We've Got a New One-Exploring the Resident-Fellow New Admission Interaction and Opportunities for Enhancing Motivation.

OBJECTIVE: To characterize the phases of a new admission interaction between collaborating pediatric residents and fellows; to explore trainee perspectives on motivating and demotivating qualities of that interaction; and to identify behaviors that lead to an optimal new admission interaction. METHODS: The authors used modified grounded theory with experiential learning theory and self-determination theory as sensitizing concepts to conduct 6 focus groups and journey mapping at Stanford Children's Health from January to March 2021. The sessions were audio-recorded and transcribed verbatim. Two authors independently coded the transcripts and developed categories and themes using constant comparison, while a third author reviewed these findings. The qualitative data were triangulated with surveys and journey mapping data and conceptualized into a model of trainee motivation during the new admission interaction. They outlined an optimal new admission interaction using behaviors consistently described by participants as motivating. RESULTS: Developing inter-trainee trust and educational buy-in is essential for both residents and fellows to feel intrinsically motivated and engaged during a new admission. Residents need to feel autonomous, competent, and related to the team in order to develop trust and buy-in. Fellows require assurance of patient safety to develop trust and a sense of self-efficacy in fostering resident growth to develop buy-in. Lack of trust or buy-in from either party leads to a cycle of trainee disengagement. CONCLUSIONS: Trainee motivation and engagement with patient care can be impacted by discreet, modifiable behavior by their fellow or resident counterpart, which may help improve the quality of care delivered.

Reduction of Nontyphoidal Salmonella enterica in Broth and on Raw Chicken Breast by a Broad-spectrum Bacteriophage Cocktail.

Globally, nontyphoidal Salmonella (NTS) causes approximately 150 million foodborne illnesses annually; many of which are linked to poultry products. Thus, improving food safety interventions in the poultry sector can reduce foodborne illness associated with prevalent NTS serotypes. Bacteriophages (phages) have shown promise as food-safe alternatives to current antimicrobial practices. However, challenges such as limited host range, bactericidal effectiveness in practical production settings, and the risk of developing host resistance remain as barriers for the widespread use of phages in commercial poultry operations. A broad-spectrum three-phage cocktail was evaluated against S. enterica subsp. enterica serotypes Enteritidis, Typhimurium, and Kentucky. The impact of multiplicity of infection (MOI) on NTS growth was assessed in broth at 22°C for 18 hours (h). Then, phage cocktail efficacy was evaluated on raw chicken breast samples inoculated with the NTS cocktail and stored at 10°C or 22°C for 0, 1, and 5 days or 0, 4, 8, and 16 h, respectively. Most probable number (MPN) calculations were performed for NTS counts on chicken after phage treatment and storage at 10°C to account for samples with NTS counts below the detection limit. In general, a higher MOI corresponded to reduced NTS growth; however, residual nutrition in growth media and initial NTS contamination level affected samples treated with the phage cocktail at identical MOIs. On chicken, phage cocktail treatment significantly reduced NTS counts at 10°C and 22°C. After storage at 10°C for 5 days, NTS counts were reduced by >3.2 log compared to the control. After storage at 22°C for 16 h, NTS counts were reduced by >1.7 log compared to the control. Overall, the phage cocktail was effective at reducing a diverse set of prominent NTS strains in broth and on raw chicken breast, highlighting its potential for commercialization and use alongside other hurdles in poultry production.

River Basin Simulations Reveal Wide-Ranging Wetland-Mediated Nitrate Reductions.

River basin-scale wetland restoration and creation is a primary management option for mitigating nitrogen-based water quality challenges. However, the magnitude of nitrogen reduction that will result from adding wetlands across large river basins is uncertain, partly because the areal extent, location, and physical and functional characteristics of the wetlands are unknown. We simulated over 3600 wetland restoration scenarios across the ∼450,000 km2 Upper Mississippi River Basin (UMRB) depicting varied assumptions for wetland areal extent, physical and functional characteristics, and placement strategy. These simulations indicated that restoring wetlands will reduce local nitrate yields and nitrate loads at the UMRB outlet. However, the projected magnitude of nitrate reduction varied widely across disparate scenario assumptions─e.g., restoring 4500 km2 of wetlands (i.e., 1% of UMRB area) decreased mean annual nitrate loads at the UMRB outlet between 3 and 42%. Higher magnitude nitrate reductions correlated with best-case assumptions, particularly for characteristics controlling nitrate loading rates to the wetlands. These results show that simplified claims about basin-scale wetland-mediated water quality improvements discount the breadth of possible wetland impacts across disparate wetland physical and functional conditions and highlight a need for greater clarity regarding the likelihood of these conditions at river basin scales.

