Measuring pediatric hematology-oncology fellows' skills in humanism and professionalism: A novel assessment instrument

BACKGROUND

Educators in pediatric hematology-oncology lack rigorously developed instruments to assess fellows' skills in humanism and professionalism.

PROCEDURE

We developed a novel 15-item self-assessment instrument to address this gap in fellowship training. Fellows (N = 122) were asked to assess their skills in five domains: balancing competing demands of fellowship, caring for the dying patient, confronting depression and burnout, responding to challenging relationships with patients, and practicing humanistic medicine. An expert focus group predefined threshold scores on the instrument that could be used as a cutoff to identify fellows who need support. Reliability and feasibility were assessed and concurrent validity was measured using three established instruments: Maslach Burnout Inventory (MBI), Flourishing Scale (FS), and Jefferson Scale of Physician Empathy (JSPE).

RESULTS

For 90 participating fellows (74%), the self-assessment proved feasible to administer and had high internal consistency reliability (Cronbach's α = 0.81). It was moderately correlated with the FS and MBI (Pearson's r = 0.41 and 0.4, respectively) and weakly correlated with the JSPE (Pearson's r = 0.15). Twenty-eight fellows (31%) were identified as needing support. The self-assessment had a sensitivity of 50% (95% confidence interval [CI]: 31-69) and a specificity of 77% (95% CI: 65-87) for identifying fellows who scored poorly on at least one of the three established scales.

CONCLUSIONS

We developed a novel assessment instrument for use in pediatric fellowship training. The new scale proved feasible and demonstrated internal consistency reliability. Its moderate correlation with other established instruments shows that the novel assessment instrument provides unique, nonredundant information as compared to existing scales.

Synchrotron-based phase-sensitive imaging of leaves grown from magneto-primed seeds of soybean

Experiments were conducted to study the effects of static magnetic fields (SMFs) on the venation network of soybean leaves using the synchrotron-based X-ray micro-imaging technique. The seeds of soybean (Glycine max, variety JS-335) were pretreated with different SMFs from 50 to 300 mT in steps of 50 mT for 1 h. The phase-contrast images obtained showed that, as the strength of the SMF increased, the area, width of the midrib, area of the midrib and minor vein of the middle leaflets of third trifoliate leaves also increased up to the SMF strength of 200 mT (1 h) and decreased thereafter. Quantification of the major conducting vein also showed the differences in the major and minor vein structures of the soybean leaves as compared with control leaves. Further, the phase-retrieval technique has been applied to make the segmentation process easy and to quantify the major and minor veins in the venation network. The width and area of midrib enhancement by pre-treatment with SMF implies an enhancement in the uptake of water, which in turn causes an increased rate of photosynthesis and stomatal conductance.

Biomechanical investigation of 'figure of 8' flexor tendon repair techniques

This biomechanical study compared the original Al-Qattan repair with other modifications postulated to reduce bulk and friction, thereby potentially improving outcome. A total of 32 cadaveric digits with intact flexor apparatus were used. In each digit, the flexor digitorum profundus and flexor digitorum superficialis tendons were cut cleanly in Zone 2. We tested Al-Qattan's technique along with three modifications using stronger suture material and varying the number of strands across the repair site. Of the four repair techniques, the modified Al-Qattan's technique using two 'figure of 8' 4-0 Fiberwire core sutures (Group 4) had the best balance of ultimate tensile strength (50.9 N), 2 mm gapping force (38 N) and friction. The modified technique provided a stronger repair for early active mobilization and has less friction than the originally described repair.

