Pediatric Pulmonary Milestones 2.0: Development, Lessons Learned, and Future Directions.

Pediatric pulmonology fellowship training programs are required by the Accreditation Council for Graduate Medical Education to report Pediatric Subspecialty Milestones biannually to track fellow progress. However, several issues, such as lack of subspecialty-specific context and ambiguous language, have raised concerns about their validity and applicability to use for fellow assessment and curriculum development. In this Perspective, we briefly share the process of the Pediatric Pulmonology Milestones 2.0 Work Group in creating new specialty-specific Milestones and tailoring information on the Harmonized Milestones to pediatric pulmonologists, with the goal of improving the Milestones' utility for stakeholders, including pulmonology fellows, faculty, program directors, and accrediting bodies. In addition, we created a supplemental guide to better link the Milestones to pulmonary-specific scenarios to create a shared mental model between stakeholders and remove a potential detriment to validity. Through the process, a number of guiding principles were clarified, including: 1) every Milestone should be able to be assessed independently, without overlap with other Milestones; 2) there should be clear developmental progression from one Milestone to the next; 3) Milestones should be based on the unique skills expected of pediatric pulmonologists; and 4) health equity should be a core component to highlight as a top priority to all stakeholders. In this Perspective, we describe these principles that guided formulation of the Pediatric Pulmonary Milestones to help familiarize the pediatric pulmonary community with the new Milestones. In addition, we share lessons learned and challenges in our process to inform other specialties that may soon participate in this process.

A 13-Year-Old Male Patient With Severe Multifocal Pneumonia and Bronchiectasis That Required Extracorporeal Membrane Oxygenation.

CASE PRESENTATION: A 13-year-old male patient with intermittent asthma and joint hypermobility presented to the ED in acute hypoxemic respiratory distress. He reported experiencing cough, increased work of breathing, and worsening chest pain for 3 days before presentation. He also reported fatigue and decreased appetite for 2 weeks. He had no known fever, myalgias, or recent weight loss. His medical history included two hospitalizations during early childhood for viral respiratory illnesses, one of which required intubation at 8 months of age. He had a gastrostomy tube placed shortly after his hospitalization because of failure to thrive secondary to aspiration based on a swallow study. His weight gain and growth improved with adequate nutrition, and his gastrostomy tube was removed at 2 years of age. His newborn screen, which included immunoreactive trypsinogen, was normal. He was noted to have hypermobile joints on physical examination at a clinic visit in childhood, but his examination results were not concerning for a hypermobility syndrome, and further diagnosis was not pursued. His parents endorsed that he has been a "healthy child" overall other than the occasional cough, which was attributed to asthma. His lifestyle was described as sedentary; he did not play any sports or have any unusual hobbies. He did not take any daily medications and no environmental exposures were reported. There was no family history of pulmonary, autoimmune, or connective tissue disease.

Characteristics of Patients Requiring Surgical Removal of Subdermal Contraceptive Implants: A Case-Control Study.

Purpose: Etonogestrel subdermal implants are a commonly used contraceptive device placed in the medial upper arm. Plastic and orthopedic surgeons may be consulted for difficult implant removals. We performed a case-control study comparing patients undergoing surgical and uncomplicated in-office removal at our institution. Patients and Methods: We identified patients who underwent operative removal of implantable contraceptive devices by plastic or orthopedic surgeons at our institution from January 2014 to October 2019. Patients who underwent uncomplicated office removal during the same time were compared. Demographic and surgical variables were collected, and descriptive statistics were calculated. Univariate and multivariate logistic regression was performed with surgical versus outpatient removal as the outcome of interest. Results: A total of 669 patients undergoing etonogestrel subdermal implant removals were identified during the five-year study period, of which thirteen patients required surgical removal (1.9%) and 326 were selected as uncomplicated removal comparisons. There were no significant differences in median (IQR) body mass index (BMI) (31.1 [28.2, 35.2] versus 29.3 [24.0, 35.1], p = 0.19), median (IQR) weight gain since device placement (5 [-0.6, 14.7] kilograms versus 1.6 [-1.2, 5.8] kilograms, p = 0.15), or length of time since device insertion (2.3 [0.8, 2.8] years versus 1.0 [0.4, 2.2] years, p = 0.17). Of those who needed surgical removal, the most common indication for implant removal was device expiration (n = 5, 38.5%). Devices placed by OBGYN attendings were less likely to require surgical removal (p = 0.02). Family medicine attendings were more likely to refer patients for surgical removal (p = 0.02). No significant findings were detected on univariate or multivariate regression. Among surgical removals, radiography was the most frequently used imaging modality. Implants were most frequently subdermal (n = 11, 84.6%) though intramuscular placement was also identified (n = 2, 15.4%). Only one patient had residual paresthesia along the length of the incision. No other complications were identified. Conclusion: We did not identify risk factors associated with the difficult removal of etonogestrel subdermal implants. Practitioners should consult upper extremity surgeons if they encounter difficult removals.