Fat Embolism Syndrome After Knee Arthroscopy in a Pediatric Patient.

Fat embolism syndrome describes a constellation of symptoms that follow an insult and that results in a triad of respiratory distress, neurologic symptoms, and petechia. The antecedent insult usually entails trauma or orthopedic procedure, most frequently involving long bone (especially the femur) and pelvic fractures. The underlying mechanism of injury remains unknown but entails biphasic vascular injury with vascular obstruction from fat emboli followed by an inflammatory response. We present an unusual case of a pediatric patient with acute onset of altered mental status, respiratory distress, hypoxemia, and subsequent retinal vascular occlusions after knee arthroscopy and lysis of adhesions. Diagnostic findings most supportive of the fat embolism syndrome included anemia, thrombocytopenia, pulmonary parenchymal, and cerebral pathologic findings on imaging studies. This case highlights the importance of fat embolism syndrome as a diagnostic consideration after an orthopedic procedure, even absent major trauma or long bone fracture.

The Delta Robot-A long travel nano-positioning stage for scanning x-ray microscopy.

A new stage design concept, the Delta Robot, is presented, which is a parallel kinematic design for scanning x-ray microscopy applications. The stage employs three orthogonal voice coils, which actuate parallelogram flexures. The design has a 3 mm travel range and achieves rms position jitter, integrated from 1 Hz to 1 kHz, of 2.8 and 1.3 nm perpendicular to the beam and 5.6 nm along the beam direction with loads up to 350 g. The Delta Robot design process used a mechatronics approach of iterative modeling and simulation to develop the system and validate performance. The design considerations, design process, stability, and operational performance on the hard x-ray nanoprobe at Diamond Light Source are presented.

Patient mistreatment of health care professionals.

BACKGROUND: Mistreatment of health care professionals by patients is an ongoing problem. We aimed to construct and evaluate a curriculum that would prepare health care professionals for mistreatment by patients. METHODS: Lessons learned from 15 interviews and 2 focus groups with health care professionals were distilled into a multi-modal curriculum including didactics, simulation videos and role-play scenarios aimed to improve confidence in addressing mistreatment. This curriculum was disseminated at five educational workshops to health care professionals of various training groups and experience levels. Pre- and post-surveys were distributed to assess changes in participant's perspectives on readiness to address mistreatment. The signed-rank test was implemented to compare pre- and post- data. RESULTS: Participants were more likely to agree post-workshop that they had the right words to say, had a plan for what to do, and were more willing to speak up when they themselves or someone else was mistreated (p < .001). They were also more likely to agree post-workshop that there was something they could do to address patient mistreatment (p < .001). CONCLUSIONS: Participant familiarity and confidence in responding to patient mistreatment increased. Our curriculum may serve as a foundation for institutions seeking to equip their educators, health care professionals, and trainees with strategies for addressing this important issue.

Breakthrough Trichosporon asahii in a Patient With New Diagnosis B-ALL on Echinocandin Prophylaxis: A Case Report.

Invasive fungal disease is a difficult to diagnose complication of therapy in patients with hematologic malignancy. Antifungal prophylaxis is recommended in high-risk populations, but its use in other populations is less clear. This brief report describes a patient with Trisomy 21 on caspofungin prophylaxis who died of disseminated Trichosporon asahii during induction therapy for new diagnosis low-risk B-cell acute lymphoblastic leukemia, accompanied by a review of similar cases in the literature. Her case highlights the utility of relatively novel diagnostic modalities and reinforces the need for caution in placing patients on antifungal prophylaxis.

Considerations on the use of carbon and nitrogen isotopic ratios for sediment fingerprinting.