Synchrotron X-ray phase contrast imaging of leaf venation in soybean (Glycine max) after exclusion of solar UV (280-400 nm) radiation

The hydraulic efficiency of a leaf depends on its vascular structure as this is responsible for transport activities. To investigate the effect of exclusion of UVAB and UVB radiation from the solar spectrum on the micro-structure of leaves of soybean (Glycine max, variety JS-335), a field experiment was conducted using synchrotron-based phase contrast imaging (PCI). Plants were grown in specially designed UV exclusion chambers, and wrapped with filters that excluded UVB (280-315 nm) or UVAB (280-400 nm), or transmitted all the ambient solar UV (280-400 nm) radiation (filter control). Qualitative observation of high-resolution X-ray PCI images obtained at 10 keV has shown the differences in major and minor vein structures of the leaves. The mid-rib width of the middle leaflet of third trifoliate leaves, for all treatments, were obtained using quantitative image analysis. The width of the mid-rib of the middle leaflet of third trifoliate leaves of UVB excluded plants was found to be more compared to leaves of filter control plants, which are exposed to ambient UV. The mid-rib or the main conducting vein transports water and sugars to the whole plant; therefore, mid-rib enhancement by the exclusion of solar UV radiation possibly implies enhancement in the leaf area which in turn causes an increased rate of photosynthesis.

Application of X-ray micro-CT for micro-structural characterization of APCVD deposited SiC coatings on graphite conduit

SiC coatings are commonly used as oxidation protective materials in high-temperature applications. The operational performance of the coating depends on its microstructure and uniformity. This study explores the feasibility of applying tabletop X-ray micro-CT for the micro-structural characterization of SiC coating. The coating is deposited over the internal surface of pipe structured graphite fuel tube, which is a prototype of potential components of compact high-temperature reactor (CHTR). The coating is deposited using atmospheric pressure chemical vapor deposition (APCVD) and properties such as morphology, porosity, thickness variation are evaluated. Micro-structural differences in the coating caused by substrate distance from precursor inlet in a CVD reactor are also studied. The study finds micro-CT a potential tool for characterization of SiC coating during its future course of engineering. We show that depletion of reactants at larger distances causes development of larger pores in the coating, which affects its morphology, density and thickness.

Non-destructive evaluation of teeth restored with different composite resins using synchrotron based micro-imaging

BACKGROUND

Application of high resolution synchrotron micro-imaging in microdefects studies of restored dental samples.

OBJECTIVE

The purpose of this study was to identify and compare the defects in restorations done by two different resin systems on teeth samples using synchrotron based micro-imaging techniques namely Phase Contrast Imaging (PCI) and micro-computed tomography (MCT). With this aim acquired image quality was also compared with routinely used RVG (Radiovisiograph).

METHODS

Crowns of human teeth samples were fractured mechanically involving only enamel and dentin, without exposure of pulp chamber and were divided into two groups depending on the restorative composite materials used. Group A samples were restored using a submicron Hybrid composite material and Group B samples were restored using a Nano-Hybrid restorative composite material. Synchrotron based PCI and MCT was performed with the aim of visualization of tooth structure, composite resin and their interface.

RESULTS

The quantitative and qualitative comparison of phase contrast and absorption contrast images along with MCT on the restored teeth samples shows comparatively large number of voids in Group A samples.

CONCLUSIONS

Quality assessment of dental restorations using synchrotron based micro-imaging suggests Nano-Hybrid resin restorations (Group B) are better than Group A.

Design, development and first experiments on the X-ray imaging beamline at Indus-2 synchrotron source RRCAT, India

A full-field hard X-ray imaging beamline (BL-4) was designed, developed, installed and commissioned recently at the Indus-2 synchrotron radiation source at RRCAT, Indore, India. The bending-magnet beamline is operated in monochromatic and white beam mode. A variety of imaging techniques are implemented such as high-resolution radiography, propagation- and analyzer-based phase contrast imaging, real-time imaging, absorption and phase contrast tomography etc. First experiments on propagation-based phase contrast imaging and micro-tomography are reported.

