Characteristics and Outcomes of Sepsis Presenting in Inpatient Pediatric Settings.

OBJECTIVE: The pediatric sepsis literature lacks studies examining the inpatient setting, yet sepsis remains a leading cause of death in children's hospitals. More information is needed about sepsis arising in patients already hospitalized to improve morbidity and mortality outcomes. This study describes the clinical characteristics, process measures, and outcomes of inpatient sepsis cases compared with emergency department (ED) sepsis cases within the Improving Pediatric Sepsis Outcomes data registry from 46 hospitals that care for children. METHODS: This retrospective cohort study included Improving Pediatric Sepsis Outcomes sepsis cases from January 2017 to December 2019 with onset in inpatient or ED. We used descriptive statistics to compare inpatient and ED sepsis metrics and describe inpatient sepsis outcomes. RESULTS: The cohort included 26 855 cases; 8.4% were inpatient and 91.6% were ED. Inpatient cases had higher sepsis-attributable mortality (2.0% vs 1.4%, P = .025), longer length of stay after sepsis recognition (9 vs 5 days, P <.001), more intensive care admissions (57.6% vs 54.1%, P = .002), and greater average vasopressor use (18.0% vs 13.6%, P <.001) compared with ED. In the inpatient cohort, >40% of cases had a time from arrival to recognition within 12 hours. In 21% of cases, this time was >96 hours. Improved adherence to sepsis treatment bundles over time was associated with improved 30-day sepsis-attributable mortality for inpatients with sepsis. CONCLUSIONS: Inpatient sepsis cases had longer lengths of stay, more need for intensive care, and higher vasopressor use. Sepsis-attributable mortality was significantly higher in inpatient cases compared with ED cases and improved with improved sepsis bundle adherence.

Exploring Effects of Sensory Garments on Participation of Children on the Autism Spectrum: A Pretest-Posttest Repeated Measure Design.

Objective: Autistic children experience sensory challenges that interfere with participation and increase parent stress. Sensory-based interventions are used to address children's behaviors affected by sensory processing difficulties, but research is limited regarding use of sensory garments to support participation of autistic children. This study explored sensory garment effects on participation, parental competence, and perceived stress of autistic children and their parents. Method: Twenty-one children were recruited and 17 males with ASD and atypical sensory processing patterns completed the 14-week study. The Canadian Occupational Performance (COPM) and Goal Attainment Scaling (GAS) were used to set and monitor participation goals. After a baseline period, children wore sensory garment(s) for 8 weeks. The COPM, GAS, Parent Stress Index-Short Form (PSI-SF), and Parent Sense of Competence Scale (PSOC) were administered four times (prebaseline, before and after the intervention, and three weeks postintervention). Results: There were moderate to large significant differences in both COPM and GAS scores after the intervention and from the beginning to the end of the study indicating sensory garments may improve participation of autistic children. There were no significant differences in PSI or PSOC at any timepoint. Two children rejected the garments. Conclusions: Parent- or child-selected sensory garments may improve participation in individually meaningful activities for children who can tolerate wearing them. Children's improvement in participation did not improve parent stress or competence, possibly due to the passive nature of the intervention. More research is needed explore the influence of heterogeneous sensory patterns on response to intervention.

Using Quality Improvement Science to Promote Reliable Communication During Family-Centered Rounds.

BACKGROUND AND OBJECTIVES: Family-centered rounds (FCR) can lead to improved communication, satisfaction, and care delivery. However, FCR are variable in practice. Our primary goal was to implement and sustain consistent communication practices during FCR (a subset of all rounds in which parents were present) for patients on a pediatric hospital medicine service. We aimed to achieve 80% reliability for the following FCR practices: (1) discussion of risk factors and prevention strategies for hospital-acquired conditions (HACs), (2) discussion of discharge planning, and (3) asking families for questions. METHODS: Research assistants observed FCR on a pediatric acute care unit at an academic medical center and recorded if the rounding team discussed HAC risk factors, discussed discharge, or asked families for questions. Using the Model for Improvement, we performed multiple plan-do-study-act cycles to test and implement interventions, including (1) standardized note templates, (2) education via peer-led group discussions and team e-mails, and (3) routine provider feedback about performance. Data were analyzed by using statistical process control charts. RESULTS: From October 2017 to April 2019, reliability increased to >80% and sustained for (1) discussion of HAC risk factors (increased from 11% to 89%), (2) discussion of discharge planning (from 60% to 92%), and (3) asking families for questions (from 61% to 87%). Peer-led physician education, reminder e-mails, and physician engagement were the most impactful interventions corresponding to centerline shifts. CONCLUSIONS: Using multiple interventions, we achieved and sustained improvements in key communication-related elements of FCR. Future work will focus on determining if improved practices impact clinical outcomes.