Carbon and nitrogen stable isotopic ratios are increasingly used in sediment fingerprinting studies. However, questions remain regarding tracer conservativeness during sediment transport and other error considerations. We investigate conservativeness processes, including carbon oxidation and nitrogen mineralization, using experiments. We also test how other considerations impact the isotopic ratios including algae accrual into temporary sediment deposits in the river, the physical loss of organic matter via disaggregation, concentration dependent mixing, and time-varying isotopic ratios of sediment sources. Results show all processes and considerations can change isotope abundance, however, significance varied. Carbon oxidation, nitrogen mineralization and upland seasonality of sediment sources did not significantly change isotopic ratios. Algae accrual, concentration dependency mixing, physical loss of organic matter during transport, and seasonality of the in-stream sediment source significantly changed the isotopic ratios for the conditions tested. Fertilization significantly impacted the stable carbon isotopic ratio in one case considered. Results from sediment fingerprinting simulations and testing how well the virtual mixture fits the mass balance equation agreed with significance results for tracer changes, and some uncertainty considerations changed fractional contribution of sources by as much as 50%. A noteworthy recommendation is the mean isotopic ratios of sediment sources should be separated by at least 1‰ to lessen tracer conservativeness concerns in fingerprinting simulation. We recommend concentration dependent mixing becomes the accepted practice when using isotopic ratios, however, we warn against using particle size corrections. We recommend the loss of organic matter during disaggregation be accounted for in fingerprinting estimates. We recommend algae accrual in in-stream sediment deposits should either be accounted for or in-stream sediment should be treated as a time-varying source in sediment fingerprinting simulations. Finally, we recommend both the carbon and nitrogen isotopic ratio should be tested as potential tracers because the two tracers performed similarly when testing how well the virtual mixture fits the mass balance equations.

Associations between Listeria monocytogenes genomic characteristics and adhesion to polystyrene at 8 °C.

Listeria monocytogenes remains a threat to the food system and has led to numerous foodborne outbreaks worldwide. L. monocytogenes can establish itself in food production facilities by adhering to surfaces, resulting in increased resistance to environmental stressors. The aim of this study was to evaluate the adhesion ability of L. monocytogenes at 8 °C and to analyse associations between the observed phenotypes and genetic factors such as internalin A (inlA) genotypes, stress survival islet 1 (SSI-1) genotype, and clonal complex (CC). L. monocytogenes isolates (n = 184) were grown at 8 °C and 100% relative humidity for 15 days. The growth was measured by optical density at 600 nm every 24 h. Adherent cells were stained using crystal violet and quantified spectrophotometrically. Genotyping of inlA and SSI-1, multi-locus sequence typing, and a genome-wide association study (GWAS) were performed to elucidate the phenotype-genotype relationships in L. monocytogenes cold adhesion. Among all inlA genotypes, truncated inlA isolates had the highest mean adhered cells, ABS595nm = 0.30 ± 0.15 (Tukey HSD; P < 0.05), while three-codon deletion inlA isolates had the least mean adhered cells (Tukey HSD; P < 0.05). When SSI-1 was present, more cells adhered; less cells adhered when SSI-1 was absent (Welch's t-test; P < 0.05). Adhesion was associated with clonal complexes which have low clinical frequency, while reduced adhesion was associated with clonal complexes which have high frequency. The results of this study support that premature stop codons in the virulence gene inlA are associated with increased cold adhesion and that an invasion enhancing deletion in inlA is associated with decreased cold adhesion. This study also provides evidence to suggest that there is an evolutionary trade off between virulence and adhesion in L. monocytogenes. These results provide a greater understanding of L. monocytogenes adhesion which will aid in the development of strategies to reduce L. monocytogenes in the food system.

Wetland restoration yields dynamic nitrate responses across the Upper Mississippi river basin.

