DLX6 and MSX1 from saliva samples as potential predictors of mandibular size: A cross-sectional study.

INTRODUCTION: Morphologic features of the mandible are influenced by the genes of each individual. Mandible size is important to orthodontists because the mandible is the mechanism by which the lower face influences facial esthetics and dental function. To date, no biological marker has been identified that indicates eventual mandible size. This study aimed to correlate the expression of DLX5, DLX6, EDN1, HAND2, PRRX1, and MSX1 to mandible size. METHODS: Fifty-nine orthodontic patients aged >6 years who had available cephalometric radiographs were studied. Patients were classified on the basis of condylion-to-gnathion measurements. Messenger RNA was isolated from saliva and subjected to real-time quantitative polymerase chain reaction. RESULTS: Threshold cycle values for subjects with small mandibles (>1 standard deviation [SD] from the mean) had the least expression of DLX6 and MSX1. Threshold cycle values for subjects with large mandibles (>1 SD) had less expression of DLX6 and MSX1 than subjects within 1 SD but more than those with small mandibles. CONCLUSIONS: DLX6 and MSX1 are related to mandible development and size. This finding could be used to improve treatment planning for medical and dental professionals seeking to understand the impact of genetics on bone growth.

Appropriate use criteria for ancillary diagnostic testing in dermatopathology: New recommendations for 11 tests and 220 clinical scenarios from the American Society of Dermatopathology Appropriate Use Criteria Committee.

BACKGROUND: Appropriate use criteria (AUC) provide patient-centered physician guidance in test selection. An initial set of AUC was reported by the American Society of Dermatopathology (ASDP) in 2018. AUC reflect evidence collected at single timepoints and may be affected by evolving evidence and experience. The objective of this study was to update and expand AUC for selected tests. METHODS: RAND/UCLA (RAND Corporation [Santa Monica, CA]/University of California Los Angeles) methodology used includes the following: (a) literature review; (b) review of previously rated tests and previously employed clinical scenarios; (c) selection of previously rated tests for new ratings; (d) development of new clinical scenarios; (e) selection of additional tests; (f) three rating rounds with feedback and group discussion after rounds 1 and 2. RESULTS: For 220 clinical scenarios comprising lymphoproliferative (light chain clonality), melanocytic (comparative genomic hybridization, fluorescence in situ hybridization, reverse transcription polymerase chain reaction, telomerase reverse transcriptase promoter), vascular disorders (MYC), and inflammatory dermatoses (periodic acid-Schiff, Gömöri methenamine silver), consensus by panel raters was reached in 172 of 220 (78%) scenarios, with 103 of 148 (70%) rated "usually appropriate" or "rarely appropriate" and 45 of 148 (30%), "appropriateness uncertain." LIMITATIONS: The study design only measures appropriateness. Cost, availability, test comparison, and additional clinical considerations are not measured. The possibility that the findings of this study may be influenced by the inherent biases of the dermatopathologists involved in the study cannot be excluded. CONCLUSIONS: AUC are reported for selected diagnostic tests in clinical scenarios that occur in dermatopathology practice. Adhering to AUC may reduce inappropriate test utilization and improve healthcare delivery.

Cheek Donor Site for Full-Thickness Skin Graft Repair of the Nasal Ala: Outcomes of a Retrospective Cohort Study.

BACKGROUND: Full-thickness skin grafts (FTSGs) are useful repairs for reconstructing nasal alar defects. Traditional donor sites include the preauricular, postauricular, and supraclavicular skin. OBJECTIVE: To evaluate esthetic outcomes and complications of nasal alar defects repaired with FTSGs from the medial cheek. MATERIALS AND METHODS: A retrospective chart review of Mohs surgery patients who had FTSG repair of the nasal ala between January 2015 and August 2020 was performed. Demographic, surgery, and follow-up visit data were reviewed. Cosmesis was rated by a facial plastic surgeon, a Mohs surgeon, and a plastic surgeon using baseline, defect, and follow-up visit photographs. RESULTS: Sixty-nine patients with FTSG repairs of nasal alar defects were identified. 51 of 69 patients (73.9%) had the cheek donor site, and 18 of 69 patients (26.1%) had a noncheek donor site. The mean (SD) rater visual analog score for both cohorts was good with no significant difference (cheek: 65.9 [13.8]; noncheek: 66.1 [15.3]; p = .96). A notable difference in the complication rate by donor site was observed (cheek: 6.9%, noncheek: 16.7%; p = .13), although it did not reach significance. CONCLUSION: The cheek is a reliable FTSG donor site for nasal alar defects after Mohs micrographic surgery, with a trend toward fewer complications.

