Carey, William A.

ABSTRACT Background Virtual interviews may limit an applicant’s ability to ascertain the culture of a training program. No-stakes campus visits (NSCVs) have been offered but their value is unknown. Objective The purpose of our study was to determine factors that influence applicants’ rank lists and determine barriers to and perceptions of NSCVs and their impact on applicants’ final rank lists. Methods All interviewed applicants of graduate medical education (GME) programs who agreed to participate in the study were emailed a survey after the 2023 National Resident Matching Program Match. The survey contained sections on demographics, perspectives on factors affecting ranking decisions, and perceptions of NSCVs. Results Of 796 applicants, 183 (22.9%) who interviewed at 16 different Mayo Clinic GME programs responded to the survey. Of 131 respondents who answered whether they accepted an NSCV offer, 39 (29.8%) accepted. Of 35 respondents who answered whether they thought attending NSCVs impacted their rank, 19 (54.3%) were either uncertain or said yes. Of 34 respondents who answered whether the NSCV influenced their ranking of the program, 16 (47.1%) said their rank did not change, 12 (35.3%) said they ranked the program higher, and 5 (14.7%) said they ranked the program lower. For respondents who did not attend NSCVs, financial burden and lack of time were primary reasons. Conclusions NSCVs are perceived positively by most respondents. Many either believed they influenced their position on the program’s rank list or were unsure. Most respondents said NSCVs either improved or did not change their ranking of the program.

Abstract Background Pediatric residents frequently manage critically ill neonates but have limited systematic training in mechanical ventilation (MV). Competing demands, varying learner levels, and topic complexity contribute to inconsistent education. A blended learning approach may be ideally suited to achieve meaningful learning but has not been described for this topic and learner. Objective To design, implement, and evaluate a flipped classroom for pediatric residents in neonatal MV. Methods We used Kern’s six-step framework for curricular development to create a flipped classroom curriculum in neonatal MV. Individual prework included interaction with six prerecorded animated whiteboard videos, while in-person learning occurred in small groups at the bedside of a ventilated infant. A mixed-methods evaluation included surveys, quantitative knowledge test scores (before, immediately after, and six months after course completion), and qualitative analysis of participant focus groups. Results Twenty-six learners participated in the curriculum. Mean knowledge test scores rose and were sustained after course completion (51% baseline, 82% immediate posttest, 90% retention; P < 0.001). Learners identified various design elements, technology affordances, and instructor factors as meaningful, and they identified unexpected impacts of the curriculum beyond knowledge acquisition, including effects on professional identities, interdisciplinary communication skills, and contribution to the culture of safety. Conclusion This curriculum aligned with resident roles, was meaningful to learners, and led to long-term increases in knowledge scores and access to quality education; flipped classroom design using meaningful learning theory and leveraging animated whiteboard technology may be a useful strategy for other highly complex topics in graduate medical education.

Abstract Background Respiratory distress is a leading cause of preterm infant mortality in sub-Saharan Africa. Bubble continuous positive airway pressure (CPAP) is emerging as a potentially safe, cost-effective way of delivering noninvasive respiratory support in low-income and middle-income countries. However, without healthcare providers who are knowledgeable and skilled in the use of this technology, suboptimal neonatal care and related health disparities are likely to persist. Objective We hypothesized that an Internet-based, blended curriculum on bubble CPAP for bedside providers in low-resource mother-baby units (MBUs) could be developed and implemented and lead to improvements in clinical knowledge, reasoning, and learner confidence in bubble CPAP. Methods Clinical educators from Israel, Ghana, and the United States used the analysis, design, development, implementation, and evaluation (ADDIE) design framework to create an online curriculum for two MBUs in Kumasi, in the Ashanti Region of Ghana. Participants completed pre and post curriculum knowledge tests and completed surveys on their perspectives. Results Fifty-four interdisciplinary health professionals from the MBUs participated in the curriculum. Median knowledge test scores improved from 64% (interquartile range [IQR] = 50–72%) to 81% (IQR = 71–89%) after participation in the curriculum (P < 0.001). Learners reported high levels of confidence with bubble CPAP after participating in the curriculum and evaluated the curricular components highly. Conclusion An online curriculum was successfully implemented and led to changes in healthcare worker knowledge in bubble CPAP. This may be an effective way to deliver education to healthcare professionals in resource-constrained countries and warrants further study.