Wetland restoration is a primary management option for removing surplus nitrogen draining from agricultural landscapes. However, wetland capacity to mitigate nitrogen losses at large river-basin scales remains uncertain. This is largely due to a limited number of studies that address the cumulative and dynamic effects of restored wetlands across the landscape on downstream nutrient conditions. We analyzed wetland restoration impacts on modeled nitrate dynamics across 279 subbasins comprising the ∼0.5 million km2 Upper Mississippi River Basin (UMRB), USA, which covers eight states and houses ∼30 million people. Restoring ∼8,000 km2 of wetlands will reduce mean annual nitrate loads to the UMRB outlet by 12%, a substantial improvement over existing conditions but markedly less than widely cited estimates. Our lower wetland efficacy estimates are partly attributed to improved representation of processes not considered by preceding empirical studies - namely the potential for nitrate to bypass wetlands (i.e., via subsurface tile drainage) and be stored or transformed within the river network itself. Our novel findings reveal that wetlands mitigate surplus nitrogen basin-wide, yet they may not be as universally effective in tiled landscapes and because of river network processing.

Hemolysis as Cause of Hemodialysis Blood Leak Alarm: Case Study of a Patient with Freshwater Near-Drowning.

Hemolysis may be an infrequent cause of hemodialysis blood leak alarms. We report the case of an unresponsive adult male who was placed on hemodialysis with a high-flux dialyzer. Within five minutes, the blood leak alarm sounded. The care team discontinued treatment and made two additional attempts to reinitiate hemodialysis with different machines, blood tubing lots, and brands of high-flux dialyzers, but continued to receive blood leak alarms. Laboratory studies were consistent with severe hemolysis. The attending nephrologist subsequently ordered continuous veno-venous hemofiltration, which was initiated and continued into the following day without incident or alarm. The patient later expired from complications of near-drowning. In the event of significant hemolysis, continuous kidney replacement therapy or hemodialysis with a low-flux dialyzer, and a lower ultrafiltration rate may be indicated.

The Hard X-ray Nanoprobe beamline at Diamond Light Source.

The Hard X-ray Nanoprobe beamline, I14, at Diamond Light Source is a new facility for nanoscale microscopy. The beamline was designed with an emphasis on multi-modal analysis, providing elemental mapping, speciation mapping by XANES, structural phase mapping using nano-XRD and imaging through differential phase contrast and ptychography. The 185 m-long beamline operates over a 5 keV to 23 keV energy range providing a ≤50 nm beam size for routine user experiments and a flexible scanning system allowing fast acquisition. The beamline achieves robust and stable operation by imaging the source in the vertical direction and implementing horizontally deflecting primary optics and an overfilled secondary source in the horizontal direction. This paper describes the design considerations, optical layout, aspects of the hardware engineering and scanning system in operation as well as some examples illustrating the beamline performance.

The Challenges of Multisource Feedback: Feasibility and Acceptability of Gathering Patient Feedback for Pediatric Residents.

OBJECTIVE: The Accreditation Council for Graduate Medical Education calls for residency programs to incorporate multisource feedback, which may include patient feedback, into resident competency assessments. Program directors face numerous challenges in gathering this feedback. This study assesses the feasibility and acceptability of patient feedback collection in the inpatient and outpatient setting at 3 institutions. METHODS: Patient feedback was collected using a modified version of the Communication Assessment Tool (CAT). Trained research assistants administered the CAT to eligible patients and families in pediatric ward, intensive care, and outpatient settings from July to October 2015. Completion rates and reasons for non-completion were recorded. Patient satisfaction with the CAT was assessed on a 5-point Likert scale. RESULTS: The CAT was completed by 860/1413 (61%) patients. Completion rates in the pediatric ward and intensive care settings were 45% and 38%, respectively, compared to 91% in the outpatient setting. In inpatient settings, survey non-completion was typically due to participant unavailability; this was rarely a reason in the outpatient setting. A total of 93.4% of patients were satisfied or very satisfied with using the CAT. It was found that 6.36 hours of research assistant time would be required to gather a valid quantity of patient feedback for a single resident in the outpatient setting, compared to 10.14 hours in the inpatient setting. CONCLUSIONS: Although collecting feedback using our standardized protocol is acceptable to patients, obtaining sufficient feedback requires overcoming several barriers and a sizable time commitment. Feedback collection in the outpatient setting may be higher yield than in the inpatient setting due to greater patient/family availability. Future work should focus on innovative methods to gather patient feedback in the inpatient setting to provide program directors with a holistic view of their residents' communication skills.