Effects of Sensory Garments on Sleep of Children with Autism Spectrum Disorder.

OBJECTIVE: The purpose of this study is to assess the effectiveness of the use of sensory garments for improving sleep in children with autism spectrum disorder. METHOD: Using a single-subject ABAB reversal design, the researchers evaluated the effectiveness of a sensory garment on sleep duration, sleep latency, and parental stress related to a child's sleep. Four children aged 4-10 participated. We measured sleep duration and sleep latency using the Garmin watches and parent-report sleep logs, parent stress using the Parenting Stress Index Short Form, and sleep behaviors using the Children's Sleep Habits Questionnaire. Results/Discussion. Data showed variable effects on sleep duration and latency across children. The oldest child with the hyposensitive sensory patterns experienced the greatest sleep improvements. All parents experienced stress from daily life, and some reported increased stress due to study participation. Future research is recommended to further investigate the effectiveness of sensory garments on sleep for children with ASD. Therapists are encouraged to evaluate children's development and sensory preferences prior to recommending sensory garments for sleep.

Meds to Beds: A Quality Improvement Approach to Optimizing the Discharge Medication Process for Pediatric Patients.

BACKGROUND: Using an on-site pharmacy or medication to bedside (MTB) program allows patients to obtain prescriptions and education before discharge, potentially improving adherence and preventing harm. The aim of this project was to improve discharge processes for pediatric acute care patients by increasing the proportion of oral antibiotics (1) prescribed to the on-site pharmacy from 15% to 70% and (2) delivered to bedside from 0% to 50%. METHODS: The Model for Improvement was used to iteratively implement interventions: increased on-site pharmacy capabilities, MTB program creation and streamlined enrollment, and secure electronic health record (EHR) messaging between clinicians and pharmacy staff regarding prescriptions. Process measures were proportion of antibiotics prescribed to the on-site pharmacy and delivered to bedside. Outcomes included surveys of family satisfaction with discharge medication education and discharge medication-related safety reports. Discharge before noon (DBN) was the balancing measure. Aims were analyzed using statistical process control charts and chi-square tests. RESULTS: A total of 1,908 antibiotics were prescribed over 28-months. On-site pharmacy prescriptions increased from 15% to 46% after pharmacy capabilities increased, then to 86% after MTB program launch, optimized workflow, and initiation of EHR messaging. Bedside medication delivery increased from 0% to 58% with these interventions. Family satisfaction with discharge medication education and frequency of discharge medication-related safety reports was not significantly different pre- and postintervention. DBN varied throughout the study. CONCLUSION: Through clinician and pharmacy staff partnership, this initiative increased on-site pharmacy use and discharge antibiotics delivered to bedside. Key interventions included increased pharmacy capabilities, MTB program with streamlined workflow, and EHR-based communication.

Medical Student Experiences With Electronic Health Records Nationally: A Longitudinal Analysis Including School-Level Effects.

