Faculty Bibliography

OBJECTIVE:Objective structured clinical exams (OSCE) are used to train and assess resident foundational family-centered communication skills incorporating key stakeholders. In 2020 encounters were conducted virtually. We sought to compare standardized patient (SP) and family faculty (FF) assessment across OSCE and virtual OSCE (VOSCE) formats. METHODS:The intern classes of 2019 and 2020 completed a live OSCE and VOSCE respectively where they disclosed an error to an SP. The 10 minute encounter was observed by an FF and facilitator followed by a 20 minute debrief. The SP and FF completed a behavioral checklist to evaluate skill mastery. RESULTS:Eighteen (90%) of the 20 interns completed the encounter each year. Total mastery scores were significantly higher for SP assessment than for FF assessment in both OSCE [68% vs 46% (z=-3.005, p<.05)] and VOSCE formats [68% vs 53% (z=-2.105, p<0.05)]. Total mastery scores of SPs across OSCE and VOSCE formats did not significantly differ, nor did FF scores based on evaluation format. CONCLUSIONS:Our current experience suggests VOSCEs are a viable alternative to in person sessions given the comparable assessment across the two modalities. The ease of participating in virtual sessions may provide a way to more easily partner with key stakeholders.

Near-infrared spectroscopy (NIRS) is a technology that is easy to use and can provide helpful information about organ oxygenation and perfusion by measuring regional tissue oxygen saturation (rSO2) with near-infrared light. The sensors can be placed in different anatomical locations to monitor rSO2 levels in several organs. While NIRS is not without limitations, this equipment is now becoming increasingly integrated into modern healthcare practice with the goal of achieving better outcomes for patients. It can be particularly applicable in the monitoring of pediatric patients because of their size, and especially so in infant patients. Infants are ideal for NIRS monitoring as nearly all of their vital organs lie near the skin surface which near-infrared light penetrates through. In addition, infants are a difficult population to evaluate with traditional invasive monitoring techniques that normally rely on the use of larger catheters and maintaining vascular access. Pediatric clinicians can observe rSO2 values in order to gain insight about tissue perfusion, oxygenation, and the metabolic status of their patients. In this way, NIRS can be used in a non-invasive manner to either continuously or periodically check rSO2. Because of these attributes and capabilities, NIRS can be used in various pediatric inpatient settings and on a variety of patients who require monitoring. The primary objective of this review is to provide pediatric clinicians with a general understanding of how NIRS works, to discuss how it currently is being studied and employed, and how NIRS could be increasingly used in the near future, all with a focus on infant management.

OBJECTIVE:The use of oral dextrose gel (DG) reduces IV dextrose use. Prior studies used weight-based dosing (WD), though barriers exist, and are mitigated using standard dosing (SD). Our outcomes include IV dextrose use, NICU admissions, breastfeeding, adverse events, and assessment of WD vs SD. STUDY DESIGN/METHODS:Retrospective chart review comparing pre-DG, WD, and SD in 16490 newborns (1329 hypoglycemic) ≥ 35 weeks admitted to the nursery over 3 years. RESULTS:There was reduction in IV dextrose use 10.9% vs 6.5% (p = 0.004) and NICU admissions 27.9% vs 16.1% (p < 0.001) associated with DG use, and increased rate of breastfed infants 33.8% vs 43.5% (p = 0.001), with no difference between WD and SD. No difference noted in adverse events across the study period. CONCLUSIONS:DG utilization is associated with reduced IV dextrose use, NICU admissions, and improved breastfeeding rates without changes in adverse events. We offer SD as a safe alternative to WD.

OBJECTIVE:Curricula designed to teach and assess the communication skills of pediatric residents variably integrates the parent perspective. We compared pediatric residents' communication skills in an objective structured clinical exam (OSCE) case as assessed by Family Faculty (FF), parents of pediatric patients, versus standardized patients (SP). METHODS:Residents participated in an OSCE case with a SP acting as a patient's parent. We compared resident performance as assessed by FF and SP with a behaviorally-anchored checklist. Items were rated as not done, partly done or well done, with well-done indicating mastery. The residents evaluated the experience. RESULTS:42 residents consented to study participation. FF assessed a lower percentage of residents as demonstrating skill mastery as compared to SP in 19 of the 23 behaviors. There was a significant difference between FF and SP for Total Mastery Score and Mastery of the Competency Scores in three domains (Respect and Value, Information Sharing and Participation in Care and Decision Making). The majority of residents evaluated the experience favorably. CONCLUSION/CONCLUSIONS:Involving parents of pediatric patients in the instructive and assessment components of a communication curriculum for pediatric residents adds a unique perspective and integrates the true stakeholders in parent-physician communication.

OBJECTIVE:To compare the efficacy of video-assisted self-directed neonatal resuscitation skills course with video-assisted facilitator-led course. METHODS:This multicenter, randomized, blinded, non-inferiority-controlled trial compared two methods of teaching basic neonatal resuscitation skills using mask ventilation. Groups of novice providers watched an instructional video. One group received instructor facilitation (Ins-Video). The other group did not (Self-Video). An Objective Structured Clinical Exam (OSCE) measured skills performance, and a written test gauged knowledge. RESULTS:One hundred and thirty-four students completed the study. Sixty-three of 68 in the Self-Video Group (92.6%) and 59 of 66 in the Ins-Video Group (89.4%) achieved post-training competency in positive pressure ventilation (primary outcome). OSCE passing rates were low in both groups. Knowledge survey scores were comparable between groups and non-inferior. CONCLUSIONS:Video self-instruction taught novice providers positive pressure ventilation skills and theoretical knowledge, but it was insufficient for mastery of basic neonatal resuscitation in simulation environment.