Reproducible Research Practices in the Plastic Surgery Literature.

BACKGROUND: Reproducible research-defined as the ability to replicate a study with its published materials and procedures-is integral to ensuring the validity of published studies and promoting scientific advancement. The primary aim of this study was to quantitatively evaluate the reproducibility and transparency of research in the plastic surgery literature. METHODS: A cross-sectional study was performed. Articles published in 12 plastic surgery journals over a 5-year period were randomly selected. Reproducibility-related and transparency-related variables were blindly and independently collected by two reviewers using previously published methods. Descriptive statistics and univariate analysis were performed for outcomes of interest. RESULTS: The initial search yielded 18,461 publications, from which 400 were randomly selected. A total of 397 publications met inclusion criteria, of which 203 were empirical studies eligible for analysis of reproducibility-related and transparency-related variables. Among the empirical studies, most did not have a data availability statement (97.0 percent; 95 percent CI, 93.7 to 98.9). Only seven (3.4 percent; 95 percent CI, 1.4 to 7.0) were linked to an accessible protocol, four (2.0 percent; 95 percent CI, 0.5 to 5.0) were preregistered, and no studies provided analysis scripts or claimed to replicate another study. Of the 202 studies evaluated for material availability, only 17 (8.4 percent; 95 percent CI, 5.0 to 13.1) had a material availability statement. CONCLUSIONS: There is an evident lack of reproducible research practices in plastic surgery literature. The majority of plastic surgery publications do not provide information and raw materials necessary to reproduce empirical studies. Increasing awareness at the individual and institutional levels can improve research quality and transparency.

Influence of Enema and Dietary Restrictions on Prostate MR Image Quality: A Multireader Study.

PURPOSE: To evaluate the effect of enema and dietary restrictions on prostate MR image quality metrics and to assess inter-reader agreement for these metrics. METHODS: This retrospective study included 195 men divided into groups based on their compliance with preparation instructions before prostate MRI (Enema + Diet, n = 98; Enema, n = 42; Diet, n = 35; Control [no compliance], n = 20). Four readers independently assessed six image quality metrics on a 5-point scale. Between-group comparisons were made using Wilcoxon rank sum test. Inter-reader agreement was calculated using Fleiss' kappa. RESULTS: Compared with the Control group, image quality with respect to rectal stool/gas, distortion of diffusion-weighted images, overall image quality, and confidence in assessment was higher in the Enema + Diet, Enema, and Diet groups (p  < 0.05 for all comparisons). The Enema + Diet and Enema groups had significantly higher scores than the Diet group for rectal stool/gas (p < 0.001 and 0.005, respectively). The Enema + Diet and Diet groups had higher scores than the Control group for rectal peristalsis (p = 0.027 and 0.009, respectively), but there were no significant differences in motion artifacts on T2-weighted images. Agreement among readers was fair, with kappa values ranging from 0.25 to 0.37. CONCLUSION: Enema and dietary restriction can improve the quality of prostate MRI by decreasing rectal distension and distortion of diffusion-weighted images and by increasing reader confidence in image assessment. Inter-reader agreement using subjective criteria for analysis of MRI quality is fair.

Maternal Depressive Symptoms, Lung Function, and Severe Asthma Exacerbations in Puerto Rican Children.