PURPOSE: Increasingly, medical school graduates have been expected to be competent in the knowledge and skills associated with effective electronic health record (EHR) use. Yet little is known about how student experiences with EHRs have changed over time or how these trends vary by medical school. This study examined shifts in U.S. medical student interactions with EHRs during their clinical education, 2012-2016, and how these interactions varied by clerkship within and across medical schools. METHOD: Data came from an online survey about EHR use administered to medical students after completing the Step 2 Clinical Knowledge portion of the United States Medical Licensing Examination. For a sample of 17,202 medical students from 140 U.S.-based Liaison Committee on Medical Education accredited medical school campuses, multilevel modeling techniques were used to estimate overall and school-specific trends in student access to and entry of information into EHRs for 7 core inpatient clerkships. RESULTS: Results showed upward trajectories in likelihood of student EHR experiences, with smaller increases found for information entry compared with access. These trends varied by inpatient clerkship rotation, with some disciplines exhibiting more rapid increases than others. For both access and information entry, estimated clerkship-specific trajectories differed by medical school in terms of size and direction. For all clerkships, greater school-to-school variation in the likelihood of student entry, compared with student access, remained at the end of the study period. CONCLUSIONS: Increases in medical student interactions with EHRs suggest a growing commitment to educating students on safe and effective EHR use. Nonetheless, at some schools and in some clerkships, students may receive inadequate educational opportunities to practice using EHRs. In turn, medical students may be differentially prepared to effectively engage with EHRs upon entering residency, particularly with the knowledge and skills needed to effectively document and transmit information in EHRs.

A Digital Health Fall Prevention Program for Older Adults: Feasibility Study.

BACKGROUND: About 1 in 3 adults aged 65 and older falls annually. Exercise interventions are effective in reducing the fall risk and fall rate among older adults. In 2020, startup company Age Bold Inc. disseminated the Bold Fall Prevention Program, aiming to reduce falls among older adults through a remotely delivered, digital exercise program. OBJECTIVE: We conducted a feasibility study to assess the delivery of the Bold Fall Prevention Program remotely and evaluate the program's impact on 2 primary outcomes-annualized fall rate and weekly minutes of physical activity (PA)-over 6 months of follow-up. METHODS: Older adults at high risk of falling were screened and recruited for the feasibility study via nationwide digital advertising strategies. Self-reported outcomes were collected via surveys administered at the time of enrollment and after 3 and 6 months. Responses were used to calculate changes in the annualized fall rate and minutes of PA per week. RESULTS: The remote delivery of a progressive digital fall prevention program and associated research study, including remote recruitment, enrollment, and data collection, was deemed feasible. Participants successfully engaged at home with on-demand video exercise classes, self-assessments, and online surveys. We enrolled 65 participants, of whom 48 (74%) were women, and the average participant age was 72.6 years. Of the 65 participants, 54 (83%) took at least 1 exercise class, 40 (62%) responded to at least 1 follow-up survey at either 3 or 6 months, 20 (31%) responded to both follow-up surveys, and 25 (39%) were lost to follow-up. Among all participants who completed at least 1 follow-up survey, weekly minutes of PA increased by 182% (ratio change=2.82, 95% CI 1.26-6.37, n=35) from baseline and annualized falls per year decreased by 46% (incidence rate ratio [IRR]=0.54, 95% CI 0.32-0.90, n=40). Among only 6-month survey responders (n=31, 48%), weekly minutes of PA increased by 206% (ratio change=3.06, 95% CI 1.43-6.55) from baseline to 6 months (n=30, 46%) and the annualized fall rate decreased by 28% (IRR=0.72, 95% CI 0.42-1.23) from baseline to 6 months. CONCLUSIONS: The Bold Fall Prevention Program provides a feasible strategy to increase PA and reduce the burden of falls among older adults.

Investigation of the effects of dietary supplementation with 25-hydroxyvitamin D3 and vitamin D3 on indicators of vitamin D status in healthy dogs.

