"Play How We Practice": A Residency Program's Snapshot of Pediatric Resident Perspectives on Education During the COVID-19 Pandemic.

OBJECTIVES: Our objective was to understand the perspectives of current and recently graduated pediatric residents concerning the impact of the COVID-19 pandemic, and subsequent curriculum changes, to their education. INTRODUCTION: Residency programs have experienced unprecedented alterations to education in the form of changing expectations, schedules, and opportunities during the COVID-19 pandemic. Little is known regarding resident perceptions of how these changes impact their education and ultimate career preparation. METHODS: An anonymous and voluntary electronic IRB exempt survey was sent to pediatric residents at a mid-sized residency program in the mid-Atlantic in August of 2020. This cross-sectional study survey consisted of a series of multiple choice questions with optional short answer responses. RESULTS: Twenty-two pediatric residents across all training years completed the survey for a response rate of 36%. The majority of residents, 59.1%, were interested in directly caring for COVID + patients; however, the minority (36%) felt prepared to care for COVID + patients. Most residents (63%) responded that graduate medical education programs should not have authority to exclude residents from taking care of patients with certain diagnoses and 95% of respondents indicated that they would prefer an opt out system instead. CONCLUSION: The majority of resident respondents had a strong interest in caring for COVID + patients and report that they value frequent updates from program leadership to guide their patient care. Residents also overwhelmingly support an opt out system when caring for future patients with particular infectious diagnoses rather than a mandated exclusion approach.

The genogram as a recruitment tool for identifying primary caregivers of youth living with sickle cell disease preparing for transition.

AIMS: The purpose of this secondary analysis was to describe the impact of using genograms to identify family caregivers from an original research study which used family caregiver-adolescents/young adults (AYA) dyads. BACKGROUND: Research to improve transition preparation for AYA with chronic disease is essential as 90% will survive into adulthood. Family-based transition research is specifically needed as a majority of transition preparation will occur in the home setting. Dyadic research on transition has not previously described strategies for recruiting appropriate family caregivers. DESIGN: A descriptive, secondary analysis was conducted using genograms developed during the original study conducted between October 2019 and February 2020. METHODS: For this secondary analysis conducted between July 2020 and August 2021, 50 genograms were analysed using descriptive statistics to describe family structures, relationships and responsibilities in families of AYAs living with sickle cell disease. RESULTS: In 43 genograms, there was only one primary caregiver in the family. In seven genograms, there were multiple primary caregivers who met the inclusion criteria for primary caregiver in a single family. In five genograms, there were two appropriate primary caregivers in a single family, and in two genograms, there were three appropriate individuals in a single family who met study criteria as a primary caregiver. CONCLUSIONS: Findings from the analysis of the genograms used in the original study demonstrated potential ability to improve on dyad recruitment by more specifically identifying the family member most involved in supporting the AYA's disease management. IMPACT: Genograms are an established tool for gathering information on families and application with recruitment could improve research in the realm of transition and other family-based research. NO PATIENT OR PUBLIC CONTRIBUTION: This was a secondary analysis that assessed already existing data.

Uncovering Family Treatment Decision-Making Processes: The Value and Application of Case Study Methods to Family Research.

Research on how and why family processes influence phenomena is essential to advancing many areas of science. Case study methods offer an approach that overcomes some of the sampling and analysis obstacles researchers face when studying families. This article aims to illustrate the benefits of case study methods for studying complex family processes using an example from treatment decision-making in sickle cell disease. Using survey, observation, and interview data from various family members within multiple family units, we detail our application of the following analytic strategies: (a) proposition-building, (b) pattern-matching, and (c) cross-case synthesis. Incorporating propositions from a conceptual framework assisted us in study development, data collection, and analysis. Development of graphs and matrices to create thematic family profiles uncovered how and why treatment decision-making occurred as a family process in a pediatric chronic illness. Case study methods are an established, but innovative approach to investigating various phenomena in families.

Themes Depicted in Running-Related Films: An Opportunity for Co-Viewing and Active Mediation.

