Reliability of the Behaviorally Anchored Rating Scale (BARS) for assessing non-technical skills of medical students in simulated scenarios.

PURPOSE: Caring for critically ill patients requires non-technical skills such as teamwork, communication, and task management. The Behaviorally Anchored Rating Scale (BARS) is a brief tool used to assess non-technical skills. The investigators determined inter- and intra-rater reliability of the BARS when used to assess medical students in simulated scenarios. METHOD: The investigators created simulation scenarios for medical students during their pediatric clerkship. Content experts reviewed video recordings of the simulations and assigned BARS scores for four performance components (Situational Awareness, Decision-Making, Communication, and Teamwork) for the leader and for the team as a whole. Krippendorff's alpha with ordinal difference was calculated to measure inter- and intra-rater reliability. RESULTS: Thirty medical students had recordings available for review. Inter- and intra-rater reliability for performance components were, respectively, Individual Situational Awareness (0.488, 0.638), Individual Decision-Making (0.529, 0.691), Individual Communication (0.347, 0.473), Individual Teamwork (0.414, 0.466), Team Situational Awareness (0.450, 0.593), Team Decision Making (0.423, 0.703), Team Communication (0.256, 0.517), and Team Teamwork (0.415, 0.490). CONCLUSIONS: The BARS demonstrated limited reliability when assessing medical students during their pediatric clerkship. Given the unique needs of this population, a modified or new objective scoring system for assessing non-technical skills may be needed for medical students.

Metabolic Regulation of Thymic Epithelial Cell Function.

The thymus is the primary site of T lymphocyte development, where mutually inductive signaling between lymphoid progenitors and thymic stromal cells directs the progenitors along a well-characterized program of differentiation. Although thymic stromal cells, including thymic epithelial cells (TECs) are critical for the development of T cell-mediated immunity, many aspects of their basic biology have been difficult to resolve because they represent a small fraction of thymus cellularity, and because their isolation requires enzymatic digestion that induces broad physiological changes. These obstacles are especially relevant to the study of metabolic regulation of cell function, since isolation procedures necessarily disrupt metabolic homeostasis. In contrast to the well-characterized relationships between metabolism and intracellular signaling in T cell function during an immune response, metabolic regulation of thymic stromal cell function represents an emerging area of study. Here, we review recent advances in three distinct, but interconnected areas: regulation of mTOR signaling, reactive oxygen species (ROS), and autophagy, with respect to their roles in the establishment and maintenance of the thymic stromal microenvironment.

Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin-producing Escherichia coli-infected Children.

BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. METHODS: We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible. RESULTS: Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69-.85] per year), leukocyte count ≥13.0 × 103/µL (2.54 [1.42-4.54]), higher hematocrit (1.83 [1.21-2.77] per 5% increase) and serum creatinine (10.82 [1.49-78.69] per 1 mg/dL increase), platelet count <250 × 103/µL (1.92 [1.02-3.60]), lower serum sodium (1.12 [1.02-1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14-5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54-.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14-4.50]), younger age (0.83 [.74-.92] per year), lower serum sodium (1.15 [1.04-1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/µL (2.35 [1.17-4.72]) and creatinine (7.75 [1.20-50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18-6.21]). CONCLUSIONS: The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.

Evaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service.

BACKGROUND: Propofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra-short acting barbiturate is utilized instead of propofol. OBJECTIVE: Describe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. METHODS: Retrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. RESULTS: Methohexital was used in 240 patient encounters. Median age was 4years (IQR 2-7), 71.8% were male, and 80.4% were ASA-PS I or II. Indications for MHX use: egg+soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1mg/kg (IQR, 1.9-2.8), median maintenance infusion was 4.5mg/kg/h (IQR, 3.0-6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5min (IQR 28-57). CONCLUSION: Methohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.

Lessons Learned from an Industry, Government and University Collaboration to Restore Stream Habitats and Mitigate Effects.

Restoration ecologists conduct both basic and applied research using a diversity of funding and collaborative models. Over the last 17 years we have assessed the effectiveness of a stream compensation project in Canada's north, where an independent university-based research program was a condition of the regulatory approval process. This resulted in a non-traditional university-government-industry partnership. Here we share seven lessons that we learned from our collective experiences with the research partnership and use the Ekati diamond mine as a case study to illustrate and support lessons learned. Our advice includes opinions on the importance of: engaging collaborators early, defining roles and responsibilities, data sharing and standardization, the use of natural streams to set restoration targets, expect setbacks and surprises, treating restoration as an opportunity to experiment, and how to define success. Many of the lessons learned are broadly applicable to those whom embark on research collaborations among industry, universities, and consulting companies within a regulatory framework and may be of particular value to collaborators in early stages of their career.

Assessing the effectiveness of a constructed Arctic stream using multiple biological attributes.

Objective assessment of habitat compensation is a central yet challenging issue for restoration ecologists. In 1997, a 3.4-km stream channel, designed to divert water around an open pit diamond mine, was excavated in the Barrenlands region of the Canadian Arctic to create productive stream habitat. We evaluated the initial success of this compensation program by comparing multiple biological attributes of the constructed stream during its first three years to those of natural reference streams in the area. The riparian zone of the constructed stream was largely devoid of vegetation throughout the period, in contrast to the densely vegetated zones of reference streams. The constructed stream also contained lower amounts of woody debris, coarse particulate organic matter (CPOM), and epilithon; had lower coverage by macrophytes and bryophytes; and processed leaf litter at a lower rate than reference streams. Species richness and densities of macroinvertebrates were consistently lower in the constructed stream compared to natural streams. This contributed to differences in macroinvertebrate assemblage structure throughout the period, although assemblages showed some convergence by year 3. The effectiveness of the constructed stream to emulate natural streams varied somewhat depending on the biological attribute being evaluated. Assessments based on individual attributes showed that minimal to moderate levels of similarity between the constructed stream and natural streams were achieved. A collective assessment of all biological and ecosystem attributes suggested that the constructed stream was not a good surrogate for natural streams during these first years. Additional time would be required before many characteristics of the constructed stream would resemble those of reference streams. Because initial efforts to improve fish habitat in the constructed stream focused on physical structures (e.g., weirs, vanes, rock, groins), ecological factors limiting fish growth were not considered and likely constrained success. We suggest that a greater focus on organic characteristics and vegetation within the stream and its riparian zone could have accelerated compensation. The addition of woody debris and CPOM, combined with planting of shrubs and herbs along the stream, should provide a source of allochthonous matter for the biotic community while large cobble and boulders should improve the physical stability of stream system, protecting its organic components.