OBJECTIVE: To compare the effects of short-term dietary supplementation with vitamin D3 and 25-hydroxyvitamin D3 (25[OH]D3) on indicators of vitamin D status in healthy dogs. ANIMALS: 13 purpose-bred adult dogs. PROCEDURES: 20 extruded commercial dog foods were assayed for 25(OH)D3 content. Six dogs received a custom diet containing low vitamin D concentrations and consumed a treat with vitamin D2 (0.33 µg/kg0.75) plus 1 of 3 doses of 25(OH)D3 (0, 0.23, or 0.46 µg/kg0.75) once daily for 8 weeks followed by the alternate treatments in a crossover-design trial. In another crossover-design trial, 7 dogs received a custom diet supplemented with vitamin D3 or 25(OH)D3 (targeted content, 3,250 U/kg [equivalent to 81.3 µg/kg] and 16 µg/kg, respectively, as fed) for 10 weeks followed by the alternate treatment. In washout periods before each trial and between dietary treatments in the second trial, dogs received the trial diet without D-vitamer supplements. Dietary intake was monitored. Serum or plasma concentrations of vitamin D metabolites and biochemical variables were analyzed at predetermined times. RESULTS: 25(OH)D3 concentrations were low or undetected in evaluated commercial diets. In the first trial, vitamin D2 intake resulted in quantifiable circulating concentrations of 25-hydroxyvitamin D2 but not 24R,25-dihydroxyvitamin D2. Circulating 25(OH)D3 concentration appeared to increase linearly with 25(OH)D3 dose. In the second trial, circulating 25(OH)D3 concentration increased with both D vitamer-supplemented diets and did not differ significantly between treatments. No evidence of vitamin D excess was detected in either trial. CONCLUSIONS AND CLINICAL RELEVANCE: Potency of the dietary 25(OH)D3 supplement estimated on the basis of targeted content was 5 times that of vitamin D3 to increase indicators of vitamin D status in the study sample. No adverse effects attributed to treatment were observed in short-term feeding trials.

Leptomeningeal disease and neurologic death after surgical resection and radiosurgery for brain metastases: A multi-institutional analysis.

PURPOSE: Postoperative stereotactic radiosurgery (SRS) is associated with up to 30% risk of subsequent leptomeningeal disease (LMD). Radiographic patterns of LMD (classical sugarcoating [cLMD] vs. nodular [nLMD]) in this setting has been shown to be prognostic. However, the association of these findings with neurologic death (ND) is not well described. METHODS AND MATERIALS: The records for patients with brain metastases who underwent surgical resection and adjunctive SRS to 1 lesion (SRS to other intact lesions was allowed) and subsequently developed LMD were combined from 7 tertiary care centers. Salvage radiation therapy (RT) for LMD was categorized according to use of whole-brain versus focal cranial RT. RESULTS: The study cohort included 125 patients with known cause of death. The ND rate in these patients was 79%, and the rate in patients who underwent LMD salvage treatment (n = 107) was 76%. Univariate logistic regression demonstrated radiographic pattern of LMD (cLMD vs. nLMD, odds ratio: 2.9; P = .04) and second LMD failure after salvage treatment (odds ratio: 3.9; P = .02) as significantly associated with ND. The ND rate was 86% for cLMD versus 68% for nLMD. Whole-brain RT was used in 95% of patients with cLMD and 52% with nLMD. In the nLMD cohort (n = 58), there was no difference in ND rate based on type of salvage RT (whole-brain RT: 67% vs. focal cranial RT: 68%, P = .92). CONCLUSIONS: LMD after surgery and SRS for brain metastases is a clinically significant event with high rates of ND. Classical LMD pattern (vs. nodular) and second LMD failure after salvage treatment were significantly associated with a higher risk of ND. Patients with nLMD treated with salvage focal cranial RT did not have higher ND rates compared with WBRT. Methods to decrease LMD and the subsequent high risk of ND in this setting warrant further investigation.

Implementation of Febrile Infant Management Guidelines Reduces Hospitalization.

The clinical management of well-appearing febrile infants 7-60 days of age remains variable due in part to multiple criteria differentiating the risk of a serious bacterial infection. The purpose of this quality improvement study was to standardize risk stratification in the emergency department and length of stay in the inpatient unit by implementing an evidence-based clinical practice guideline (CPG). METHODS: The Model for Improvement was used to implement a CPG for the management of well-appearing febrile infants, with collaboration between pediatric emergency medicine and pediatric hospital medicine physicians. Interventions included physician education, process audit/feedback, and development of an electronic orderset. We used statistical process control charts to assess the primary aims of appropriate risk stratification and length of stay. RESULTS: Over a 34-month period, 168 unique encounters (baseline n = 65, intervention n = 103) were included. There was strong adherence for appropriate risk stratification in both periods: the proportion of low-risk patients admitted inappropriately decreased from 14.8% to 10.8%. Among admitted high-risk patients, the mean length of stay decreased from 49.4 to 38.2 hours, sustained for 18 months. CONCLUSION: CPG implementation using quality improvement methodology can increase the delivery of evidence-based care for febrile infants, leading to a reduction in length of stay for high-risk infants.