BACKGROUND: Maternal depression has been linked to health care use for asthma in cross-sectional or short-term follow-up studies of school-aged children. OBJECTIVE: To examine whether increased or persistent maternal depressive symptoms over approximately 5 years are associated with severe asthma exacerbations or worse lung function in youth. METHODS: A prospective study of 386 youth living in Puerto Rico, aged 6 to 14 years at a baseline visit and 9 to 20 years at a second visit, was performed. Our exposure of interest was change in persistence of maternal depressive symptoms, assessed at both visits using the Center for Epidemiologic Studies Depression Scale (CESD). Our outcomes of interest were change in percent predicted forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity (FVC) between the first and second visits in all subjects, and ≥1 severe asthma exacerbation in the year before the second visit in subjects with asthma. RESULTS: In a multivariable analysis, each 1-point increment in the CESD score was associated with decrements of 0.15% in percent predicted FEV1 (95% confidence interval [CI] = -0.28% to -0.01%; P = .03) and 0.10% in percent predicted FEV1/FVC (95% CI = -0.20% to 0.001%; P = .05) between visits, as well as with 1.03 times increased odds of ≥1 severe asthma exacerbation at the second visit (95% CI for odds ratio = 0.99 to 1.06, P = .09). In a multivariable analysis, the presence of maternal depressive symptoms (a CESD score ≥21 points) at the second visit or at both visits was significantly associated with 3.17 to 3.52 times increased odds of ≥1 severe asthma exacerbation in the year before the second visit. CONCLUSIONS: Increasing or persistent maternal depressive symptoms over approximately 5 years are associated with worse lung function measures and severe asthma exacerbations among Puerto Rican youth, a high-risk population.

Clinical utility of PSAD combined with PI-RADS category for the detection of clinically significant prostate cancer.

PURPOSE: The goal of this study was to determine the predictive value of prostate-specific antigen density (PSAD) plus Prostate Imaging Reporting and Data System (PI-RADS) category for the detection of clinically significant prostate cancer. MATERIALS AND METHODS: This retrospective study included 526 men without known prostate cancer (initial diagnosis group) and 133 men with prostate cancer grade group 1 (active surveillance group) who underwent magnetic resonance imaging-guided and/or systematic prostate biopsy procedures between August 2014 and October 2018. Prostate specific antigen (PSA), PSAD, and PI-RADS category were entered into logistic regression models for predicting clinically significant prostate cancer (grade group ≥2) at biopsy. Receiver operating characteristic curve analysis was performed to assess model accuracy. RESULTS: The area under the curve (AUC) increased when PSAD was combined with PI-RADS in the initial diagnosis group (difference in AUC = 0.031; 95% confidence interval: 0.012, 0.050; P = 0.002) but not in the active surveillance group (difference in AUC = 0.016; 95% confidence interval: -0.040, 0.071; P = 0.579). When a PSAD threshold of 0.15 was applied, the frequency of clinically significant prostate cancer in patients with a PI-RADS score of 3 or lower decreased from 9.8% to 5.6% in the initial diagnosis group and from 10.7% to 2.7% in the active surveillance group. CONCLUSIONS: The addition of PSAD improves the predictive performance of PI-RADS in men without known prostate cancer. A PSAD threshold of 0.15 can help to minimize the number of missed clinically significant prostate cancer cases in men with a PI-RADS score of 3 or lower who decide to defer biopsy.

Early Experience with a Novel Strategy for Assessment of Sepsis Risk: The Shock Huddle.

