Pediatric cardiology fellows receive limited training on delivering serious news. This is a teachable skill through simulation-based communication. While studies have shown the use of communication ...courses in pediatrics, there have been none in pediatric cardiology. Pediatric cardiologists recognize the importance of good communication and desire further development of these skills. Based on an internal needs assessment, three cases were developed; fetal hypoplastic left heart syndrome, teenager with new hypertrophic cardiomyopathy, and young-adult with Fontan failure. A 4-h simulation course using evidence-based methods to teach delivering serious news was designed, consisting of a didactic session, case demonstration and small group case-based encounters with simulated patients. Trainees completed standardized pre/post-course surveys to assess perception of skill and preparedness. Paired survey responses were compared. Six pediatric cardiology fellows participated. Only 33% had received formal training in delivering serious news and 17% in techniques of responding to patient's emotions. The proportion of participants who felt good about their ability to deliver serious news and deal with a family's emotions increased from 0 to 83%. The proportion of participants who felt prepared to provide serious news about a patient's illness increased from 17 to 67%. Given the small number of participants, results were not statistically significant. All participants felt that the course was valuable in improving communication skills. A formal communication course increased perception of skill and preparedness among trainees. We provide an evidence-based framework and clinical cases for delivering serious news in pediatric cardiology, which is generalizable to other training programs.
The purpose of this study was to examine whether subgroups of disability-sport athletes exist on morality- and norm-based doping cognitions and whether these groups differ in anticipated guilt or ...doping intentions. A survey was completed by 186 athletes (Mage = 37.5 years, 78.0% male, 45.1% wheelchair basketball) assessing norms, doping moral disengagement, anticipated guilt, and intentions to dope. Cluster analysis revealed four distinct subgroups of athletes, including one potentially high-risk subgroup characterized by relatively high scores on doping moral disengagement, subjective norms, and descriptive norms. One-way analysis of variance revealed significantly lower anticipated guilt in two athlete subgroups characterized by relatively higher doping moral disengagement than the other two subgroups. Moreover, the potentially high-risk group had a greater proportion of athletes showing some presence of intention to dope. This study suggests there is a small subgroup of disability-sport athletes at elevated risk of doping who might benefit from targeted antidoping interventions.
Shields down! Adjuvant molecules that have the ability to restore the susceptibility of multi‐drug‐resistant bacteria, such as MRSA, to clinically available antibiotics are a promising alternative to ...the development of novel antimicrobials. Pictured is a potent small molecule (1) that, at sub‐minimum inhibitory concentration (sub‐MIC) levels, lowers the MIC of oxacillin (2) against a number of MRSA strains by up to 512‐fold.
OBJECTIVEVirtual (VR), augmented (AR), mixed reality (MR) and haptic interfaces make additional avenues available for surgeon assessment, guidance and training. We evaluated applications for open ...trauma and emergency surgery to address the question: Have new computer-supported interface developments occurred that could improve trauma training for civilian and military surgeons performing open, emergency, non-laparoscopic surgery? DESIGNSystematic literature review. SETTING AND PARTICIPANTSFaculty, University of Maryland School of Medicine, Baltimore., Maryland; Womack Army Medical Center, Fort Bragg, North Carolina; Temple University, Philadelphia, Pennsylvania; Uniformed Services University of Health Sciences, and Walter Reed National Military Medical Center, Bethesda, Maryland. METHODSStructured literature searches identified studies using terms for virtual, augmented, mixed reality and haptics, as well as specific procedures in trauma training courses. Reporting bias was assessed. Study quality was evaluated by the Kirkpatrick's Level of evidence and the Machine Learning to Asses Surgical Expertise (MLASE) score. RESULTSOf 422 papers identified, 14 met inclusion criteria, included 282 enrolled subjects, 20% were surgeons, the remainder students, medics and non-surgeon physicians. Study design was poor and sample sizes were low. No data analyses were beyond descriptive and the highest outcome types were procedural success, subjective self-reports, except three studies used validated metrics. Among the 14 studies, Kirkpatrick's level of evidence was level zero in five studies, level 1 in 8 and level 2 in one. Only one study had MLASE Score greater than 9/20. There was a high risk of bias in 6 studies, uncertain bias in 5 studies and low risk of bias in 3 studies. CONCLUSIONSThere was inadequate evidence that VR,MR,AR or haptic interfaces can facilitate training for open trauma surgery or replace cadavers. Because of limited testing in surgeons, deficient study and technology design, risk of reporting bias, no current well-designed studies of computer-supported technologies have shown benefit for open trauma, emergency surgery nor has their use shown improved patient outcomes. Larger more rigorously designed studies and evaluations by experienced surgeons are required for a greater variety of procedures and skills. COMPETENCIESMedical Knowledge, Practice Based Learning and Improvement, Patient Care, Systems-Based Practice.