Medical student experiences with accessing and entering patient information in electronic health records during the obstetrics-gynecology clerkship.

BACKGROUND: Medical school graduates should be able to enter information from patient encounters and to write orders and prescriptions in the electronic health record. Studies have shown that, although students often can access electronic health records, some students may receive inadequate preparation for these skills. Greater understanding of student exposure to electronic health records during their obstetrics and gynecology clerkships can help to determine the extent to which students receive the educational experiences that may best prepare them for their future training and practice. OBJECTIVE: The purpose of this study was to examine medical student reporting of electronic health record use during the obstetrics and gynecology clerkship. STUDY DESIGN: A Step 2 Clinical Knowledge End-of-Examination Survey about electronic health record use was administered to medical students after they completed the Step 2 Clinical Knowledge component of the United States Medical Licensing Examination. For inpatient and outpatient rotations, students were asked if they accessed a record and if they entered notes or orders into it. Descriptive statistics for a sample of 16,366 medical students who graduated from Liaison Committee on Medical Education-accredited schools from 2012-2016 summarize student interactions with electronic health records by rotation type and graduation year. Chi-square techniques were used to examine mean differences in access and entry. RESULTS: The survey had an overall response rate of 70%. In 2016, most survey respondents (94%) accessed electronic health records during their obstetrics and gynecology clerkship, but 26% of them reported "read-only" access. On the inpatient service, <10% of students reported any order entry; 58% of them reported entering progress notes, and 47% of them reported entering an admitting history and physical. CONCLUSION: Medical school graduates who are entering obstetrics and gynecology residencies are expected to be competent in documenting clinical encounters and entering orders, including those that are unique to obstetrics and gynecology. This study shows that some students may receive less experience with entering information into electronic health records during their obstetrics and gynecology clerkships than others, which could result in unequal levels of preparedness for graduate medical education.

Pediatric Radiography Education: A Survey of Recent Graduates' Experiences.

PURPOSE: To examine recent radiologic science graduates' perceptions of pediatric radiography training and provide educators with information regarding the delivery of pediatric education in entry-level radiography programs. METHODS: Radiologic technologists with fewer than 24 months of experience who, at the time, were American Society of Radiologic Technologists (ASRT) members in the Graduate Bridge membership level were asked to complete an original survey that was created using a cross-sectional research design. The survey asked questions about their pediatric radiography education experience, level of training, level of agreement regarding various techniques and challenges associated with pediatric radiography, and demographic information. RESULTS: A total of 280 responses was analyzed for this study. The majority (151, 53.9%) of the participants were satisfied or very satisfied with the training and education they received in their respective radiography programs to perform imaging studies on pediatric patients. However, 149 (53.2%) of the participants strongly agreed that more curricula and training specific to pediatric radiography would benefit future students. DISCUSSION: Opportunities for additional education might include providing more training on using Pigg-O-Stats and other immobilization devices, catheterizing pediatric patients for voiding cystourethrograms, and communicating effectively with pediatric patients and their family members. Moreover, providing students with clinical experiences to gain confidence in pediatric radiography at a dedicated pediatric facility should be considered. CONCLUSION: Although most entry-level radiographers in this study considered their preparation for pediatric imaging satisfactory, they also strongly believed that additional pediatric-specific training would benefit future radiographers. Radiography educators should consider various opportunities to enhance the pediatric imaging curriculum and encourage or require clinical rotations in pediatric facilities. Further research that addresses educators' perceptions of pediatric radiography instruction might be warranted.