Umbilical Cord Milking in Extremely Preterm Infants: A Randomized Controlled Trial Comparing Cord Milking with Immediate Cord Clamping.

OBJECTIVE: This study aimed to assess potential benefits of umbilical cord milking (UCM) when compared with immediate cord clamping (ICC) in extremely preterm infants. STUDY DESIGN: This is a single-center, randomized controlled trial of infants 240/7 to 276/7 weeks' gestation who received UCM versus ICC. In the experimental group, 18 cm of the umbilical cord was milked three times. The primary aim was to assess the initial hemoglobin and to assess the number of blood transfusions received in the first 28 days after birth. Secondary outcomes were also assessed, including intraventricular hemorrhage (IVH). A priori, neurodevelopmental follow-up was planned at 15 to 18 months corrected gestational age (CGA). RESULTS: Baseline characteristics for 56 enrolled infants were similar in both groups with a mean gestational age of 26.1 ± 1.2 weeks and a mean birth weight of 815 ± 204 g. There were no differences in the mean initial hemoglobin in the UCM group when compared with the ICC group, 13.7 ± 2.0 and 13.8 ± 2.6 g/dL, respectively (p = 0.95), with no differences in median number of blood transfusions after birth between the ICC group and the UCM group, 2 (interquartile range [IQR]: 1-4) versus 2.5 (IQR: 1-5) (p = 0.40). There was also no difference in the rate of severe IVH. At 15 to 18 months CGA, there were no differences in death or disability in the ICC group compared with the UCM group (26 vs. 22%; p = 1.0) and no differences in neurodevelopmental outcomes. CONCLUSION: In a randomized trial of ICC versus UCM in extremely preterm infants, no differences were seen in initial hemoglobin or number of blood transfusions. KEY POINTS: · Umbilical cord milking may be an alternative to delayed cord clamping, but its safety and efficacy are not established in extremely premature infants.. · There are minimal available published data on the longer term neurodevelopmental outcomes in extremely premature infants who receive umbilical cord milking compared with immediate clamping.. · We did not find a significant difference in the primary outcomes of initial hemoglobin and blood transfusions between the groups, nor did we find a difference in severe IVH with umbilical cord milking..

Sun Protection Outreach Teaching by Students (SPOTS)-Evaluating the Efficacy of Skin Cancer Prevention Education for Adolescents.

BACKGROUND: The Sun Protection Outreach Teaching by Students (SPOTS) program addresses an unmet need by training medical students to teach adolescents about skin cancer prevention and early detection. OBJECTIVE: To measure (1) changes in adolescents' knowledge, attitudes, and behaviors regarding sun protection and (2) the impact on medical students' confidence in skin cancer preventive counseling. METHODS: Pre-SPOTS and 1-month post-SPOTS program surveys were completed by adolescent participants and medical student instructors. RESULTS: Amongst adolescent students, analysis of 1,142 pre-program surveys and 618 post-program surveys revealed statistically significant improvements in knowledge, attitudes, and behaviors. Among the favorable results, 26%, 41%, and 20% improvements over baseline were observed in SPF knowledge, preference for natural untanned skin, and intent to wear sunscreen, respectively (p < .001). One-third of adolescents reported having tried to increase sunscreen use. Amongst medical students, analysis of 78 pre-teaching and 74 post-teaching surveys revealed an increase in feeling "very confident" in counseling patients, from 23% pre-teaching to 82% post-teaching (p < .001). CONCLUSION: SPOTS demonstrated a dual benefit to adolescents and medical students. The program is available for dermatologists to implement in their communities.