INTRODUCTION: Severe sepsis/septic shock (SS), a leading cause of death in children, is a complex clinical syndrome that can be challenging to diagnose. To assist with the early and accurate diagnosis of this illness, we instituted an electronic scoring tool and developed a novel strategy for the assessment of currently hospitalized children at risk for SS. METHODS: The Shock Tool was created to alert providers to children at risk for SS. Above a threshold score of 45, patients were evaluated by a team from the pediatric intensive care unit (PICU), led by the Shock Nurse (RN), a specially trained PICU nurse, to assess their need for further therapies. Data related to this evaluation, termed a Shock Huddle, were collected and reviewed with the intensivist fellow on service. RESULTS: Over 1 year, 9,241 hospitalized patients were screened using the Shock Score. There were 206 Shock Huddles on 109 unique patients. Nearly 40% of Shock Huddles included a diagnostic or therapeutic intervention at the time of patient assessment, with the most frequent intervention being a fluid bolus. Shock Huddles resulted in a patient transfer to the PICU 10% of the time. CONCLUSION: Implementation of an electronic medical record-based sepsis recognition tool paired with a novel strategy for rapid assessment of at-risk patients by a Shock RN is feasible and offers an alternative strategy to a traditional medical emergency team for the delivery of sepsis-related care. Further study is needed to describe the impact of this process on patient outcomes.

Data on the densification during sintering of binder jet printed samples made from water- and gas-atomized alloy 625 powders.

Binder jet printing (BJP) is a metal additive manufacturing method that manufactures parts with complex geometry by depositing powder layer-by-layer, selectively joining particles in each layer with a polymeric binder and finally curing the binder. After the printing process, the parts still in the powder bed must be sintered to achieve full densification (A. Mostafaei, Y. Behnamian, Y.L. Krimer, E.L. Stevens, J.L. Luo, M. Chmielus, 2016; A. Mostafaei, E. Stevens, E. Hughes, S. Biery, C. Hilla, M. Chmielus, 2016; A. Mostafaei, Y. Behnamian, Y.L. Krimer, E.L. Stevens, J.L. Luo, M. Chmielus, 2016) [1-3]. The collected data presents the characterization of the as-received gas- and water-atomized alloy 625 powders, BJP processing parameters and density of the sintered samples. The effect of sintering temperatures on the microstructure and the relative density of binder jet printed parts made from differently atomized nickel-based superalloy 625 powders are briefly compared in this paper. Detailed data can be found in the original published papers by authors in (A. Mostafaei, J. Toman, E.L. Stevens, E.T. Hughes, Y.L. Krimer, M. Chmielus, 2017) [4].

Brief data overview of differently heat treated binder jet printed samples made from argon atomized alloy 625 powder.

Powder bed binder jet printing (BJP) is an additive manufacturing method in which powder is deposited layer-by-layer and selectively joined in each layer with binder. The data presented here relates to the characterization of the as-received feedstock powder, BJP processing parameters, sample preparation and sintering profile ("Effect of solutionizing and aging on the microstructure and mechanical properties of powder bed binder jet printed nickel-based superalloy 625" (A. Mostafaei, Y. Behnamian, Y.L. Krimer, E.L. Stevens, J.L. Luo, M. Chmielus, 2016) [1], "Powder bed binder jet printed alloy 625: densification, microstructure and mechanical properties" (A. Mostafaei, E. Stevens, E. Hughes, S. Biery, C. Hilla, M. Chmielus, 2016) [2]). The data presented here relates to the characterization of the as-received feedstock powder, BJP processing parameters, sample preparation and sintering profile. Effect of post heat treatments including solutionizing and aging on the microstructure and mechanical properties of powder bed binder jet printed nickel-based superalloy 625 were compared to that of sintered samples.

Designing metal hemispheres on silicon ultrathin film solar cells for plasmonic light trapping.

We systematically investigate the design of two-dimensional silver (Ag) hemisphere arrays on crystalline silicon (c-Si) ultrathin film solar cells for plasmonic light trapping. The absorption in ultrathin films is governed by the excitation of Fabry-Perot TEMm modes. We demonstrate that metal hemispheres can enhance absorption in the films by (1) coupling light to c-Si film waveguide modes and (2) exciting localized surface plasmon resonances (LSPRs). We show that hemisphere arrays allow light to couple to fundamental TEm and TMm waveguide modes in c-Si film as well as higher-order versions of these modes. The near-field light concentration of LSPRs also may increase absorption in the c-Si film, though these resonances are associated with significant parasitic absorption in the metal. We illustrate how Ag plasmonic hemispheres may be utilized for light trapping with 22% enhancement in short-circuit current density compared with that of a bare 100 nm thick c-Si ultrathin film solar cell.