Sport participation is an important part of the development of children and adolescents. The objective of this study was to identify and quantify themes depicted in a select number of running-related films. Thirty-one running-related films were independently viewed and analyzed by 4 reviewers. The number of positive and negative themes was 29.5 (95% confidence interval = 26.1-33.4) and 9.0 (95% confidence interval = 7.9-10.2) mean events per hour for all included films, respectively. The most common positive themes were "overcoming physical limitations," "overcoming mental obstacles," and "encouragement from family/friends/fans" (2.6, 2.4, and 2.3 mean events per hour, respectively). The most common negative themes were "giving up/losing confidence," "ignoring injuries," and "discouragement/ridicule from coach/athletic trainer" (1.2, 1.1, and 0.66 mean events per hour, respectively). In conclusion, the co-viewing of running-related films with pediatric athletes in order to focus on "teachable moments" may encourage the acquisition and development of positive themes and the avoidance and de-emphasis of negative themes.

Injury and Illness Depicted in Running-Related Films.

The perception that children and adolescents have of injury and illness may be influenced by their depiction in sport-related films. The objective of this study was to determine the depiction of injury and illness in a select number of running-related films. A sample of 31 running-related films were analyzed, with a total of 77 injuries/illnesses depicted. The most common injuries/illnesses depicted were categorized as exertional heat exhaustion/stroke (26%), lower leg muscle cramps/not heat related (12%), ankle sprain (9%), knee ligamentous/meniscus injury (6%), exercise-associated collapse/not heat related (6%), and blister of the toe/foot (6%). Overall, 48/67 (64%) of the injuries/illnesses were considered severe emergencies (injury/illness requiring prompt intervention and immediate discontinuation of sport participation). The disposition of 46% of severe emergencies was the immediate continuation of training/competition. Pediatric health care providers, coaching staff, and parents should stress the importance of injury/illness recognition/disclosure and realistic expectations for rehabilitation to pediatric runners.

Treatment Decision-Making Involvement in Adolescents and Young Adults With Cancer.

PROBLEM IDENTIFICATION: Involvement in treatment decision making (TDM) is considered a key element of patient- and family-centered care and positively affects outcomes. However, for adolescents and young adults (AYAs) with cancer, little is known about the current state of knowledge about their perspective on and involvement in TDM or the factors influencing AYAs' TDM involvement. LITERATURE SEARCH: Integrative review focused on AYAs aged 15-21 years, their involvement in TDM, and factors influencing their involvement using the MEDLINE®, PsycINFO®, CINAHL®, and Web of Science databases. DATA EVALUATION: 4,047 articles were identified; 21 met inclusion criteria. SYNTHESIS: Five factors were identified. IMPLICATIONS FOR RESEARCH: Research is needed to understand AYAs' preferences for TDM, the type and degree of their involvement, and the interactions between factors that contribute to or impede TDM.

Bone marrow-derived epithelial cells and hair follicle stem cells contribute to development of chronic cutaneous neoplasms.

We used allogeneic bone marrow transplantation (BMT) and a mouse multistage cutaneous carcinogenesis model to probe recruitment of bone marrow-derived epithelial cells (BMDECs) in skin tumors initiated with the carcinogen, dimethylbenz[a]anthracene (DMBA), and promoted with 12-O-tetradecanolyphorbol-13-acetate (TPA). BMDECs clustered in the lesional epithelium, expressed cytokeratins, proliferated, and stratified. We detected cytokeratin induction in plastic-adherent bone marrow cells (BMCs) cultured in the presence of filter-separated keratinocytes (KCs) and bone morphogenetic protein 5 (BMP5). Lineage-depleted BMCs migrated towards High Mobility Group Box 1 (HMGB1) protein and epidermal KCs in ex vivo invasion assays. Naive female mice receiving BMTs from DMBA-treated donors developed benign and malignant lesions after TPA promotion alone. We conclude that BMDECs contribute to the development of papillomas and dysplasia, demonstrating a systemic contribution to these lesions. Furthermore, carcinogen-exposed BMCs can initiate benign and malignant lesions upon tumor promotion. Ultimately, these findings may suggest targets for treatment of non-melanoma skin cancers.