Efficacy, rate of tumor response, and safety of a short course (12-24 weeks) of oral vismodegib in various histologic subtypes (infiltrative, nodular, and superficial) of high-risk or locally advanced basal cell carcinoma, in an open-label, prospective case series clinical trial.

BACKGROUND: Vismodegib demonstrated 60% response rates in the ERIVANCE trial. Basal cell carcinoma has various histopathologies. Their effect on response is unclear. OBJECTIVE: The purpose of this study was to determine whether basal cell carcinoma histopathology affected vismodegib response. METHODS: This phase 2b, single-center, prospective case series study compared the efficacy of vismodegib in infiltrative, nodular, and superficial basal cell carcinomas treated for 12 or 24 weeks in 27 patients. Patients had 1 target lesion and up to 3 nontarget lesions. RESULTS: Twenty-seven patients were enrolled, with 65 tumors (27 target lesions/38 nontarget lesions). At 24 weeks, most basal cell carcinomas achieved histologic clearance, with positive biopsy results in 10.5% of target lesions, 30.4% of nontarget lesions, and 21.4% overall. No statistical differences were observed between histopathologic subtypes. One hundred percent of patients experienced an adverse event, 94% grade 1 or 2. The most common adverse events were dysgeusia/loss of taste (86%), muscle spasms (82%), and alopecia (71%). Clinically progressive disease during treatment was low (1.5%). Two patients had recurrence within 1 year of treatment. LIMITATIONS: Limitations included sample size of basal cell carcinoma histopathologic subtypes, sampling punch biopsies, and short follow-up. CONCLUSIONS: Basal cell histopathologic subtype did not significantly affect response to vismodegib. Each subtype was observed to completely respond at 12 weeks of therapy, 24 weeks, or both.

Off-label use of dupilumab for pediatric patients with atopic dermatitis: A multicenter retrospective review.

BACKGROUND: Atopic dermatitis (AD) is a common, chronic type 2 inflammatory skin disease, typically starting in infancy, with increased risk for subsequent extracutaneous atopic morbidities. Dupilumab is the first biologic agent targeting type 2 inflammation approved by the U.S. Food and Drug Administration (USFDA); it was licensed in 2017 for adults with moderate to severe AD and 2 years later for adolescents. Systemic treatment for pediatric AD remains a significant unmet medical need. OBJECTIVE: To analyze off-label use of dupilumab in children with AD. METHODS: Multicenter retrospective review that evaluated children who were prescribed dupilumab for moderate to severe AD. RESULTS: One hundred eleven of 124 patients (89.5%) gained access to dupilumab after a mean of 9 weeks. The dosing range was 4 to 15.5 mg/kg for the loading dose and 2.0 to 15.3 mg/kg every other week for maintenance. The range was widest for 6- to 11-year-olds and was related to use of either full or half of adult dosing. Associated morbidities, treatment response, and adverse events were comparable to those in previous adolescent and adult trials. LIMITATIONS: The retrospective design of the study limited uniform data collection. CONCLUSION: Access to dupilumab was achievable for the majority of children after a mean 9-week delay because of insurance payment denial. This review supports dupilumab response and tolerability in children. Optimal dosing for patients younger than 12 years has not been defined. Availability of the drug in 2 different concentrations is an important safety issue.

Dermatopathologist assessment of "pathologist-to-dermatologist" communication for dermatopathology services.

BACKGROUND: While patients are the ultimate beneficiaries of pathology services, pathologist to clinician communication is an essential component of excellent patient care. OBJECTIVE: To survey dermatologists on how well pathologists communicate with them and to assess which aspects of pathologists' communication skills are deemed most significant to dermatologists, stratified by practice type. METHODS: A survey-based instrument was developed and sent to dermatologists through various email listservs. Of the approximately 400 potential Association of Professors of Dermatology respondents, 64 returned the survey questionnaire (response rate 16%). Of the 79 state and regional dermatologic societies, seven agreed to distribute the survey on their listservs (response rate 9%). RESULTS: Surveyed dermatologists believe that the pathologists with whom they work are meeting expectations in the areas of diagnostic accuracy, communicating pertinent information in a timely fashion, integrating written pathology reports into the electronic medical record, and making a clinically meaningful histopathologic interpretation. Discussion of cost of ancillary testing is an area of improvement. University affiliated dermatologists are more likely to use electronic medical records as their predominant mode of communication compared to community dermatologists with and without academic affiliations. Community dermatologists are more likely to use faxed written pathology reports as their predominant mode of communication. CONCLUSION: Physician-to-physician communication is a key component of effective patient care. When it comes to dermatopathology services, dermatologists appear overall satisfied with the indicators examined, however, potential opportunities for improvement exist.