Strong broadband absorption in GaAs nanocone and nanowire arrays for solar cells.

We studied the influence of geometric parameters on the optical absorption of gallium arsenide (GaAs) nanocone and nanowire arrays via finite difference time domain simulations. We optimized the structural parameters of the nanocone and nanowire arrays to maximize the ultimate efficiency across a range of lengths from 100 to 1000 nm. Nanocone arrays were found to have improved solar absorption, short-circuit current density, and ultimate efficiencies over nanowire arrays for a wide range of lengths. Detailed simulations reveal that nanocones have superior absorption due to reduced reflection from their smaller tip and reduced transmission from their larger base. Breaking the vertical mirror symmetry of nanowires results in a broader absorption spectrum such that overall efficiencies are enhanced for nanocones. We also evaluated the electric field intensity, carrier generation and angle-dependent optical properties of nanocones and nanowires. The carrier generation in nanocone arrays occurs away from the surface and is more uniform over the entire structure, which should result in less recombination losses than in nanowire arrays.

Dermatologic health disparities.

Although significant data highlight the extent of health disparities, data regarding dermatologic health disparities are limited. Ethnic minorities, people of low socioeconomic status, the less educated, elderly, and uninsured have poorer melanoma and nonmelanoma skin cancer outcomes. Atopic dermatitis is more prevalent among ethnic minorities, but whether morbidity is also increased in these populations is unclear. Given the current dermatology workforce shortage, increased patient load from health care reform may have an adverse effect on access to dermatologic care. Additional concerns include status of dermatologic training, insufficient research involving ethnic minorities, and lack of investigation of dermatologic health disparities.

Neural signatures of phonetic learning in adulthood: a magnetoencephalography study.

The present study used magnetoencephalography (MEG) to examine perceptual learning of American English /r/ and /l/ categories by Japanese adults who had limited English exposure. A training software program was developed based on the principles of infant phonetic learning, featuring systematic acoustic exaggeration, multi-talker variability, visible articulation, and adaptive listening. The program was designed to help Japanese listeners utilize an acoustic dimension relevant for phonemic categorization of /r-l/ in English. Although training did not produce native-like phonetic boundary along the /r-l/ synthetic continuum in the second language learners, success was seen in highly significant identification improvement over twelve training sessions and transfer of learning to novel stimuli. Consistent with behavioral results, pre-post MEG measures showed not only enhanced neural sensitivity to the /r-l/ distinction in the left-hemisphere mismatch field (MMF) response but also bilateral decreases in equivalent current dipole (ECD) cluster and duration measures for stimulus coding in the inferior parietal region. The learning-induced increases in neural sensitivity and efficiency were also found in distributed source analysis using Minimum Current Estimates (MCE). Furthermore, the pre-post changes exhibited significant brain-behavior correlations between speech discrimination scores and MMF amplitudes as well as between the behavioral scores and ECD measures of neural efficiency. Together, the data provide corroborating evidence that substantial neural plasticity for second-language learning in adulthood can be induced with adaptive and enriched linguistic exposure. Like the MMF, the ECD cluster and duration measures are sensitive neural markers of phonetic learning.

Infants show a facilitation effect for native language phonetic perception between 6 and 12 months.

Patterns of developmental change in phonetic perception are critical to theory development. Many previous studies document a decline in nonnative phonetic perception between 6 and 12 months of age. However, much less experimental attention has been paid to developmental change in native-language phonetic perception over the same time period. We hypothesized that language experience in the first year facilitates native-language phonetic performance between 6 and 12 months of age. We tested 6-8- and 10-12-month-old infants in the United States and Japan to examine native and nonnative patterns of developmental change using the American English /r-l/ contrast. The goals of the experiment were to: (a) determine whether facilitation characterizes native-language phonetic change between 6 and 12 months of age, (b) examine the decline previously observed for nonnative contrasts and (c) test directional asymmetries for consonants. The results show a significant increase in performance for the native-language contrast in the first year, a decline in nonnative perception over the same time period, and indicate directional asymmetries that are constant across age and culture. We argue that neural commitment to native-language phonetic properties explains the pattern of developmental change in the first year.