A multidisciplinary approach to providing blended diet within the acute setting.

BACKGROUND: Due to advances in medical care, including nutrition and hydration, children with neurological impairment are surviving longer. Many of these children are fed using a commercial formula via an enteral feeding tube. However, families are now becoming more interested in administering blended diet via their child's gastrostomy in a bid to reduce often significant gastrointestinal symptoms including reflux, constipation, gagging and retching post fundoplication. AIMS: To describe the process undertaken by the authors' short-life working group to create safe, robust pathways to enable children to have access to blended diet while in the acute hospital setting. METHODS: A multidisciplinary team short-life working group was established, which consisted of representatives from nursing, dietetics and catering. Following this a scoping exercise was undertaken to assess what practices were carried out in other health boards, prior to the creation of documentation. CONCLUSION: In conjunction with senior management and the Central Legal Office, the authors' short life working group has created safe, robust documentation and pathways to enable children in a large tertiary paediatric centre to access blended diet while in the acute setting. Due to the recent COVID-19 pandemic the pilot study to trial these documents within the neurology ward was delayed, however this work is ongoing. Furthermore, the authors will be looking to train nursing staff within ward areas to administer blended diet within the ward setting.

Case Report: Rocky Mountain Spotted Fever with Adrenalectomy and a Hard-to-Find Tick.

BACKGROUND Rocky Mountain spotted fever (RMSF) is a potentially fatal infectious disease caused by the gram-negative intracellular bacterium Rickettsia rickettsii. The classic triad includes fever, rash, and history of tick exposure; however, the triad presents in only 3% to 18% of cases at the initial visit, and the tick bite is often painless and overlooked. RMSF can present with other manifestations, including hyponatremia, lymphopenia, thrombocytopenia, and coagulopathy. Some of these manifestations can be overlooked if they overlap with manifestations of a patient's pre-existing conditions. CASE REPORT A 43-year-old woman with RMSF presented with fever and treatment-resistant hyponatremia before developing a rash. Initially, the cause of her hyponatremia was attributed to adrenal insufficiency and dehydration. After appropriate treatments with hormone replacement therapy and intravenous hydration, her laboratory values remained relatively unchanged. A rash later appeared with an atypical RMSF pattern, warranting a detailed integumentary examination, which uncovered the culprit tick in an unusual location. After starting doxycycline, the patient's signs and symptoms, including her sodium level, improved. CONCLUSIONS We conclude that the diagnosis of RMSF is an empiric diagnosis based on clinical signs, symptoms, and appropriate epidemiologic settings for tick exposures. However, typical clinical signs do not always display at presentation. Other manifestations that a patient's pre-existing conditions can simultaneously cause should not be overlooked and should be examined holistically with other signs, symptoms, laboratory values, and physical examinations. Early treatment with doxycycline is encouraged as evidence strongly suggests that early treatment is correlated with lower mortality.

Outcomes From a Novel Graduate Medical Education Leadership Program in Advancing Diversity, Equity, and Inclusion.

BACKGROUND: Academic medicine needs more diverse leadership from racial/ethnic minorities, women, people with disabilities, and LGBTQIA+ physicians. Longitudinal structural support programs that bring together underrepresented in medicine (UiM) and non-UiM trainees are one approach to build leadership and scholarship capacity in diversity, equity, and inclusion (DEI). OBJECTIVE: To describe the creation, satisfaction with, and feasibility of a Leadership Education in Advancing Diversity (LEAD) Program and evaluate scholars' changes in self-efficacy, intended and actual behavior change, and outputs in leadership and DEI scholarship. METHODS: In 2017, we created the LEAD Program, a 10-month longitudinal, single institution program that provides residents and fellows ("scholars") across graduate medical education (GME) with leadership training and mentorship in creating DEI-focused scholarship. In the first 3 cohorts (2017-2020), we assessed scholars' self-efficacy, actual and planned behavior change, and program satisfaction using IRB-approved, de-identified retrospective pre-/post-surveys. We measured scholarship as the number of workshops presented and publications developed by the LEAD scholars. We used descriptive statistics and paired 2-tailed t tests to analyze the data. RESULTS: Seventy-five trainees completed LEAD; 99% (74 of 75) completed the retrospective pre-/post-surveys. There was statistically significant improvement in scholars' self-efficacy for all learning objectives. All trainees thought LEAD should continue. LEAD scholars have created workshops and presented at local, regional, and national conferences, as well published their findings. Scholars identified the greatest benefits as mentorship, developing friendships with UiM and ally peers outside of their subspecialty, and confidence in public speaking. CONCLUSIONS: LEAD is an innovative, feasible GME-wide model to improve resident and fellow self-efficacy and behaviors in DEI scholarship and leadership.

