Positive Impact of Transition From Noon Conference to Academic Half Day in a Pediatric Residency Program.

OBJECTIVE: To evaluate the impact of transitioning from noon conference (NC) to academic half day (AHD) on conference attendance, interruptions, and perceived protected educational time and to describe pediatric resident experiences with AHD. METHODS: In this mixed-methods study, data before and after AHD implementation were collected. Quantitative data were analyzed with a 2-variable t test or chi-square test. Five focus groups and 5 individual interviews of pediatric residents were conducted. Data were analyzed using constant comparative methods, and were collected until reaching saturation. In accordance with grounded theory methodology, we developed codes using an iterative approach and identified major themes. RESULTS: After AHD implementation, resident attendance increased from 55% (of residents expected at NC) to 94% (of residents scheduled for AHD) (P < .001); interruptions decreased from 0.25 to 0.01 per resident per hour (P < .001). Positive responses regarding perceived protected educational time improved from 50% to 95% (2015 class) and from 19% to 50% (2016 class) (P < .001). Thirty-two residents participated in focus groups and interviews. Analysis yielded 5 themes: aids and barriers to AHD attendance; teaching; curricular content; learning and engagement; and resident well-being. Residents felt aided attending AHD when clinical supervisors supported their educational time. Compared to NC, residents noted better topic selection but fewer covered topics. Residents valued protected educational time without clinical responsibilities and thought that small-group discussions at AHD facilitated learning. Although cross-covering was stressful, AHD positively contributed to resident well-being. CONCLUSIONS: AHD improves resident attendance, interruptions, and perceived learning, and it contributes to resident wellness. More work is needed to mitigate the workload of cross-covering residents.

Microvascular shunts in the pathogenesis of high intracranial pressure.

Hyperemia in the infarcted brain has been -suggested for years by "red veins" reported by neurosurgeons, shunt peaks in radioactive blood flow clearance curves, and quantitative cerebral blood flow using stable xenon CT. Histological characterization of infarcted brain revealed capillary rarefaction with prominent microvascular shunts (MVS). Despite abundant histological evidence, the presence of cerebrovascular shunts have been largely ignored, perhaps because of a lack of physiological evidence demonstrating the transition from capillary flow to MVS flow. Our studies have shown that high intracranial pressure induces a transition from capillary to microvascular shunt flow resulting in cerebral hypoperfusion, tissue hypoxia and brain edema, which could be delayed by increasing cerebral perfusion pressure. The transition from capillary to microvascular shunt flow provides for the first time a physiological basis for evaluating the optimal cerebral perfusion pressure with increased intracranial pressure. It also provides a physiological basis for evaluating the effectiveness of various drugs and therapies in reducing intracranial pressure and the development of brain edema and tissue hypoxia after brain injury and ischemia. In summary, the clear-cut demonstration of the transition from capillary to MVS flow provides an important method for evaluating various therapies for the treatment of brain edema and loss of autoregulation.

Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature.

OBJECTIVE: To evaluate the efficacy of routine follow-up CT scans of the head after complicated mild traumatic brain injury (TBI). METHODS: 74 English language studies published from 1999 to February 2011 were reviewed. The papers were found by searching the PubMed database using a combination of keywords according to Cochrane guidelines. Excluding studies with missing or inappropriate data, 1630 patients in 19 studies met the inclusion criteria: complicated mild TBI, defined as a GCS score 13-15 with abnormal initial CT findings and the presence of follow-up CT scans. For these studies, the progression and type of intracranial haemorrhage, time from trauma to first scan, time between first and second scans, whether second scans were obtained routinely or for neurological decline and the number of patients who had a neurosurgical intervention were recorded. RESULTS: Routine follow-up CT scans showed hemorrhagic progression in 324 patients (19.9%). Routine follow-up head CT scans did not predict the need for neurosurgical intervention (p=0.10) but a CT scan of the head performed for decline in status did (p=0.00046). For the 56 patients (3.4%) who declined neurologically, findings on the second CT scan were worse in 38 subjects (67%) and unchanged in the rest. Overall, 39 patients (2.4%) underwent neurosurgical intervention. CONCLUSION: Routine follow-up CT scans rarely alter treatment for patients with complicated mild TBI. Follow-up CT scans based on neurological decline alter treatment five times more often than routine follow-up CT scans.