School Nurses on the Front Lines of Medicine: Uppers and Downers: The Approach to the Student With Altered Mental Status.

Although a student presenting with altered mental status due to substance use may occur infrequently in the school setting, it is of utmost importance to develop a differential diagnosis and to initiate stabilization of the student. This article describes the initial assessment and management of a student presenting with altered mental status, focusing on the differential diagnosis of altered mental status, on the varying presentations associated with common intoxications and ingestions, and on the screening tools available for the detection of depression and substance use.

Measuring Transition Readiness: A Correlational Study of Perceptions of Parent and Adolescents and Young Adults with Sickle Cell Disease.

Adolescents and young adults (AYAs) often transfer from pediatric to adult care without adequate preparation, resulting in increased morbidity and mortality. The purpose of this descriptive research study of parent/AYA dyads was to measure perceptions of transition readiness. Factors that were found to be associated with perceptions of increased readiness to transition included AYA age, the amount of responsibility AYAs assume for their healthcare and the degree of parent involvement. More attention should be focused on these aspects of care to improve transition from pediatric to adult care for AYAs with sickle cell disease.

A novel extract from bovine colostrum whey supports anti-bacterial and anti-viral innate immune functions in vitro and in vivo: I. Enhanced immune activity in vitro translates to improved microbial clearance in animal infection models.

OBJECTIVE: To evaluate effects on the innate immune system after exposure to, a consumable low-molecular weight fraction (CLMWF) of immunoglobulin-depleted bovine colostrum whey. METHODOLOGY: Cell-based immune assays were performed in vitro, and host resistance towards bacterial and viral infection was evaluated in two mouse studies. RESULTS: In vitro data showed a multimodal effect, as CLMWF treatment resulted in a rapid increase in phagocytosis. CLMWF increased chemotaxis of polymorphonuclear cells towards the bacterial peptide f-MLP. CLMWF treatment of natural killer cells increased expression of the CD69 activation marker. Mononuclear phagocytes showed decreased numbers of CD14(bright) and increased number of CD14(dim) cells. The remaining CD14(bright) cells showed reduced expression of CD80 and CD86, whereas CD14(dim) cells showed increased expression of CD80 and CD86, suggesting dendritic cell maturation. Mouse models were applied to evaluate the immune-modulating capacity of CLMWF when consumed acutely during bacterial (Streptococcus) and viral (Influenza) infections in vivo. Reduced bacterial and viral loads were observed in lungs within 24h. Viral load was also reduced when CLMWF was introduced intranasally. CONCLUSION: The data suggest that the support of antimicrobial immune defense mechanisms and maturation of antigen-presenting cells in vitro translates to protection in vivo when product is introduced across mucosal membranes.

"Shifting family boundaries" after the diagnosis of childhood cancer in stepfamilies.

The childhood cancer experiences of stepfamilies have not been described despite the fact that nearly one third of U.S. children will live in a stepfamily household. To describe the impact of diagnosis on parental relationships in stepfamilies, we undertook a secondary analysis of data from a study of parental decision making in structurally diverse families. As described by 13 parents of six stepfamilies, the crisis of a childhood cancer diagnosis immediately changed family dynamics. Parental relationships changed, which shifted family boundaries, creating instability in families who were trying to cope with a very stressful life experience. Through increased understanding of parental relationship changes that occur after the diagnosis of childhood cancer in stepfamilies, clinicians can anticipate these changes and provide supportive interventions to reduce overall family conflict and distress. These distinctive stepfamily responses underscore the need to include structurally diverse families in future trials targeting parental coping in childhood cancer.

In vitro and in vivo antioxidant and anti-inflammatory capacities of an antioxidant-rich fruit and berry juice blend. Results of a pilot and randomized, double-blinded, placebo-controlled, crossover study.