Addressing Goals of Parents of Hospitalized Children: A Qualitative Analysis of Parents' and Physicians' Perspectives.

OBJECTIVE: Goals of care discussions are crucial in helping parents navigate complex medical decisions and shown to improve quality of care. Little is known about whether physicians elicit or address parents' goals during a child's hospitalization. The purpose of this study was to understand the current practice of goal setting at the beginning of hospitalization by exploring the perspectives of parents of hospitalized children and their hospital physicians. METHODS: A qualitative study with semi-structured interviews was conducted from 2018 to 2019 at a 361-bed quaternary suburban freestanding children's hospital. Twenty-seven parents of hospitalized children and 16 pediatric hospital medicine faculty were matched to participate. Data were analyzed using modified grounded theory, with themes identified through constant comparative approach. RESULTS: Five themes were identified: 1) Majority of hospitalized children's parents want to share their goals with physicians. 2) Parents and physicians share the same underlying goal of getting the child better to go home. 3) Parents of children with chronic diseases identified nonhospital goals that were not addressed. 4) Physicians do not explicitly elicit but rather assume what parents' goals of care are. 5) Factors related to patient, parent, and physician were identified as barriers to goal setting. CONCLUSIONS: Physicians may not consistently elicit parents' goals of care for their hospitalized children at the start of hospitalization. Parents desire their physicians to explicitly ask about their goals and involve them in goal setting during hospitalization. Strategies were identified by parents and physicians to improve goal setting with parents of hospitalized children.

Review of the Basics of Cognitive Error in Emergency Medicine: Still No Easy Answers.

Emergency physicians (EP) make clinical decisions multiple times daily. In some instances, medical errors occur due to flaws in the complex process of clinical reasoning and decision-making. Cognitive error can be difficult to identify and is equally difficult to prevent. To reduce the risk of patient harm resulting from errors in critical thinking, it has been proposed that we train physicians to understand and maintain awareness of their thought process, to identify error-prone clinical situations, to recognize predictable vulnerabilities in thinking, and to employ strategies to avert cognitive errors. The first step to this approach is to gain an understanding of how physicians make decisions and what conditions may predispose to faulty decision-making. We review the dual-process theory, which offers a framework to understand both intuitive and analytical reasoning, and to identify the necessary conditions to support optimal cognitive processing. We also discuss systematic deviations from normative reasoning known as cognitive biases, which were first described in cognitive psychology and have been identified as a contributing factor to errors in medicine. Training physicians in common biases and strategies to mitigate their effect is known as debiasing. A variety of debiasing techniques have been proposed for use by clinicians. We sought to review the current evidence supporting the effectiveness of these strategies in the clinical setting. This discussion of improving clinical reasoning is relevant to medical educators as well as practicing EPs engaged in continuing medical education.

Shared Decision-making With Parents of Hospitalized Children: A Qualitative Analysis of Parents' and Providers' Perspectives.