Chest pain is a common complaint among paediatric patients and cardiac troponin (cTn) level is often part of the initial emergency department evaluation. It is well known that after intense endurance ...exercise cTn levels can be elevated in patients with otherwise healthy hearts, however the effect shorter duration exercise has on cTn levels in this population is not known.
Determine the behaviour of cTn levels in healthy children and adolescent patients after short burst, high-intensity aerobic exercise.
Patients without haemodynamically significant heart disease referred for a treadmill exercise stress test (EST) were recruited over a 6-month period. cTn levels were measured prior to exercise and 4 hours after exercise.
Thirteen patients enrolled. Indications for EST were exertional syncope (six), chest pain (four), and long QT syndrome (three). The median exercise time was 12.9 (9.9-13.7) minutes with an average endurance at the fiftieth percentile for age and maximum heart rate rose to an average of 92 (74-98)% of the predicted peak for age. cTn levels prior to exercise were undetectable in all patients. There was no cTn rise in any patient after exercise. There were no ischaemic changes or arrhythmias on exercise electrocardiograms.
Serum cTn levels do not rise significantly in healthy children after short duration, high-intensity aerobic exercise. Physicians evaluating paediatric patients with an elevated cTn level after less than prolonged strenuous activity likely cannot attribute this lab value solely to exercise and may need to undertake further cardiac investigation.
Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 is commonly associated with cardiac involvement. Studies found myocardial dysfunction, as measured by decreased ejection fraction ...and abnormal strain, to be common early in illness. However, there is limited data on longitudinal cardiac outcomes. We aim to describe the evolution of cardiac findings in pediatric MIS-C from acute illness through at least 2-month follow-up. A retrospective single-center review of 36 patients admitted with MIS-C from April 2020 through September 2021 was performed. Echocardiographic data including cardiac function and global longitudinal strain (GLS) were analyzed at initial presentation, discharge, 2–4-week follow-up, and at least 2-month follow-up. Patients with mild and severe disease, normal and abnormal left ventricular ejection fraction (LVEF), and normal and abnormal GLS at presentation were compared. On presentation, 42% of patients with MIS-C had decreased LVEF < 55%. In patients in whom GLS was obtained (
N
= 18), 44% were abnormal (GLS < |− 18|%). Of patients with normal LVEF, 22% had abnormal GLS. There were no significant differences in troponin or brain natriuretic peptide between those with normal and abnormal LVEF. In most MIS-C patients with initial LVEF < 55% (90%), LVEF normalized upon discharge. At 2-month follow-up, all patients had normal LVEF with 21% having persistently abnormal GLS. Myocardial systolic dysfunction and abnormal deformation were common findings in MIS-C at presentation. While EF often normalized by 2 months, persistently abnormal GLS was more common, suggesting ongoing subclinical dysfunction. Our study offers an optimistic outlook for recovery in patients with MIS-C and carditis, however ongoing investigation for longitudinal effects is warranted.
