluated by the NRP steering committee. To assess internal structure of the tool, we filmed 10 simulated resuscitation scenarios, 9 of which contained errors. Experienced resuscitation team members used the tool to assess performance of the team leader in the videos. To evaluate the response process, the tool was used to assess experienced resuscitators in real time at academic and non-academic sites. RESULTS: The NRP steering committee approved the tool, providing evidence of content validity. Performance of the team leader in the simulated videos was assessed by 16 evaluators using the tool. There was an intraclass coefficient of 0.86, showing excellent agreement. There was no statistical difference in scores between 102 resuscitations led by experienced resuscitators at academic and nonacademic hospitals (P = .98), which demonstrates generalizability. CONCLUSIONS: The tool we have developed to assess performance in initiating newborn resuscitation shows evidence of construct validity based on assessment of content and internal structure (interobserver agreement, response processes, and generalizability).

The amount of supervision trainees receive during neonatal resuscitation is variable and often dependent on subjective criteria.

OBJECTIVE: Measure variation in delivery room supervision provided by neonatologists using hypothetical scenarios and determine the factors used to guide entrustment decisions. STUDY DESIGN: A survey was distributed to members of the American Academy of Pediatrics Section on Perinatal Pediatrics. Neonatologists were presented with various newborn resuscitation scenarios and asked to choose the level of supervision they thought appropriate and grade factors on their importance in making entrustment decisions. RESULTS: There was significant variation in supervision neonatologists deemed necessary for most scenarios (deviation from the mode 0.36-0.69). Post-graduate year of training and environmental circumstances influence the amount of autonomy neonatologists grant trainees. Few neonatologists have objective assessment of a trainees' competence in neonatal resuscitation available to them and most never document how the trainee performed. CONCLUSION: Delivery room supervision is often determined by subjective evaluation of trainees' competence and may not provide a level of supervision congruent with their capability.

Anti-ribosomal-phosphoprotein autoantibodies penetrate to neuronal cells via neuronal growth associated protein, affecting neuronal cells in vitro.

OBJECTIVE: Anti-ribosomal-phosphoprotein antibodies (anti-Ribos.P Abs) are detected in 10-45% of NPSLE patients. Intracerebroventricular administration of anti-ribosomal-P Abs induces depression-like behaviour in mice. We aimed to discern the mechanism by which anti-Ribos.P Abs induce behavioural changes in mice. METHODS: Anti-Ribos.P Abs were exposed to human and rat neuronal cell cultures, as well as to human umbilical vein endothelial cell cultures for a control. The cellular localization of anti-Ribo.P Abs was found by an immunofluorescent technique using a confocal microscope. Identification of the target molecules was undertaken using a cDNA library. Immunohistochemistry and an inhibition assay were carried out to confirm the identity of the target molecules. Neuronal cell proliferation was measured by bromodeoxyuridine, and Akt and Erk expression by immunoblot. RESULTS: Human anti-Ribos.P Abs penetrated into human neuronal cells and rat hippocampal cell cultures in vitro, but not to endothelial cells as examined. Screening a high-content human cDNA-library with anti-Ribos.P Abs identified neuronal growth-associated protein (GAP43) as a target for anti-Ribos.P Abs. Ex vivo anti-Ribos.P Abs bind to mouse brain sections of hippocampus, dentate and amygdala. Anti-Ribos.P Abs brain-binding was prevented by GAP43 protein. Interestingly, GAP43 inhibited in a dose-dependent manner the anti-Ribos.P Abs binding to recombinant-ribosomal-P0, indicating mimicry between the ribosomal-P0 protein and GAP43. Furthermore, anti-Ribos.P Abs reduced neuronal cell proliferation activity in vitro (P < 0.001), whereas GAP43 decreased this inhibitory activity by a factor of 7.6. The last was related to Akt and Erk dephosphorylation. CONCLUSION: Anti-Ribos.P Abs penetrate neuronal cells in vitro by targeting GAP43. Anti -Ribos.P Abs inhibit neuronal-cell proliferation via inhibition of Akt and Erk. Our data contribute to deciphering the mechanism for anti-Ribos.P Abs' pathogenic activity in NPSLE.

Epitope presentation is an important determinant of the utility of antigens identified from protein arrays in the development of autoantibody diagnostic assays.