Improving nonattendance rates among pediatric patients with Medicaid or private insurance.

BACKGROUND: Access to dermatologists is low among Medicaid-insured patients. Higher clinic nonattendance among Medicaid-insured patients might affect provider decisions to accept these patients. OBJECTIVE: To determine the effect of different scheduling policies on the attendance among children seen at a pediatric dermatology clinic. METHODS: In this retrospective review, we compared nonattendance among children for 3 different scheduling policies implemented over 3 consecutive years. The scheduling policies used were a first-available open scheduling policy, a 2-week in advance scheduling policy, and a 4-week in advance scheduling policy. Subset analyses were performed by clinic location and insurance type. RESULTS: The interval between scheduling and appointment date was directly related to nonattendance rates; rates were higher for Medicaid-insured than privately insured patients. Open scheduling was associated with a 37% nonattendance rate for Medicaid-insured patients and 18% nonattendance rate for privately insured patients. A 4-week in advance scheduling policy significantly decreased the nonattendance rate to 19% among Medicaid-insured and 7% among privately insured patients. A 2-week in advance policy further decreased the nonattendance rate to 11% among Medicaid-insured patients and 4% among privately insured patients. LIMITATIONS: This is a retrospective study, and same-day cancellations were not tracked. CONCLUSION: Decreasing the time interval between scheduling and appointment dates can significantly decrease nonattendance. This strategy might help dermatologists incorporate more Medicaid-insured patients into their practices.

Mechanical Strain of the Nasal Bilobed Transposition Flap-Graduated Changes in Skin Thickness Superiorly Displace the Location of the Pivot Point.

BACKGROUND: The bilobed transposition flap recruits the relatively thinner and laxer skin of the nasal dorsum and sidewall to reconstruct defects of the more sebaceous nasal tip and alae. There have been no studies performed to quantify how the material properties of skin alter the bilobed flap's performance during nasal reconstruction. OBJECTIVE: To determine the effects of skin thickness and stiffness on bilobed flap mechanics to help guide flap design principles and optimize surgical outcomes. MATERIALS AND METHODS: Two-dimensional artificial silicone skin models of varying thickness were created. The bilobed flap was incised, transposed, and secured in standard fashion. Digital image correlation was used to translate model deformation and displacement into local stress and mechanical strain forces within the bilobed flap pedicle. RESULTS: Qualitatively, the center of rotation of the bilobed flap rotates superiorly up the flap pedicle as model skin thickness increased. CONCLUSION: Location of the bilobed flap's pivot point may be dependent on local tissue characteristics-oversizing of the primary lobe can be considered in stiff, immobile tissue such as highly sebaceous Zone II nasal skin.

Patient-Centered Outcomes for Skin Cancer Management: Utilization of a Patient Delphi Process to Identify Important Treatment Themes.

BACKGROUND: Patient-reported outcomes are critical to research directed at maximizing patient benefit. The outcomes patients consider most relevant in the treatment of skin cancer have not been directly investigated. OBJECTIVE: To develop a ranked list of outcomes deemed most important by patients with skin cancer through a proctored Delphi process. METHODS: Twenty-one patients with a history of skin cancer volunteered to participate in the patient summit. The patient members participated in a guided discussion to generate a long list of potentially relevant outcomes. The list was then condensed and ranked through 2 rounds of a proctored Delphi process. RESULTS: Patients were diverse in their skin cancer histories and complexities, ages, and states of residence. Twelve themes were rated as highly important by 70% or more of participants. Most of these themes related to patient education and the collaborative nature of the physician-patient relationship. Fear of recurrence and cosmetic outcome were also highly rated. Limitations include a preponderance of older patients and patients from the midwest and northeast. CONCLUSION: Patients with skin cancer overwhelmingly prioritize a shared decision-making process, in which they are actively engaged and value detailed education regarding their disease. This should inform future research directed at skin cancer treatment and current physician-patient interactions.