This research used four-parameter multi-cycle logistic growth curve models on US Energy Information Agency annual data from 1949 to 2015 to produce fixed condition forecasts of US energy production ...and consumption to 2040. These models and forecasts were used to assess the ability of US energy production sources to meet demand, to anticipate production and technology challenges, and to make general policy recommendations. The logistic fixed condition forecasts indicated the ongoing increases in total US energy production dominated by crude oil and natural gas production will likely peak in 2017 (at 95.0 quadrillion “quad” BTU) then rapidly decrease through 2040 (at 36.2 quad BTU), while total US energy consumption indicated an ongoing plateau (at 98.1 quad BTU). New growth cycles not evident in the 2015 data will certainly occur, mitigating the decline in energy production before 2040. However, without adequate foresight and preemptive action, it is possible that new production growth would not be adequate to reverse the decline given historical growth trends. Therefore, in addition to continued increases in energy efficiency, reductions in use, and implementation of carbon management technologies, direct effort towards the sustainable development of substantial new growth cycles in all energy production sources (through adequate investment of resources) should be a priority of the US energy industry, policy makers, and the public alike.
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•S-shaped growth curves (with plateaus) fit renewable and nuclear energy production.•Bell-shaped growth curves (with peaks/declines) fit fossil fuel energy production.•The total US energy production model indicated a 95 quadrillion BTU peak in 2017.•The total US energy consumption model indicated an ongoing 98 quad BTU plateau.•To meet projected demand, new growth cycles are needed for US energy production.
National forests in the United States are undergoing a spatially and temporally uneven governance transition in response to Congressional policies, agency mandates, and social and economic pressures, ...with many moving from a wholly state-led 'dominant federal' model to a more collaborative networked governance model which we refer to as 'social forestry'. While the broad contours of this transition have been observed and studied previously, there have been few attempts to characterize it using quantitative, qualitative, or geospatial methods. Here, we combine a novel remote sensing-based method with qualitative social science research to understand the emergence of social forestry and its implications for land use/land cover change associated with implementation of the Northwest Forest Plan (NWFP) in the Western Cascades of Oregon. We linked time-series satellite data with forest inventory data to track patterns of timber harvest at scales commensurate with timber management decision-making. We then compared these patterns to policy-based expectations. We found a significant disconnect between NWFP policy and actual timber harvest patterns, raising questions about the effectiveness of the NWFP land use allocation system and the 'land sparing' approach to managing tensions between conservation and production. Qualitative research, including semi-structured interviews with federal agency personnel and local stakeholders, shed light on the causal mechanisms and reciprocal relationships driving spatial patterns of timber harvesting, which we discuss in terms of the emergence of social forestry involving complex, place-based negotiations between the federal government and local veto actors advocating for conservation. Findings have implications for US Forest Service public engagement strategies and efforts to establish zones of agreement regarding timber harvesting, as well as broader discussions about the agency's future.
Evidence supports the role of coach doping confrontation efficacy (DCE; Sullivan et al., 2015) as a deterrent against athletes’ doping cognitions (Boardley et al., 2019; Sullivan & Razavi, 2017), but ...the role of the athlete has largely been ignored. Current anti-doping campaigns encourage athletes to report doping misconduct (i.e., whistleblowing), but some athletes would prefer to confront the athlete directly (Erickson et al., 2017). Thus, it is important to consider what may contribute to athletes’ likelihood to confront a doping teammate or opponent. The purpose of this study was to determine whether DCE could predict an athlete’s likelihood to confront a doping teammate or opponent. Additionally, doping moral disengagement (MD) was included as a possible moderator of this relationship. Surveys were completed by 155 college athletes (nmale = 145) to measure their perceived DCE, doping MD, likelihood to confront a teammate, and likelihood to confront an opponent. Separate linear regression analyses were run for the two targets of confrontation. In the teammate model, both DCE and doping MD were significant predictors of confrontation likelihood. DCE was the only significant predictor in the opponent model. Neither model presented with a significant interaction, suggesting no moderation effect. Results suggest perceived DCE is associated with a greater likelihood to confront a doping athlete, regardless of whether they are a teammate or opponent; however, moral disengagement plays a greater role if the athlete is a teammate. These findings imply that confrontation may be the first line of defense against doping before whistleblowing action is taken. Research should continue to explore antecedents and consequences of athlete doping confrontation, providing greater insight into the whistleblowing process.
•Athletes equally likely to confront a teammate as an opponent for doping.•Confidence in ability to confront predicts likelihood to confront teammate/opponent.•Moral disengagement may decrease likelihood of an athlete to confront a teammate only.•Confrontation may be a possible first step in the whistleblowing process.
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