The Effect of Faculty Coaching on Resident Attitudes, Confidence, and Patient-Rated Communication: A Multi-Institutional Randomized Controlled Trial.

OBJECTIVE: Despite a national focus on physician-patient communication, there is a paucity of literature on how patient and family feedback (PFF) can be used as a tool to help residents learn communication skills. The purpose of this study was to assess the effect of coaching on residents' attitudes towards PFF, self-confidence in communication, and patient-rated communication skills. METHODS: This was an institutional review board-approved, randomized-controlled trial with pediatric residents at 3 institutions from 2015 to 2016. Pre- and postintervention, residents completed a self-assessment of their attitudes and self-confidence in communication. PFF was collected for each resident using the Communication Assessment Tool, which has been validated in other medical disciplines. Intervention group residents reviewed their baseline PFF with a faculty coach; control group residents reviewed their PFF independently. RESULTS: In total, 114 residents completed the study, 57 in each arm. Intervention group residents were significantly more likely to ask for PFF compared with control group residents (mean change 0.36 vs -0.11, P = .01). There were no other significant differences in resident attitudes, confidence, or patient-rated communication between groups. Both groups had increased self-confidence over time and with increasing postgraduate year level. Patient ratings of resident communication did not differ over time or between groups. CONCLUSIONS: Residents who reviewed PFF with a faculty coach were significantly more likely to report they would ask patients for feedback than residents who reviewed PFF independently, suggesting review of feedback with a coach may enhance appreciation of patient feedback. Although self-confidence improved over time in both groups, patient ratings of resident communication skills were not significantly different over time or between groups.

The dialysis orders objective structured clinical examination (OSCE): a formative assessment for nephrology fellows.

BACKGROUND: Few quantitative nephrology-specific simulations assess fellow competency. We describe the development and initial validation of a formative objective structured clinical examination (OSCE) assessing fellow competence in ordering acute dialysis. METHODS: The three test scenarios were acute continuous renal replacement therapy, chronic dialysis initiation in moderate uremia and acute dialysis in end-stage renal disease-associated hyperkalemia. The test committee included five academic nephrologists and four clinically practicing nephrologists outside of academia. There were 49 test items (58 points). A passing score was 46/58 points. No item had median relevance less than 'important'. The content validity index was 0.91. Ninety-five percent of positive-point items were easy-medium difficulty. Preliminary validation was by 10 board-certified volunteers, not test committee members, a median of 3.5 years from graduation. The mean score was 49 [95% confidence interval (CI) 46-51], κ = 0.68 (95% CI 0.59-0.77), Cronbach's α = 0.84. RESULTS: We subsequently administered the test to 25 fellows. The mean score was 44 (95% CI 43-45); 36% passed the test. Fellows scored significantly less than validators (P < 0.001). Of evidence-based questions, 72% were answered correctly by validators and 54% by fellows (P = 0.018). Fellows and validators scored least well on the acute hyperkalemia question. In self-assessing proficiency, 71% of fellows surveyed agreed or strongly agreed that the OSCE was useful. CONCLUSIONS: The OSCE may be used to formatively assess fellow proficiency in three common areas of acute dialysis practice. Further validation studies are in progress.

Role of LIGHT in the pathogenesis of joint destruction in rheumatoid arthritis.