Pseudomyxoma peritonei originating from urachus-case report and review of the literature

Pseudomyxoma peritonei (pmp) is a rare clinical condition defined as extensive intraperitoneal spread of mucus associated with a variety of mucinous tumours of varying biologic behavior. Although appendix or ovaries have usually been implicated as the primary site, cases have been reported in association with neoplastic lesions of other sites. Pseudomyxoma peritonei originating from urachal remnants is a unique entity, reported only 18 times in the English literature thus far. Considering the rarity of the lesion, we report the case of a 50-year-old man surgically treated for pmp associated with a low-grade mucinous urachal neoplasm. Unique aspects of case are the low histologic aggressiveness of the causative lesion (reported only twice worldwide) and the early stage of the disease, with a relatively small amount of intraperitoneal free mucin. Review of the literature about pmp in general and a collation of previously reported cases of pmp originating from the urachus are presented and discussed.

Treatment of Kaposi sarcoma in children with HIV-1 infection

BACKGROUND

Kaposi sarcoma (KS) remains the second most frequently diagnosed HIV-related malignancy (HRM) worldwide and most common HRM in sub-Saharan Africa where HIV is most prevalent and human herpesvirus 8 (HHV-8), the precipitating agent for the development of KS, is endemic. The majority of KS patients would likely benefit from systemic chemotherapy in addition to the initiation of antiretroviral therapy (ART). However, as paediatric staging and treatment criteria are not readily available, there are no uniform treatment criteria.

OBJECTIVES

To describe the efficacy and effectiveness of current treatment options for HIV-associated KS in ART-treated paediatric populations.

SEARCH METHODS

We used standard Cochrane methods to search electronic databases and conference proceedings with relevant search terms without limits to language.

SELECTION CRITERIA

Randomised controlled trials, cohort studies, and case-control studies of HIV-infected infants and children <18 years old treated with ART and diagnosed with KS.

DATA COLLECTION AND ANALYSIS

Abstracts of all studies identified by electronic or bibliographic scanning were examined independently by two authors. We initially identified 920 references and examined 15 in detail for study eligibility. Data were abstracted independently using a standardised abstraction form.

MAIN RESULTS

After initially screening 920 titles, 15 full-text articles were closely examined by two authors. We identified four cohort studies that met our inclusion criteria for data extraction, coding, and potential meta-analysis.Using the Newcastle-Ottawa Scale and Cochrane risk of bias assessments, all observational studies had cohorts that were representative of average (treated and untreated) HIV-infected children with Kaposi sarcoma. For all outcomes of interest, no study adjusted for any other potential confounders. Two of four observational studies either explicitly described complete follow up of the study participants and/or described the characteristics of the participants lost to follow up.The use of ART together with a chemotherapeutic regimen versus ART alone appears to increase the likelihood of KS remission in HIV-infected children diagnosed with KS, although data are sparse and not adequately adjusted for staging of disease and comorbidities. Additionally, though data are sparse, the use of ART together with a chemotherapeutic regimen versus chemotherapy alone in some analyses appears to increase the likelihood of KS remission and reduce the risk of death in HIV-infected children diagnosed with KS.In this analysis, we found that the quality of evidence was very low due to small sample sizes and a paucity of paediatric literature.

AUTHORS' CONCLUSIONS

Data describing the efficacy of different treatment options for pediatric KS, to include chemotherapy and ART, are sparse. However, the use of ART together with a chemotherapy regimen may be superior to the use of ART alone or of chemotherapy alone.

Salsolinol induced apoptotic changes in neural stem cells: amelioration by neurotrophin support