Objective We characterize the most recent natural history of necrotizing enterocolitis (NEC), as this is an essential first step in guiding the prevention and treatment of this disease in the present day. Study Design We performed a retrospective cohort study of neonates who were born at 23 to 29 weeks' gestation and birth weight <1,500 g who received care from the Pediatrix Medical Group between 2004 and 2019. We assessed the incidence of medical and surgical NEC and the patterns of initial antibiotic treatment to develop a contemporary cohort for further analysis. Among patients discharged between 2015 and 2019, we characterized the stage-specific risk factors for patients diagnosed with medical or surgical NEC, as well as patterns of disease onset, progression, biomarkers, and outcomes. We used the same approach to characterize patients diagnosed with suspected NEC. Results Among 34,032 patients in the contemporary cohort, 1,150 (3.4%) were diagnosed with medical NEC and 543 (1.6%) were diagnosed with surgical NEC. The temporal pattern of disease onset was different for medical and surgical NEC, with gestational age– and birth weight–specific risk disparities emerging earlier in surgical NEC. Thirty-day mortality was much greater among surgical NEC patients (medical NEC 16.4% vs. surgical NEC 43.0%), as were rates of various in-hospital and long-term outcomes. Suspected NEC was diagnosed in 1,256 (3.7%) patients, among whom risk factors and disease onset, progression, and outcomes closely resembled those of medical NEC. Conclusion Analyzing data from a contemporary cohort enabled us to characterize the current, stage-specific natural history of NEC, including novel insights into suspected NEC. Future studies could leverage this cohort to characterize how specific patient characteristics, care processes, or biomarkers may influence or predict disease outcomes. Key Points

BACKGROUND: Severe intraventricular hemorrhage (IVH) is a leading mortality risk factor among extremely premature neonates. Because other life-threatening conditions also occur in this population, it is unclear whether severe IVH is independently associated with death. The existence and potential implications of regional variation in severe IVH–associated mortality are unknown. METHODS: We performed a retrospective cohort study of mechanically ventilated neonates born at 22 to 29 weeks’ gestation who received care in 242 American NICUs between 2000 and 2014. After building groups composed of propensity score–matched and center-matched pairs, we used the Cox proportional hazards analysis to test our hypothesis that severe IVH would be associated with greater all-cause in-hospital mortality, defined as death before transfer or discharge. We also performed propensity score–matched subgroup analyses, comparing severe IVH–associated mortality among 4 geographic regions of the United States. RESULTS: In our analysis cohort, we identified 4679 patients with severe IVH. Among 2848 matched pairs, those with severe IVH were more likely to die compared with those without severe IVH (hazard ratio 2.79; 95% confidence interval 2.49–3.11). Among 1527 matched pairs still hospitalized at 30 days, severe IVH was associated with greater risk of death (hazard ratio 2.03; 95% confidence interval 1.47–2.80). Mortality associated with severe IVH varied substantially between geographic regions. CONCLUSIONS: The early diagnosis of severe IVH is independently associated with all-cause in-hospital mortality in extremely premature neonates. Regional variation in severe IVH–associated mortality suggests that shared decision-making between parents and neonatologists is strongly influenced by ultrasound-based IVH assessment and classification.

AbstractBackgroundPlasma ammonia is commonly measured in the diagnostic evaluation of hospitalized newborns, but reference values are not well defined.MethodsWe prospectively enrolled newborns admitted to the level III/IV neonatal intensive care unit and level II intermediate special care nursery from January 2017 to January 2018. Infants with inborn errors of metabolism or liver disease were excluded. Plasma ammonia concentrations were measured once within the first week of life and evaluated by sex, gestational age, timing of the draw, blood collection method, and type of nutrition. Reference intervals were calculated.Results127 neonates were included; one third (34%) were term infants born at ≥37 weeks gestation, and two thirds (66%) were born preterm at &lt;37 weeks gestation. Median plasma ammonia concentrations were 32 μmol/L (range &lt;10 to 86 μmol/L). Median ammonia concentrations were higher among preterm compared to term infants (35 vs. 28 μmol/L, p = 0.0119), and term female compared to term male infants (34 vs. 26 μmol/L, p = 0.0228). There was no difference in median ammonia concentrations between female and male preterm infants, based on gestational age within the preterm group, timing of the blood draw, presence of hyperbilirubinemia, blood collection method, or type of nutritional intake.ConclusionsPlasma ammonia concentrations among newborns are higher than the expected adult concentrations and may vary by gestational age and sex. Blood collection method, type of nutrition, hyperbilirubinemia, and timing of the draw do not impact concentrations. We propose a reference limit of ≤82 μmol/L for newborns less than one week of age.