This study investigated the in vitro and in vivo antioxidant and anti-inflammatory properties of a juice blend (JB), MonaVie Active, containing a mixture of fruits and berries with known antioxidant activity, including acai, a palm fruit, as the predominant ingredient. The phytochemical antioxidants in the JB are primarily in the form of anthocyanins, predominantly cyanidin 3-rutoside, cyanidin 3-diglycoside, and cyanidin 3-glucoside. The cell-based antioxidant protection of erythrocytes (CAP-e) assay demonstrated that antioxidants in the JB penetrated and protected cells from oxidative damage ( p < 0.001), whereas polymorphonuclear cells showed reduced formation of reactive oxygen species ( p < 0.003) and reduced migration toward three different pro-inflammatory chemoattractants: fmlp ( p < 0.001), leukotriene B4 ( p < 0.05), and IL-8 ( p < 0.03). A randomized, double-blinded, placebo-controlled, crossover trial with 12 healthy subjects examined the JB's antioxidant activity in vivo. Blood samples at baseline, 1 h, and 2 h following consumption of the JB or placebo were tested for antioxidant capacity using several antioxidant assays and the TBARS assay, a measure of lipid peroxidation. A within subject comparison showed an increase in serum antioxidants at 1 h ( p < 0.03) and 2 h ( p < 0.015), as well as inhibition of lipid peroxidation at 2 h ( p < 0.01) postconsumption.

Natural killer cell activation and modulation of chemokine receptor profile in vitro by an extract from the cyanophyta Aphanizomenon flos-aquae.

The present research was designed to study the effects of an extract from the edible cyanophyta Aphanizomenon flos-aquae on human natural killer (NK) cells. We have previously shown, using a double-blind randomized placebo-controlled crossover design, that ingestion of 1.5 g of dried whole A. flos-aquae resulted in a transient reduction in peripheral blood NK cells in 21 healthy human volunteers, suggesting increased NK cell homing into tissue. We have now identified an extract from A. flos-aquae (AFAe) that directly activates NK cells in vitro and modulates the chemokine receptor profile. NK cell activation was evaluated by expression of CD25 and CD69 on CD3-CD56+ cells after 18 hours. Changes in CXCR3 and CXCR4 chemokine receptor expression after 5-60 minutes were evaluated by immunostaining and flow cytometry. AFAe induced the expression of CD69 on CD3-CD56+ NK cells, induced CD25 expression on 25% of these cells, and acted in synergy with interleukin 2. NK cells enriched by RosetteSep (StemCell Technologies Inc., Vancouver, BC, Canada) were not activated by AFAe, indicating that the NK activation was dependent on other cells such as monocytes. The low-molecular-weight fraction <5,000 of AFAe was responsible for the most robust NK cell activation, suggesting novel compounds different from previously reported macrophage-activating large polysaccharides.

Preliminary reliability and validity testing of a new Skin Toxicity Assessment Tool (STAT) in breast cancer patients undergoing radiotherapy.

Clear consensus on the clinical evaluation of acute skin toxicity among cancer patients undergoing radical radiotherapy (RT) is currently lacking. This study investigates the reliability and validity of a new Skin Toxicity Assessment Tool (STAT) to evaluate the objective and subjective manifestations of RT-induced acute skin effects. The STAT was designed by a multidisciplinary team involved in the management of radiation skin reactions. The tool has 3 components: patient and treatment parameters, observer scoring, and patient-reported symptoms, and was piloted in a cohort of 27 breast cancer patients by pairs of independent blinded observers. Each patient was assessed weekly during RT and 2 weeks after therapy completion. Validity and reliability testing of the STAT was performed. Information on the tool's ease of use was obtained by recording the time necessary to complete the assessment at each visit and by a survey among the tool's users. All subjects developed some degree of skin reaction during breast RT. The level of agreement between observers in eliciting subjective complaints ranged from 72% to 92% (95% CI = 63-96%; kappa = 0.33-0.68). The interobserver agreement in scoring skin reactions ranged from 65.0 to 97.5% (kappa = 0.46-0.81). Objective and subjective toxicity scores were significantly correlated (P < 0.05). The STAT was easy to use and required on average a few minutes to complete at each visit. The STAT is an easy-to-use, standardized instrument to evaluate acute skin reaction and may be applied to clinical care and research in patients undergoing radiotherapy.

Quality improvement in critical access hospitals: addressing immunizations prior to discharge.