Background: Clear family-centered communication is a foundation of practicing effective pediatric medicine. Formal communications training during residency is often limited and experience is mostly observational. Publications have shown that communication skills of trainees improve after a standardized curriculum, but family representatives were not included. In July 2019 we launched a communications curriculum for pediatric residents anchored in tenants of family-centered care that incorporates Family Faculty (FF), trained parents of patients cared for at our children's hospital.
Objective(s): To investigate how FF assessment of learners in an objective structured clinical exam (OSCE) differs from the gold standard of Standardized Patient (SP) assessment.
Method(s): We designed an OSCE in which the resident disclosed a medical error to a SP (playing a patients parent). The SP was trained in character portrayal and checklist completion. The 10-minute encounter was observed by an experienced clinician (EC) and FF through one-way glass, followed by a 20 minute debrief with the learner, SP, EC and FF. The SP, EC and FF all completed a 23-item behavioral anchored checklist that reflected 5 core competencies of family centered communication. Items were rated as not done, partly done or well-done, with well-done indicating mastery.
Result(s): 52 residents participated in the OSCE and 42 consented to study participation. The overall average % of learners considered to achieve mastery in each competency was lower as assessed by the FF vs SP: respect and value (50%vs.70%), information sharing (48%vs.67%), participation in care and decision making (40%vs.70%), follow-up (47%vs.60%), and team work (33%vs.52%).
Conclusion(s): Across all 5 competencies a lower % of learners reached skill mastery when assessed by FF as compared to SP. Involving FF in the evaluative and instructive components of the curriculum offers a more holistic approach and integrates true stakeholders in parent-physician communication. This initial data suggests that the resources needed to include FF in communications training is likely worthwhile.
Copyright

Congenital heart defects are the most common birth anomaly affecting approximately 1% of births. With improved survival in this population, there is enhanced ability to assess long-term morbidities including neurodevelopment. There is a wide range of congenital heart defects, from those with minimal physiologic consequence that do not require medical or surgical intervention, to complex structural anomalies requiring highly specialized medical management and intricate surgical repair or palliation. The impact of congenital heart disease on neurodevelopment is multifactorial. Susceptibility for adverse neurodevelopment increases with advancing severity of the defect with initial risk factors originating during gestation. Complex structural heart anomalies may pre-dispose the fetus to abnormal circulatory patterns in utero that ultimately impact delivery of oxygen rich blood to the fetal brain. Thus, the brain of a neonate born with complex congenital heart disease may be particularly vulnerable from the outset. That vulnerability is compounded during the newborn period and through childhood, as this population endures a myriad of medical and surgical interventions. For each individual patient, these factors are likely cumulative and synergistic with progression from fetal life through childhood. This review discusses the spectrum of risk factors that may impact neurodevelopment in children with congenital heart disease, describes current recommendations and practices for neurodevelopmental follow-up of children with congenital heart disease and reviews important neurodevelopmental trends in this high risk population.

Vaginolysin (VLY), a cytotoxic protein produced by Gardnerella vaginalis, may contribute to bacterial vaginosis (BV). Women with G. vaginalis, low levels of lactobacilli, history of vaginal douching, higher Nugent scores, and higher vaginal pH had increased VLY. Inflammatory markers were not highly expressed with increasing VLY. VLY's role in BV warrants further evaluation.

Background: Streptococcus agalactiae (group B Streptococcus [GBS]) is an important neonatal pathogen and emerging cause of disease in adults. The major risk factor for neonatal disease is maternal vaginal colonization. However, little is known about the relationship between GBS and vaginal microbiota. Methods: Vaginal lavage samples from nonpregnant women were tested for GBS, and amplicon-based sequencing targeting the 16S ribosomal RNA V3-V4 region was performed. Results: Four hundred twenty-eight of 432 samples met the high-quality read threshold. There was no relationship between GBS carriage and demographic characteristics, alpha-diversity, or overall vaginal microbiota community state type (CST). Within the non-Lactobacillus-dominant CST IV, GBS positive status was significantly more prevalent in CST IV-A than CST IV-B. Significant clustering by GBS status was noted on principal coordinates analysis, and 18 individual taxa were found to be significantly associated with GBS carriage by linear discriminant analysis. After adjusting for race/ethnicity, 4 taxa were positively associated with GBS, and 6 were negatively associated. Conclusions: Vaginal microbiota CST and alpha-diversity are not related to GBS status. However, specific microbial taxa are associated with colonization of this important human pathogen, highlighting a potential role for the microbiota in promotion or inhibition of GBS colonization.

Gardnerella vaginalis, the bacterial species most frequently isolated from women with bacterial vaginosis (BV), produces a cholesterol-dependent cytolysin (CDC), vaginolysin (VLY). At sublytic concentrations, CDCs may initiate complex signaling cascades crucial to target cell survival. Using live-cell imaging, we observed the rapid formation of large membrane blebs in human vaginal and cervical epithelial cells (VK2 and HeLa cells) exposed to recombinant VLY toxin and to cell-free supernatants from growing liquid cultures of G. vaginalis. Binding of VLY to its human-specific receptor (hCD59) is required for bleb formation, as antibody inhibition of either toxin or hCD59 abrogates this response, and transfection of nonhuman cells (CHO-K1) with hCD59 renders them susceptible to toxin-induced membrane blebbing. Disruption of the pore formation process (by exposure to pore-deficient toxoids or pretreatment of cells with methyl-beta-cyclodextrin) or osmotic protection of target cells inhibits VLY-induced membrane blebbing. These results indicate that the formation of functional pores drives the observed ultrastructural rearrangements. Rapid bleb formation may represent a conserved response of epithelial cells to sublytic quantities of pore-forming toxins, and VLY-induced epithelial cell membrane blebbing in the vaginal mucosa may play a role in the pathogenesis of BV.