OBJECTIVES: Shared decision-making (SDM) is the pinnacle of patient-centered care and has been shown to improve health outcomes, especially for children with chronic medical conditions. However, parents perceive suboptimal involvement during hospitalization. The objective was to explore the perspectives of parents of hospitalized children and their hospital providers on facilitators and barriers to SDM in the hospital and identify strategies to increase SDM. METHODS: A qualitative study was conducted by using semistructured interviews with parents of hospitalized children with and without complex chronic conditions and their pediatric hospital medicine faculty. Parents and faculty were matched and individually interviewed on the same day. Two investigators iteratively coded transcripts and identified themes using modified grounded theory, with an additional author reviewing themes. RESULTS: Twenty-seven parents and 16 faculty participated in the interviews. Four themes emerged: (1) parents and providers value different components of SDM; (2) providers assume SDM is easier with parents of children with medical complexity; (3) factors related to providers, parents, patients, and family-centered rounds were identified as barriers to SDM; and (4) parents and providers identified strategies to facilitate SDM in the hospital. CONCLUSIONS: There is a discrepancy between parents' and providers' understanding of SDM, with parents most valuing their providers' ability to actively listen and explain the medical issue and options with them. There are many barriers that exist that make it difficult for both parties to participate. Several strategies related to family-centered rounds have been identified that can be implemented into clinical practice to mitigate these barriers.

To Tweet or Not to Tweet, That Is the Question.

In the past 20 years, a variety of social media platforms have significantly changed how we interact, communicate, learn, and engage. Social media use by physicians and physicians in training has expanded dramatically and evolved in recent years. Here, we focus on the use of Twitter by medical professionals (#medtwitter) and analyze Twitter's role as a new tool for learning, teaching, networking, professional development, mentorship/sponsorship, and advocacy within medicine. We discuss principles of adult learning theory to support the effectiveness of the use of Twitter as an educational tool, and share best practice pearls as well.

Peer Observations: Enhancing Bedside Clinical Teaching Behaviors.

Background Medical training relies on direct observations and formative feedback. After residency graduation, opportunities to receive feedback on clinical teaching diminish. Although feedback through learner evaluations is common, these evaluations can be untimely, non-specific, and potentially biased. On the other hand, peer feedback in a small group setting or lecture format has been shown to be beneficial to teaching behaviors, however, little is known if peer observation using a standardized tool followed by feedback results in improved teaching behaviors. Therefore, the objective of this study was to examine if feedback after peer observation results in improved inpatient teaching behaviors. Methods This study was conducted at a tertiary care hospital. Academic hospitalists in the Division of Hospital Medicine developed a standardized 28-item peer observation tool based on the Stanford Faculty Development Program to observe their peers during bedside teaching rounds and provide timely feedback after observation. The tool focused on five teaching domains (learning climate, control of session, promotion of understanding and retention, evaluation, and feedback) relevant to the inpatient teaching environment. Teaching hospitalists were observed at the beginning of a two-week teaching rotation, given feedback, and then observed at the end of the rotation. Furthermore, we utilized a post-observation survey to assess the teaching and observing hospitalists' comfort with observation and the usefulness of the feedback. We used mixed linear models with crossed design to account for correlations between the observations. Models were adjusted for gender, age, and years of experience. We tested the internal validity of the instrument with Cronbach's alpha. Results Seventy (range: one to four observations per faculty) observations were performed involving 27 teaching attendings. A high proportion of teachers were comfortable with the observation (79%) and found the feedback helpful (92%), and useful for their own teaching (88%). Mean scores in teaching behavior domains ranged from 2.1 to 2.7. In unadjusted and adjusted analysis, each teaching observation was followed by higher scores in learning climate (adjusted improvement = 0.09; 95% CI = 0.02-0.15; p = 0.007) and promotion of understanding and retention (adjusted improvement = 0.09; 95% CI = 0.02-0.17; p = 0.01). The standardized observation tool had Cronbach's alpha of 0.81 showing high internal validity. Conclusions Peer observation of bedside teaching followed by feedback using a standardized tool is feasible and results in measured improvements in desirable teaching behaviors. The success of this approach resulted in the expansion of peer observation to other Divisions within the Department of Internal Medicine at our Institution.

Use of an objective structured clinical exam (OSCE) for early identification of communication skills deficits in interns.