Physician-Centered Outcomes for Skin Cancer Treatment: A Single-Day Modified Delphi Process to Assess the Importance of Themes in Skin Cancer Management.

BACKGROUND: Success in skin cancer treatment is determined through outcome measurement. Patients and physicians may prioritize different outcomes of care, and identification of such may enhance patient-centered care. OBJECTIVE: To identify gaps between patient and physician attitudes toward skin cancer outcomes. MATERIALS AND METHODS: A single-day, 21-patient, modified, in-person Delphi process to solicit and rate the importance of skin cancer-related outcomes was conducted. Twelve masked dermatologic surgeons rated patient-generated outcomes in a 2-round modified Delphi process. Each item was rated on a 1 to 9 scale (1, least important; 9, most important) using the Qualtrics web platform (Qualtrics, Provo, UT). Results of the physician ratings were compared with the patient ratings. RESULTS: A list of 53 skin cancer treatment-related themes and outcomes was generated. Eight items were ranked by physicians as "very high" (>80% importance), 5 as "high" (>70% importance), 19 as intermediate, and 21 as low. The physician and patient panels' ratings were concordant for 56% of items, whereas 7 outcome items showed a 2-category discordance. CONCLUSION: Physicians and patients were concordant regarding skin cancer treatment on multiple spheres. Areas of discordance include patient fear of unknown future risk, recurrence, or empowering patients to make treatment choices, and may be areas of continued improvement for delivery of patient-centered care.

Description of Venous Thromboembolism in Hospitalized Patients With Metastatic Cancer: A National Sample.

Background: This study aimed to determine patient-, tumor-, and hospital-level characteristics associated with venous thromboembolism (VTE), and to assess the impact of VTE on in-hospital mortality and length of hospital stay in hospitalized patients with metastatic cancer. Methods: Using the Nationwide Inpatient Sample database, a cross-sectional analysis was performed of patients aged ≥18 years with at least 1 diagnosis of primary solid tumor and subsequent secondary or metastatic tumor between 2008 and 2013. Results: Among 850,570 patients with metastatic cancer, 6.6% were diagnosed with VTE. A significant trend for increasing VTE rates were observed from 2008 to 2013 (5.7%-7.2%; P<.0001). Using an adjusted multilevel hierarchical regression model, higher odds of VTE were seen among women (odds ratio [OR], 1.04; 95% CI, 1.02-1.06), black versus white patients (OR, 1.14; 95% CI, 1.11-1.18), and those with an Elixhauser comorbidity index score of ≥3 (OR, 2.50; 95% CI, 2.38-2.63). Hospital-level correlates of VTE included treatment in a teaching hospital (OR, 1.05; 95% CI, 1.01-1.11) and an urban location (OR, 1.18; 95% CI, 1.09-1.27), and admission to hospitals in the Northeast (OR, 1.16; 95% CI, 1.08-1.24) and West (OR, 1.09; 95% CI, 1.03-1.16) versus the South. Patients with metastasis to the liver, brain, or respiratory organs and those with multiple (≥2) metastatic sites had higher odds of VTE, whereas those with metastasis to lymph nodes and genital organs had lower odds. Patients diagnosed with versus without VTE had higher odds of in-hospital mortality (OR, 1.50; 95% CI, 1.38-1.63) and prolonged hospital stay (OR, 1.65; 95% CI, 1.57-1.73). Conclusions: The frequency of VTE in patients with metastatic cancer is increasing. Patient characteristics, hospital factors, and site of metastasis independently predict the occurrence of VTE and allow for better stratification of patients with cancer according to their VTE risk.

Do Patterns of Reconstruction Choices After Mohs Surgery Vary by Specialty? A Pilot Study of Mohs Surgeons and Facial Plastic Surgeons.