Electronic Health Record Use in Internal Medicine Clerkships and Sub-internships for Medical Students Graduating from 2012 to 2016.

BACKGROUND: As electronic health records (EHRs) became broadly available in medical practice, effective use of EHRs by medical students emerged as an essential aspect of medical education. While new federal clinical documentation guidelines have the potential to encourage greater medical student EHR use and enhance student learning experiences with respect to EHRs, little is known nationally about how students have engaged with EHRs in the past. OBJECTIVE: This study examines medical student accounts of EHR use during their internal medicine (IM) clerkships and sub-internships during a 5-year time period prior to the new clinical documentation guidelines. DESIGN: An online survey about EHR use was administered to medical students immediately after they completed USMLE Step 2 CK. PARTICIPANTS: The sample included 16,602 medical students planning to graduate from US medical schools from 2012 to 2016. MAIN MEASURES: Descriptive statistics were computed to determine the average percentage of students engaged in various health record activities during their IM educational experiences by graduation year. KEY RESULTS: The vast majority (99%) of medical students used EHRs during IM clerkships or sub-internships. Most students reported that they entered information into EHRs during the inpatient component of the IM clerkship (84%), outpatient component of the IM clerkship (70%), and the IM sub-internship (92%). Yet, 43% of the students who graduated in 2016 never entered admission orders and 35% of them never entered post-admission orders. CONCLUSIONS: Medical school graduates ought to be able to effectively document clinical encounters and enter orders into EHR systems. Although most students used and entered information into EHRs during their IM clinical training, many students appear to have received inadequate opportunities to enter notes or orders, in particular. Implications for graduate medical education preparedness are considered. Future research should address similar questions using comparable national data collected after the recent guideline changes.

A multi-institutional analysis of presentation and outcomes for leptomeningeal disease recurrence after surgical resection and radiosurgery for brain metastases.

BACKGROUND: Radiographic leptomeningeal disease (LMD) develops in up to 30% of patients following postoperative stereotactic radiosurgery (SRS) for brain metastases. However, the clinical relevancy of this finding and outcomes after various salvage treatments are not known. METHODS: Patients with brain metastases, of which 1 was resected and treated with adjunctive SRS, and who subsequently developed LMD were combined from 7 tertiary care centers. LMD pattern was categorized as nodular (nLMD) or classical ("sugarcoating," cLMD). RESULTS: The study cohort was 147 patients. Most patients (60%) were symptomatic at LMD presentation, with cLMD more likely to be symptomatic than nLMD (71% vs. 51%, P = 0.01). Salvage therapy was whole brain radiotherapy (WBRT) alone (47%), SRS (27%), craniospinal radiotherapy (RT) (10%), and other (16%), with 58% receiving a WBRT-containing regimen. WBRT was associated with lower second LMD recurrence compared with focal RT (40% vs 68%, P = 0.02). Patients with nLMD had longer median overall survival (OS) than those with cLMD (8.2 vs 3.3 mo, P < 0.001). On multivariable analysis for OS, pattern of initial LMD (nodular vs classical) was significant, but type of salvage RT (WBRT vs focal) was not. CONCLUSIONS: Nodular LMD is a distinct pattern of LMD associated with postoperative SRS that is less likely to be symptomatic and has better OS outcomes than classical "sugarcoating" LMD. Although focal RT demonstrated increased second LMD recurrence compared with WBRT, there was no associated OS detriment. Focal cranial RT for nLMD recurrence after surgery and SRS for brain metastases may be a reasonable alternative to WBRT.

Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships: Results of a National Longitudinal Study.

PURPOSE: An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined. METHOD: An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences. RESULTS: The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining. CONCLUSIONS: Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.

Dyadic Supervision Evaluation: An Actor-Partner Relational Model.

This article contributes to research practices in marital and family therapy, specifically the dyadic and development over time in clinical supervision, and describes and applies methodological strategies to develop measurements congruent with the systemic and developmental principles of the field. This project evaluates the psychometric properties of the dyadic supervision evaluation (DSE) in terms of measurement equivalence and causality. A structural equation analysis is conducted utilizing the actor-partner interdependent model resulting in a goodness of fit. This study presents a longitudinal model for evaluating the supervisory relationship and proposes a model of clinical supervision evaluation. The relationship among latent constructs in the DSE and its limitations related to inference and application are discussed.