INTRODUCTION: There is limited information about whether OSCE during GME orientation can identify trainee communication deficits before these become evident via clinical performance evaluations. METHODS: Ninety-seven interns matriculating to eight residency programs in six specialties at four hospitals participated in a nine-station communication skills OSCE. Ratings were based on the "Kalamazoo, adapted" communication skills checklist. Possible association with intern performance evaluations was assessed by repeated-measures logistic regression and ROC curves were generated. RESULTS: The mean OSCE score was 4.08 ± 0.27 with a range of 3.3-4.6. Baseline OSCE scores were associated with subsequent communication concerns recorded by faculty, based on 1591 evaluations. A 0.1-unit decrease in the OSCE communication score was associated with an 18% higher odds of being identified with a communication concern by faculty evaluation (odds ratio 1.18, 95% CI 1.01-1.36, p = 0.034). ROC curves did not demonstrate a "cut-off" score (AUC= 0.558). Non-faculty evaluators were 3-5 times more likely than faculty evaluators to identify communication deficits, based on 1900 evaluations. CONCLUSIONS: Lower OSCE performance was associated with faculty communication concerns on performance evaluations; however, a "cut-off" score was not demonstrated that could identify trainees for potential early intervention. Multi-source evaluation also identified trainees with communication skills deficits.

Study protocol: a dissemination trial of computerized psychological treatment for depression and alcohol/other drug use comorbidity in an Australian clinical service.

BACKGROUND: The rise of the internet and related technologies has significant implications for the treatment of complex health problems, including the combination of depression and alcohol/other drug (AOD) misuse. To date, no research exists to test the real world uptake of internet and computer-delivered treatment programs in clinical practice. This study is important, as it is the first to examine the adoption of the SHADE treatment program, a DVD-based psychological treatment for depression and AOD use comorbidity, by clinicians working in a publicly-funded AOD clinical service. The study protocol that follows describes the methodology of this dissemination trial. METHODS/DESIGN: 19 clinicians within an AOD service on the Central Coast of New South Wales, Australia, will be recruited to the trial. Consenting clinicians will participate in a baseline focus group discussion designed to explore their experiences and perceived barriers to adopting innovation in their clinical practice. Computer comfort and openness to innovation will also be assessed. Throughout the trial, current, new and wait-list clients will be referred to the research program via the clinical service, which will involve clients completing a baseline and 15-week follow-up clinical assessment with independent research assistants, comprising a range of mental health and AOD measures. Clinicians will also complete session checklists following each clinical session with a client, outlining the extent to which the SHADE computer program was used. Therapeutic alliance will be measured at intake and discharge from both the clinician and client perspectives. DISCUSSION: This study will provide comprehensive data on the factors associated with the adoption of an innovative, computer-delivered evidence-based treatment program, SHADE, by clinicians working in an AOD service. The results will contribute to the development of a model of dissemination of SHADE, which could be applied to a range of technological innovations. CLINICAL TRIALS REGISTRY: Australian Clinical Trial Registration Number: ACTRN12611000382976.

Mycobacterium tuberculosis lipomannan blocks TNF biosynthesis by regulating macrophage MAPK-activated protein kinase 2 (MK2) and microRNA miR-125b.