BACKGROUND: Differences in approach to repair a specified defect after Mohs micrographic surgery (MMS) between specialties have not been previously examined. OBJECTIVE: To assess the difference in frequency of which reconstruction repairs are selected after MMS, among Mohs surgeons and facial plastic surgeons (FPS), and evaluate whether the level of satisfaction with the final repair outcome differed between specialties. MATERIALS AND METHODS: The study was approved by the Saint Louis University Institutional Review Board. A link to the survey was distributed to members of American College of Mohs Surgery (ACMS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), between January and May 2016. RESULTS: The reconstructive procedure selected most often ("top choice") was not significantly different between Mohs surgeons and FPS for the majority of the images. There was no material difference in how dermatologists and FPS rate the aesthetic outcome of the 3 presented closure types, with the exception of one closure type-nose with graft. CONCLUSION: Mohs surgeons were found to more likely cluster around a single preference for their reconstruction technique compared with FPS, in which a higher percentage of surgeons also selected other options.

Bending the Arc of the Trilobed Flap Through External Interlobe Angle Inequality.

BACKGROUND: The trilobed flap is a useful repair option for distal nasal defects. In certain cases, however, the placement of its quaternary defect may risk compression of the internal nasal valve or induction of ectropion. In this study, we propose a modified design of the trilobed flap, which uses unequal external interlobe angles. OBJECTIVE: To present the design principles and results of our modified trilobed flap for the reconstruction of difficult distal nasal Mohs defects. MATERIALS AND METHODS: Mohs defects of 26 patients were reconstructed (21 with long-term follow-up) using our modified trilobed flap over 1 year. Two independent masked raters graded postoperative photographs for alar symmetry and overall cosmesis. RESULTS: Median alar symmetry scores were excellent and overall cosmesis grades were between excellent and very good. CONCLUSION: The modified trilobed flap with unequal external angles offers an excellent option for reconstruction of Mohs defect of the distal nose that may not be well-suited for other repairs. Over 1 year, 21 modified trilobed repairs were performed with overall excellent outcomes.

A Novel, Disease-Specific Self-Report Instrument to Measure Body Image Concerns in Patients With Head and Neck Skin Cancer.

BACKGROUND: Skin cancer commonly occurs on areas that are salient to body image perception (i.e., head and neck). Patients with head and neck skin cancer (HNSC) may experience negative body image perceptions related to their disease, which is concerning, given the numerous negative sequelae of poor body image. However, there are no existing disease-specific measures of body image concerns in HNSC. OBJECTIVE: To develop and examine the psychometric properties of a brief self-report, disease-specific measure of body image concerns in patients with HNSC-the Body Image Questionnaire (BIQ). MATERIALS AND METHODS: Patients with HNSC completed the BIQ before (n = 239) and 6 months after (n = 80) treatment with Mohs micrographic surgery. Analyses examined the internal consistency, convergent validity, and factor structure of the BIQ. RESULTS: Internal consistency reliability was acceptable, and the measure demonstrated convergent validity with well-being. Four dimensions underlie the BIQ: appearance satisfaction, appearance avoidance, head/neck/skin-specific dissatisfaction, and perceived change. CONCLUSION: The BIQ is a valid and internally reliable disease-specific instrument that measures body image concerns in patients with HNSC.

Patients' Body Image Improves After Mohs Micrographic Surgery for Nonmelanoma Head and Neck Skin Cancer.

BACKGROUND: Most skin cancers occur on the head and neck, areas of the body that are significant to an individual's body image (BI) perception. Poor BI is a robust risk factor for depression and decreased quality of life. Thus, patients with nonmelanoma head and neck skin cancer (NMHNSC) may be more vulnerable to BI disturbance and the negative sequelae of poor BI. OBJECTIVE: Describe the nature of BI concerns in patients diagnosed with NMHNSC and assess how BI changes with treatment. METHODS AND MATERIALS: Patients undergoing Mohs micrographic surgery (MMS) for NMHNSC completed assessments of BI and well-being before (N = 239) and 6 months after (N = 80) treatment with MMS. Demographic and tumor data were gathered through retrospective chart review. RESULTS: Body image improved significantly 6 months after MMS, and the magnitude of this change was large (η = 0.18). Repair length (length of final scar irrespective of repair type) >4 cm predicted poorer BI at 6-month follow-up. CONCLUSION: Patients' BI improves after treatment with MMS for NMHNSC.