AIM: To characterise the role of substitutes for receptor-activator nuclear factor kappa-B ligand (RANKL) in rheumatoid arthritis (RA) joint destruction. METHODS: Synovial fluid (SF) macrophages isolated from the knee joint of RA patients were incubated with 25 ng/mL macrophage-colony stimulating factor (M-CSF) and 50 ng/mL LIGHT (lymphotoxin-like, exhibits inducible expression and competes with herpes simplex virus glycoprotein D for herpes virus entry mediator, a receptor expressed by T lymphocytes) in the presence and absence of 25 ng/mL RANKL and 100 ng/mL osteoprotegerin (OPG) on glass coverslips and dentine slices. Osteoclastogenesis was assessed by the formation of multinucleated cells (MNCs) expressing tartrate-resistant acid phosphatase (TRAP) on coverslips and the extent of lacunar resorption pit formation on dentine slices. The concentration of LIGHT in RA and osteoarthritis (OA) synovial fluid was measured by an enzyme-linked immunosorbent assay (ELISA) and the expression of LIGHT in RA and OA synovium was determined by immunohistochemistry using an indirect immunoperoxidase technique. RESULTS: In cultures of RA SF macrophages treated with LIGHT and M-CSF, there was significant formation of TRAP + MNCs on coverslips and extensive lacunar resorption pit formation on dentine slices. SF-macrophage-osteoclast differentiation was not inhibited by the addition of OPG, a decoy receptor for RANKL. Resorption pits were smaller and less confluent than in RANKL-treated cultures but the overall percentage area of the dentine slice resorbed was comparable in LIGHT- and RANKL-treated cultures. LIGHT significantly stimulated RANKL-induced lacunar resorption compared with RA SF macrophages treated with either RANKL or LIGHT alone. LIGHT was strongly expressed by synovial lining cells, subintimal macrophages and endothelial cells in RA synovium and the concentration of LIGHT was much higher in RA compared with OA SF. CONCLUSION: LIGHT is highly expressed in RA synovium and SF, stimulates RANKL-independent/dependent osteoclastogenesis from SF macrophages and may contribute to marginal erosion formation.

Anxiety Disorders in Primary Care.

Investigation for a possible anxiety disorder should be considered in patients with multiple or persistent anxiety symptoms or multiple somatic complaints without a clear somatic etiology. The ideal treatment for anxiety disorders is a combination of pharmacologic and behavioral strategies. As primary care health care evolves, it is expected that the management of mental health disorders (including anxiety disorders) will largely occur in the context of collaborative care models in which patients and primary care clinicians are assisted by trained case managers who help facilitate a more comprehensive, holistic treatment plan between primary care and mental health providers.

A refined model for the TSG-6 link module in complex with hyaluronan: use of defined oligosaccharides to probe structure and function.

Tumor necrosis factor-stimulated gene-6 (TSG-6) is an inflammation-associated hyaluronan (HA)-binding protein that contributes to remodeling of HA-rich extracellular matrices during inflammatory processes and ovulation. The HA-binding domain of TSG-6 consists solely of a Link module, making it a prototypical member of the superfamily of proteins that interacts with this high molecular weight polysaccharide composed of repeating disaccharides of D-glucuronic acid and N-acetyl-D-glucosamine (GlcNAc). Previously we modeled a complex of the TSG-6 Link module in association with an HA octasaccharide based on the structure of the domain in its HA-bound conformation. Here we have generated a refined model for a HA/Link module complex using novel restraints identified from NMR spectroscopy of the protein in the presence of 10 distinct HA oligosaccharides (from 4- to 8-mers); the model was then tested using unique sugar reagents, i.e. chondroitin/HA hybrid oligomers and an octasaccharide in which a single sugar ring was (13)C-labeled. The HA chain was found to make more extensive contacts with the TSG-6 surface than thought previously, such that a D-glucuronic acid ring makes stacking and ionic interactions with a histidine and lysine, respectively. Importantly, this causes the HA to bend around two faces of the Link module (resembling the way that HA binds to CD44), potentially providing a mechanism for how TSG-6 can reorganize HA during inflammation. However, the HA-binding site defined here may not play a role in TSG-6-mediated transfer of heavy chains from inter-α-inhibitor onto HA, a process known to be essential for ovulation.

Balint groups: the nuts and bolts of making better doctors.

Balint Group seminars were developed by Michael and Enid Balint based on the application of psychological principles in a group setting for the purpose of developing an improved understanding of the doctor-patient relationship. This article focuses on the development and application of the Balint method to the training of resident physicians (particularly Family Physicians) within the United States. An effort is made to describe the practicalities of resident physician Balint training (e.g., size, frequency, duration of such groups), conceptual underpinnings (e.g., biphasic nature of patient identification, disease versus illness concept, transference/counter-transference, over-identification, under-identification, biphasic nature of physician empathy), and pedagogic goals (mastering empathic skills inherent in being a good doctor) of residency-based Balint groups. In aggregate, this article provides a useful framework for behavioral science educators interested in applying the Balint seminar method to resident physician training. The authors encourage both the continued study and educational application of the Balint seminar method in the training of physicians both within and outside of the United States.