Autoantibodies represent an attractive biomarker for diagnostic assays principally due to the stability of immunoglobulin in patient serum facilitating measurement with conventional assays. Immune responses to tumorigenesis may facilitate detection of ovarian cancer in the early stages of the disease with identification of a panel of tumour specific autoantibodies. Despite the reporting of many tumour associated autoantibodies using arrays of tumour antigens, this has not led to the advance in diagnostic capability as rapidly as was initially expected. Here we examine the potential diagnostic utility of candidate autoantibody biomarkers identified via screening of serum samples on a high content human protein array from a unique cohort of early stage and late stage ovarian cancer patients. We analyse the performance of autoantibodies to the tumour suppressor protein p53 and the novel autoantigens alpha adducin and endosulfine alpha identified in our array screen. Each antigen has different performance characteristics using conventional ELISA format and Western blot immunoassay. The high attrition rate of promising autoantigens identified by array screening can in part be explained by the presentation of the epitope of the antigen in the subsequent method of validation and this study provides directions on maximising the potential of candidate biomarkers. This article is part of a Special Issue entitled: Translational Proteomics.

Optimized autoantibody profiling on protein arrays.

Profiling the autoantibody (AAb) repertoire in serum has been routinely used for many years for the diagnosis of autoimmune diseases, including rheumatoid arthritis, scleroderma, and lupus. In recent years, AAb profiling of cancers has become a prominent field in oncology research. Protein arrays enable high-throughput screening of clinical samples, characterising the serum profile using low volumes of samples. This chapter describes the use of a protein array comprising 37,200 redundant proteins (containing over 10,000 non-redundant human recombinant proteins) for identification of the proteins bound by the antibodies in human sera using a test set of serum samples. The proteins identified have the potential to be candidate biomarkers. These recombinant proteins are expressed, purified, and robotically spotted on microarrays or chips to facilitate the screening of additional serum samples with the aim of identifying a candidate biomarker or panel of potential biomarkers for applications in disease diagnosis, stage, progression, or response to therapy.

Integrated protein array screening and high throughput validation of 70 novel neural calmodulin-binding proteins.

Calmodulin is an essential regulator of intracellular processes in response to extracellular stimuli mediated by a rise in Ca(2+) ion concentration. To profile protein-protein interactions of calmodulin in human brain, we probed a high content human protein array with fluorophore-labeled calmodulin in the presence of Ca(2+). This protein array contains 37,200 redundant proteins, incorporating over 10,000 unique human neural proteins from a human brain cDNA library. We designed a screen to find high affinity (K(D) < or = 1 microm) binding partners of calmodulin and identified 76 human proteins from all intracellular compartments of which 72 are novel. We measured the binding kinetics of 74 targets with calmodulin using a high throughput surface plasmon resonance assay. Most of the novel calmodulin-target complexes identified have low dissociation rates (k(off) < or = 10(-3) s(-1)) and high affinity (K(D)

COX-2 specific inhibitors enhance the cytotoxic effects of pemetrexed in mesothelioma cell lines.

BACKGROUND: Although malignant pleural mesothelioma is a rare tumour, its incidence is increasing. The prognosis remains very poor with an average survival of 10 months from diagnosis. The choice of chemotherapy regimens for mesothelioma patients is limited and new approaches are required. COX-2 inhibition induces apoptosis in a variety of tumour cell lines. The cytotoxic effect of conventional drugs may be enhanced by the addition of a COX-2 inhibitor. In order to identify possible new therapeutic approaches we aimed to determine whether the addition of COX-2 inhibitors would enhance the cytotoxic effect of chemotherapeutic agents in mesothelioma cell lines. MATERIALS AND METHODS: Three mesothelioma cell lines MSTO-211H, NCI-H2052 and NCI-H2452 were utilised. Using the COX-2 positive A549 lung cancer cell line as control, all cell lines were assayed using an MTT assay with non-specific COX-2 inhibitors (sulindac and flurbiprofen), specific COX-2 inhibitors (DuP-697 and NS-398), and chemotherapeutic agents (cisplatin, vinorelbine and pemetrexed). RESULTS: All cell lines exhibited COX-2 expression by western blotting using two antibodies. The addition of either DuP-697 or NS-398 increased the sensitivity to pemetrexed in all cell lines. CONCLUSION: These findings suggest that the design of novel pemetrexed-containing combination regimens with increased cytotoxicity may be feasible.