Contact of Mycobacterium tuberculosis (M.tb) with the immune system requires interactions between microbial surface molecules and host pattern recognition receptors. Major M.tb-exposed cell envelope molecules, such as lipomannan (LM), contain subtle structural variations that affect the nature of the immune response. Here we show that LM from virulent M.tb (TB-LM), but not from avirulent Myocobacterium smegmatis (SmegLM), is a potent inhibitor of TNF biosynthesis in human macrophages. This difference in response is not because of variation in Toll-like receptor 2-dependent activation of the signaling kinase MAPK p38. Rather, TB-LM stimulation leads to destabilization of TNF mRNA transcripts and subsequent failure to produce TNF protein. In contrast, SmegLM enhances MAPK-activated protein kinase 2 phosphorylation, which is critical for maintaining TNF mRNA stability in part by contributing microRNAs (miRNAs). In this context, human miRNA miR-125b binds to the 3' UTR region of TNF mRNA and destabilizes the transcript, whereas miR-155 enhances TNF production by increasing TNF mRNA half-life and limiting expression of SHIP1, a negative regulator of the PI3K/Akt pathway. We show that macrophages incubated with TB-LM and live M.tb induce high miR-125b expression and low miR-155 expression with correspondingly low TNF production. In contrast, SmegLM and live M. smegmatis induce high miR-155 expression and low miR-125b expression with high TNF production. Thus, we identify a unique cellular mechanism underlying the ability of a major M.tb cell wall component, TB-LM, to block TNF biosynthesis in human macrophages, thereby allowing M.tb to subvert host immunity and potentially increase its virulence.

NOD2 controls the nature of the inflammatory response and subsequent fate of Mycobacterium tuberculosis and M. bovis BCG in human macrophages.

Mycobacterium tuberculosis (M.tb), which causes tuberculosis, is a host-adapted intracellular pathogen of macrophages. Intracellular pattern recognition receptors in macrophages such as nucleotide-binding oligomerization domain (NOD) proteins regulate pro-inflammatory cytokine production. NOD2-mediated signalling pathways in response to M.tb have been studied primarily in mouse models and cell lines but not in primary human macrophages. Thus we sought to determine the role of NOD2 in regulating cytokine production and growth of virulent M.tb and attenuated Mycobacterium bovis BCG (BCG) in human macrophages. We examined NOD2 expression during monocyte differentiation and observed a marked increase in NOD2 transcript and protein following 2-3 days in culture. Pre-treatment of human monocyte-derived and alveolar macrophages with the NOD2 ligand muramyl dipeptide enhanced production of TNF-α and IL-1ß in response to M.tb and BCG in a RIP2-dependent fashion. The NOD2-mediated cytokine response was significantly reduced following knock-down of NOD2 expression by using small interfering RNA (siRNA) in human macrophages. Finally, NOD2 controlled the growth of both M.tb and BCG in human macrophages, whereas controlling only BCG growth in murine macrophages. Together, our results provide evidence that NOD2 is an important intracellular receptor in regulating the host response to M.tb and BCG infection in human macrophages.

Mycobacterium tuberculosis activates human macrophage peroxisome proliferator-activated receptor gamma linking mannose receptor recognition to regulation of immune responses.

Mycobacterium tuberculosis enhances its survival in macrophages by suppressing immune responses in part through its complex cell wall structures. Peroxisome proliferator-activated receptor gamma (PPARgamma), a nuclear receptor superfamily member, is a transcriptional factor that regulates inflammation and has high expression in alternatively activated alveolar macrophages and macrophage-derived foam cells, both cell types relevant to tuberculosis pathogenesis. In this study, we show that virulent M. tuberculosis and its cell wall mannose-capped lipoarabinomannan induce PPARgamma expression through a macrophage mannose receptor-dependent pathway. When activated, PPARgamma promotes IL-8 and cyclooxygenase 2 expression, a process modulated by a PPARgamma agonist or antagonist. Upstream, MAPK-p38 mediates cytosolic phospholipase A(2) activation, which is required for PPARgamma ligand production. The induced IL-8 response mediated by mannose-capped lipoarabinomannan and the mannose receptor is independent of TLR2 and NF-kappaB activation. In contrast, the attenuated Mycobacterium bovis bacillus Calmette-Guérin induces less PPARgamma and preferentially uses the NF-kappaB-mediated pathway to induce IL-8 production. Finally, PPARgamma knockdown in human macrophages enhances TNF production and controls the intracellular growth of M. tuberculosis. These data identify a new molecular pathway that links engagement of the mannose receptor, an important pattern recognition receptor for M. tuberculosis, with PPARgamma activation, which regulates the macrophage inflammatory response, thereby playing a role in tuberculosis pathogenesis.