Effects and Unforeseen Consequences of Accessing References on a Maintenance of Certification Examination: Findings From a National Study.

PURPOSE: Increasing criticism of maintenance of certification (MOC) examinations has prompted certifying boards to explore alternative assessment formats. The purpose of this study was to examine the effect of allowing test takers to access reference material while completing their MOC Part III standardized examination. METHOD: Item response data were obtained from 546 physicians who completed a medical subspecialty MOC examination between 2013 and 2016. To investigate whether accessing references was related to better performance, an analysis of covariance was conducted on the MOC examination scores with references (access or no access) as the between-groups factor and scores from the physicians' initial certification examination as a covariate. Descriptive analyses were conducted to investigate how the new feature of accessing references influenced time management within the test day. RESULTS: Physicians scored significantly higher when references were allowed (mean = 534.44, standard error = 6.83) compared with when they were not (mean = 472.75, standard error = 4.87), F(1, 543) = 60.18, P < .001, ω(2) = 0.09. However, accessing references affected pacing behavior; physicians were 13.47 times more likely to finish with less than a minute of test time remaining per section when reference material was accessible. CONCLUSIONS: Permitting references caused an increase in performance, but also a decrease in the perception that the test has sufficient time limits. Implications for allowing references are discussed, including physician time management, impact on the construct assessed by the test, and the importance of providing validity evidence for all test design decisions.

Sensory Patterns, Obesity, and Physical Activity Participation of Children With Autism Spectrum Disorder.

Obesity is a public health concern for the population in general and for children with autism spectrum disorder (ASD) specifically. The purpose of this study was to understand relationships between sensory patterns, obesity, and physical activity engagement of children with ASD (N = 77) sampled from a specialized community-based swimming program. This retrospective correlational study analyzed program data. Results show that almost half (42.2%) of the children were overweight or obese, and sensory avoiding behaviors were related to higher body mass index (BMI). Children participated in few formal and informal physically active recreation activities. Sensory seeking behaviors were associated with increased participation in informal activities, and higher BMI was associated with less participation in both formal and informal activities. Practitioners should consider sensory processing patterns and BMI when developing community-based programs to promote physical activity of children with ASD.

The cardiovascular in-training examination: development, implementation, results, and future directions.

BACKGROUND: The American College of Cardiology (ACC), in collaboration with the National Board of Medical Examiners (NBME), developed the first standardized in-training examination (ITE) for cardiovascular disease fellows-in-training (FITs). In addition to testing knowledge, this examination uses the newly developed ACC Curricular Milestones to provide specific, competency-based feedback to program directors and FITs. The ACC ITE has been administered more than 5,000 times since 2011. OBJECTIVES: This analysis sought to report the initial experience with the ITE, including feasibility and reliability of test development and implementation, as well as the ability of this process to provide useful feedback in key content areas. METHODS: The annual ACC ITE has been available to cardiovascular disease fellowship programs in the United States since 2011. Questions for this Web-based, secure, multiple-choice examination were developed by a group of cardiovascular disease specialists and each question was analyzed by the NBME to ensure quality. Scores were equated and standardized to allow for comparability. Trainees and program directors were provided detailed feedback, including a list of the curricular competencies tested by those questions answered incorrectly. RESULTS: The ITE was administered 5,118 times. In 2013, the examination was taken by 1,969 fellows, representing 194 training programs. Among the 3 training years, there was consistency in the examination scores. Total test scores and scores within each of the content areas increased with each FIT year (there was a statistically significant difference in each cohort's average scale score across administration years). There was also significant improvement in examination scores across the fellowship years. CONCLUSIONS: The ACC ITE is a powerful tool available to all training programs to assess medical knowledge. This examination also delivers robust and timely feedback addressing individual knowledge gaps, and thus, may serve as a basis for improving training curricula.