The analysis of doxorubicin resistance in human breast cancer cells using antibody microarrays.

Doxorubicin is considered to be the most effective agent in the treatment of breast cancer patients. Unfortunately, resistance to this agent is common, representing a major obstacle to successful treatment. The identification of novel biomarkers that are able to predict treatment response may allow therapy to be tailored to individual patients. Antibody microarrays provide a powerful new technique, enabling the global comparative analysis of many proteins simultaneously. This technology may identify a panel of proteins to discriminate between drug-resistant and drug-sensitive samples. The Panorama Cell Signaling Antibody Microarray was exploited to analyze the MDA-MB-231 breast cancer cell line and a novel derivative, which displays significant resistance to doxorubicin at clinically relevant concentrations. The microarray comprised 224 antibodies selected from a variety of pathways, including apoptotic and cell signaling pathways. A standard >/=2.0-fold cutoff value was used to determine differentially expressed proteins. A decrease in the expression of mitogen-activated protein kinase-activated monophosphotyrosine (phosphorylated extracellular signal-regulated kinase; 2.8-fold decrease), cyclin D2 (2.5-fold decrease), cytokeratin 18 (2.5-fold decrease), cyclin B1 (2.4-fold decrease), and heterogeneous nuclear ribonucleoprotein m3-m4 (2.0-fold decrease) was associated with doxorubicin resistance. Western blotting was exploited to confirm results from the antibody microarray experiment. These results suggest that antibody microarrays can be used to identify novel biomarkers and further validation may reveal mechanisms of chemotherapy resistance and identify potential therapeutic targets. [Mol Cancer Ther 2006;5(8):2115-20].

Expression of bcl-2 family members in malignant pleural mesothelioma.

Little is known about the Bcl-2 family members in mesothelioma. These proteins are involved in the control of apoptosis, carrying out both pro- and anti- apoptotic functions. Immunohistochemistry was used to examine the expression of p53 and Bcl-2 family members in 54 archival mesothelioma samples (39 epithelial, 15 sarcomatoid tumours). Overexpression of p53 was observed in 81% (44/54). For anti-apoptotic proteins, overexpression was recorded as follows: Bcl-2 40% (22/54), Bcl-XL 24% (13/54), Mcl-1 92% (50/54). For pro-apoptotic proteins, loss of expression was recorded as follows: Bad 25% (14/54), Bak 24% (13/54), Bax 42% (23/54), Bid 37% (20/54), Bim 18% (10/54). Statistically significant differences between epithelial and sarcomatoid tumours were observed for Bid (p < 0.001), Bad (p = 0.012) and Bcl-XL (p = 0.03). Significant differences in abnormal expression of apoptosis proteins were found between epithelial and sarcomatoid subtypes but histological subtype was the only factor with significant association to patient prognosis.

Implication of the BRCA2 and putative "BRCA3" genes in Dukes' stage C, replication error-negative colon cancer.

BACKGROUND: Although BRCA genes have been implicated in certain tumors, particularly breast tumors, their role in colon tumorigenesis has not been fully explored. We aimed to investigate the association of the BRCA2 and putative "BRCA3" genes in a homogeneous series of right-sided colon cancer specimens. METHODS: Twenty-three Dukes' stage C, replication error-negative carcinomas were selected from patients with right-sided colon cancer. After histological examination and microdissection, DNA was extracted from normal colon and carcinoma from each patient. Five microsatellite markers spanning the region of BRCA2 and BRCA3 on chromosome 13 (D13S218, D13S219, D13S165, D13S156, and D13S160) and two markers intragenic to BRCA2 and BRCA3 (D13S171 and D13S1308, respectively) were used. Polymerase chain reaction products were analyzed by using a fluorescent allele imbalance assay. RESULTS: Markers demonstrating the highest allelic imbalance were D13S1308 (53%), D13S171 (33%), and D13S160 (37%). CONCLUSIONS: The intragenic markers D13S1308 (BRCA3) and D13S171 (BRCA2) on chromosome 13 demonstrated a high frequency of allelic imbalance in primary colon carcinoma. This suggests an involvement of BRCA2 and putative BRCA3 in colon tumorigenesis in right-sided, replication error-negative, Dukes' stage C cancers. Further studies are needed to confirm the precise role of these genes, and any prognostic significance, in colon cancer.