CONTEXT: Many patients hospitalized in critical access hospitals (CAHs) are at high risk for influenza and pneumonia. These hospitalizations may represent a missed opportunity to address immunizations. Addressing these missed immunizations could provide an opportunity for CAHs to gain practical experience in data-driven quality improvement. PURPOSE: To improve documentation and delivery of influenza and pneumococcal immunizations prior to hospital discharge and provide CAHs with quality improvement experience. METHODS: We recruited 17 CAHs in Kansas to participate in a rapid-cycle quality improvement project to address inpatient immunizations. Each hospital identified patient discharges on a monthly basis and abstracted medical records to see if the patient's immunization status had been assessed and if patients had been vaccinated prior to discharge. FINDINGS: Documentation of influenza immunization status improved from 17% of admissions at baseline to 62% at follow-up (P < 0.001). Documentation of pneumococcal immunization status increased from 36% at baseline to 51% at follow-up (P < 0.001). Documentation of immunizations was significantly higher among the 8 hospitals that developed standard charting forms for recording immunization status (P < 0.01). Despite improved documentation of immunization status, at remeasurement only 3.4% received an influenza vaccination and 1.3% received a pneumococcal vaccination prior to discharge. CONCLUSIONS: Critical access hospitals can effectively participate in quality improvement activities, but increased involvement of medical staff or standing immunization orders may be needed to improve actual vaccine administration prior to discharge.

Various techniques of contouring the rectum and their impact on rectal dose-volume histograms.

Late rectal bleeding resulting from radiotherapy has been correlated with rectal dose-volume histograms (DVHs). The techniques of contouring the rectum have been inconsistent within the literature, making interpretations of DVHs difficult. This study was conducted to investigate the impact on rectal DVHs when using different ways of contouring. Ten prostate cancer patients were treated with a 4-field box-technique and received 70 Gy. Six different ways of contouring the rectum were implemented by using 3 different cross-sections and 2 different lengths. The 3 different cross sections were (1) anterior rectal wall (arw): only the anterior half of the rectal wall was contoured; (2) whole rectal wall (wrw): the entire rectal wall was contoured but excluding the rectal contents; and (3) the rectum (rec): including the rectal contents. Two different lengths were used for the above 3 volumes: (1) long (Lg): cranial border starting at where the rectum turned horizontally into the sigmoid and the caudal border 2 cm below the prostatic apex; (2) short (Sh): from 2 cm above to 2 cm below the prostate. Therefore, a total of 6 different volumes (Sh arw, Lg arw, Sh wrw, Lg wrw, Sh rec, and Lg rec) were generated. DVHs of all 6 volumes were compared with the y-axis being percentage volume as well as absolute volume (cc). When using percentage volume as the y-axis, Sh arw gave an impression that a large portion of rectum (median of 41.8%) received high dose (greater than 90% prescribed dose), while the Lg wrw and Lg rec revealed a smaller portion of rectum (median of 17.1% and 14.7%, respectively) received high dose. The other contours were somewhere in-between. When using absolute volume as the y-axis, the DVHs of the 4 rectal volumes, excluding the rectal content (Sh and Lg arw, Sh and Lg wrw), merged at doses greater than 80% to 85% prescription, therefore providing similar information within these high-dose regions. Configurations of rectal DVHs varied drastically with different techniques of contouring and may lead to different interpretations. By using absolute volume (cc) as the y-axis, the shape of the 4 rectal DVHs, excluding the rectal content, were similar in the high-dose region. Reporting rectal toxicities in relations to DVHs using absolute volume, as well as percentage volume, may eliminate inconsistencies secondary to different methods of contouring.

Three instruments to assess fatigue in children with cancer: the child, parent and staff perspectives.

The purpose of this study was to develop and test three instruments to measure fatigue in children with cancer from the perspectives of the child, parents and staff. The study consisted of three phases: instrument development, content validation, and estimations of psychometric properties of the three fatigue instruments. One hundred forty-nine children between the ages of 7-12 years presently receiving chemotherapy for cancer, 147 parents and 124 staff participated in this study. The instruments demonstrated strong initial validity and reliability estimates. This study is the first to provide valid and reliable instruments to measure fatigue in children with cancer.