Positive Outcomes of Optimizing Student-Preceptor Continuity in a Traditional Block Clerkship.

PROBLEM: Student-preceptor discontinuity during 3rd-year clerkships limits the quality and quantity of supervision, teaching, and feedback. Although longitudinal integrative clerkships increase continuity and are associated with improved student and preceptor experience, they require schoolwide curricular reform. Alternative innovations enhancing student-preceptor relationships within the constraints of a traditional block clerkship may demonstrate similar benefits. INTERVENTION: We piloted a continuity-enhanced general pediatric ambulatory schedule during 2 consecutive clerkship blocks in 2013. Students in the continuity-enhanced model (n = 29) were assigned 1-3 primary clinic preceptors, whereas those in the traditional model (n = 30) worked with 5-8. Data were gathered from student assessments and anonymous student and preceptor surveys. We used t and Fisher's exact tests to compare the two groups and performed thematic analysis of free-text survey comments. CONTEXT: Our school utilizes a block clerkship model with approximately 30 students rotating through the pediatric clerkship every 8 weeks. During the 3-week ambulatory portion, students spend 8 half days in the general pediatric ambulatory clinic. At the conclusion of each clinic, attendings completed brief student evaluation cards. Traditionally, student and attending schedules were created independently, resulting in transient supervisory relationships and dissatisfaction with clinical engagement, feedback, and evaluation. OUTCOME: Seventy-three percent (43/59) of the students completed the survey. Ten general ambulatory attendings collectively completed 87.5% (35/40) of the monthly surveys. Continuity students received significantly more narrative evaluation comments (10.6 vs. 5.8, p <. 001) from general ambulatory clinic attendings and were more likely to have at least one general ambulatory clinic attending endorse being able to provide meaningful feedback and evaluation (n = 29, 100% vs. n = 20, 66.7%, p <. 001). Continuity students were also more likely to endorse being able to ask at least one of these attendings for a letter of recommendation (71.4% vs. 9.1%, p <. 001) and to have at least one general ambulatory clinic attending endorse being able to provide a meaningful letter of recommendation if asked (62.1% vs. 3.3%, p <. 001). Students (88.4%) and attendings (85.7%) preferred the continuity-enhanced schedule. The most frequent theme of both student and attending free-text survey remarks were relationships and assessment. LESSONS LEARNED: Intentional scheduling of clerkship students to enhance preceptor continuity resulted in significant positive outcomes echoing the relationship-based educational benefits of longitudinal clerkships, particularly in regards to student assessment and feedback. Clerkship directors and other medical educators should consider implementing small changes within block clerkships to maximize student-preceptor continuity.

Variation in Pediatric Organ Donor Management Practices Among US Organ Procurement Organizations.

INTRODUCTION: Reports of actual pediatric organ donor management practice among US organ procurement organizations are sparse, and the use of standardized management guidelines is unknown. A recent consensus statement from the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations offers guidelines for the management of the pediatric organ donor. RESEARCH QUESTION: To describe the use of guidelines and routine practices in the management of the pediatric organ donor with respect to hemodynamics, lung and ventilator management, fluid and electrolytes, hormonal replacement therapy, the use of blood products, thermoregulation, and prophylactic antibiotics. DESIGN: Cross-sectional observational study using a survey and follow-up telephone interview with respondents from all 58 US organ procurement organizations. RESULTS: All 58 US Organ Procurement Organizations participated. A majority employed written guidelines for the management of pediatric donor hemodynamics, thermoregulation, fluids, and electrolytes. Management of blood products, the lung, and mechanical ventilation were less commonly committed to written guidelines, but common practices were described. All used various forms of hormonal replacement therapy and the majority administered empiric antibiotic therapy. Wide variation was observed in the management of the lung, mechanical ventilation, and glycemic control. DISCUSSION: Most OPOs used forms of standardized donor management for the pediatric organ donor although variation in the content of that management exists. Barriers to an evidence-based approach to the pediatric donor need to be determined and addressed.