Immunohistochemical detection of apoptotic markers in gastric cancer.

Apoptosis proteins may play a role in prognosis and therapy response; however, they have not been fully investigated in gastric cancer. We aimed to assess the expression of proteins in the Bcl-2 family. Immunohistochemistry was employed to examine the expression of the antiapoptotic proteins Bcl-2 and Bcl-XL and the proapoptotic proteins Bad, Bak, Bax, Bid, Bim, and p53 in 21 cases of gastric cancer. Immunopositivity was observed in 12/21 (57%) cases for p53, 16/21 (76%) cases for Bcl-XL, and 5/21 (23%) cases for Bcl-2. For the proapoptotic members of the Bcl family, loss of protein expression was observed: Bid (14/21 cases; 66%), Bad (13/21 cases; 61%), Bax (12/21 cases; 57%), Bak (9/21 cases; 42%), and Bim (4/21 cases; 19%). This study identified apoptosis proteins that exhibit heterogeneous expression between primary gastric carcinomas.

Hsp27 may allow prediction of the response to single-agent vinorelbine chemotherapy in non-small cell lung cancer.

One of the most valuable objectives for oncologists is the ability to predict patient response to chemotherapy before drugs are administered in order to maximise the therapeutic benefit of treatment whilst limiting the toxicity. This is particularly relevant in non-small cell lung cancer as the initial treatment decision is important due to the inherent drug resistance of many tumours and short survival times of patients. We established a homogeneous series of pre-treatment archival biopsy samples from patients receiving first-line single-agent vinorelbine for non-small cell lung cancer. Cases were selected following strict inclusion criteria and patient response was assessed using the Response Evaluation Criteria in Solid Tumours guideline. The expression of 7 proteins was investigated and correlated with response data. Chi-square analysis revealed no association between expression of Bcl-2, Bcl-XL, Bad, Bak, Bid or p53 proteins and response to vinorelbine therapy. There was a trend for Hsp27-positive tumours to show progression but this did not reach significance (p=0.068). The results suggest that Hsp27 expression may be useful as a predictor of response to single-agent vinorelbine chemotherapy in non-small cell lung cancer patients but a larger study is required to confirm this.

The expression of Bcl-2 family proteins differs between nonsmall cell lung carcinoma subtypes.

BACKGROUND: Proteins of the Bcl-2 family play a key role in the control of apoptosis and carry out both proapoptotic and antiapoptotic functions. However, with the exception of Bcl-2 itself, little is known about the expression of these potentially critical proteins in nonsmall cell lung carcinoma. METHODS: Immunohistochemistry was used to study the expression of Bcl-2 and 6 other Bcl-2 family proteins in a pilot series of 41 archival nonsmall cell lung carcinoma specimens (19 adenocarcinomas and 22 squamous cell carcinomas). RESULTS: Overexpression of the apoptosis inhibitors Bcl-2 and Bcl-X(L) was observed in 10 of 41 samples (24%) and in 11 of 41 samples (27%), respectively. Loss of expression of proapoptotic proteins was observed as follows: Bak, 24 of 41 samples (59%); Bad, 21 of 41 samples (51%); Bid, 20 of 41 samples (49%); Bax, 14 of 41 samples (34%); and Bim/Bod, 2 of 41 samples (5%). Statistically significant differences in expression between adenocarcinoma samples and squamous cell carcinoma samples were observed for Bcl-X(L) (overexpression in 11 of 19 adenocarcinomas [58%] vs. 0 of 22 squamous cell carcinomas [0%]; P < 0.001) and for Bad (loss of expression in 5 of 19 adenocarcinomas [26%] vs. 16 of 22 squamous cell carcinomas [73%]; P = 0.004). CONCLUSIONS: Although this was only a pilot study, the results revealed significant differences in the expression of apoptosis-related proteins both between individual samples of nonsmall cell lung carcinoma and between the two main histologic subtypes. Such differences may play a role in the development of lung tumors; and, if it is found that these differences are of clinical importance, then it may be required to regard nonsmall cell lung carcinoma subtypes as separate entities rather than as one disease.