Salsolinol (SAL), a catechol isoquinoline has invited considerable attention due to its structural similarity with dopaminergic neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Its high endogenous presence in Parkinsonian brain implicated its possible association with the disease process. SAL is also present in alcohol beverages and certain food materials and can get access to brain especially in conditions of immature or impaired BBB. Besides this, the effect of SAL on neural stem cells (NSCs) which are potential candidates for adult neurogenesis and transplantation mediated rejuvenating attempts for Parkinson's disease (PD) brain has not been known so far. NSCs in both the cases have to overcome suppressive cues of diseased brain for their survival and function. In this study we explored the toxicity of SAL toward NSCs focusing on apoptosis and status of PI3K survival signaling. NSCs cultured from embryonic day 11 rat fetal brain including those differentiated to TH(+ve) colonies, when challenged with SAL (1-100μM), elicited a concentration and time dependent cell death/loss of mitochondrial viability. 10μM SAL on which significant mitochondrial impairment initiated was further used to study mechanism of toxicity. Morphological impairment, enhanced TUNEL positivity, cleaved caspase-3 and decreased Bcl-2:Bax suggested apoptosis. Sal toxicity coincided with reduced pAkt level and its downstream effectors: pCREB, pGSK-3β, Bcl-2 and neurotrophins GDNF, BDNF suggesting repressed PI3K/Akt signaling. Multiple neurotrophic factor support in the form of Olfactory Ensheathing Cell's Conditioned Media (OEC CM) potentially protected NSCs against SAL through activating PI3K/Akt pathway. This was confirmed on adding LY294002 the PI3K inhibitor which abolished the protection. We inferred that SAL exerts substantial toxicity toward NSCs. These findings will lead to better understanding of endogenous threats that might affect the fate of transplanted NSCs and their probable antidotes.

Red blood cell transfusion in pediatric patients with severe chronic anemia: how slow is necessary?

Historic practice recommends slow transfusion for children with chronic anemia and hemoglobin less than 5.0 g/dl due to the theoretical risk of transfusion-associated circulatory overload (TACO). In our pediatric intensive care unit (PICU), we have been utilizing a more liberal transfusion practice in patients without underlying cardiopulmonary disease, and a faster transfusion rate appears safe in this population. Rate of transfusion must be based on multiple factors including convenience, timeliness of procedures and transport to an appropriate care facility, risk of alloimmunization and wastage of blood, stress for the family, and need for PICU monitoring.

An unusual presentation of subcutaneous granuloma annulare in association with juvenile-onset diabetes: case report and literature review

Subcutaneous granuloma annulare (SGA) is a rarely reported subtype of granuloma annulare that occurs almost exclusively in children. The etiology of these lesions is unknown, although a possible relationship to insulin-dependent diabetes mellitus (IDDM) has been proposed in the literature. Here we present an unusual case of SGA on the right forearm in a 3-year-old girl. Unlike the typical lesions noted on the extremities, on magnetic resonance imaging her lesions involved the subcutaneous tissue and adjacent muscles in multiple locations. Histopathologically, the case was consistent with SGA but was unusual in its distribution involving multiple muscles, a finding that has not been previously reported. Weeks after incisional biopsy, she was readmitted with diabetic ketoacidosis (DKA) secondary to IDDM. After treatment of her DKA and control of her glycemia, the forearm SGA vanished, which supported the pathologic diagnosis and alleviated our concerns secondary to the unusual distribution.

Is routine computed tomographic scanning justified in the first week of persistent febrile neutropenia in children with malignancies?

BACKGROUND

Prolonged febrile neutropenia (FN) remains a common problem in pediatric oncology and often leads to empiric computed tomography (CT) of the sinuses, chest, abdomen, and pelvis. Little evidence is available as to the diagnostic utility of CT in this setting.

PROCEDURE

We performed a retrospective review of all oncology patients admitted to the hospital from January 2004 through December 2008 for FN who had daily fevers with neutropenia for 4 or more consecutive days prompting CT evaluation. Eligible patient charts were reviewed for symptomatology prior to imaging as well as antibiotic and antifungal regimens throughout therapy.

RESULTS

Fifty-two patients had 68 unique episodes of prolonged FN that resulted in CT imaging. Positive findings occurred in 18%, 12%, and 25% of initial chest, abdomen, and sinus CTs, respectively. There were no positive findings on initial pelvic CT. Only two of the initial positive CT scans led to a change in management (6.5% of positive scans, 0.8% of all initial scans). These were both scans of the chest. All patients with concern for occult fungal infection had findings on chest CT. Patients with clinically important infections had no statistical difference in days of fever or neutropenia or type of underlying malignancy compared with those without infection. Clinical symptomatology was most helpful for typhlitis.

CONCLUSIONS

Treatment alteration rarely results from empiric CT imaging in the early days of prolonged FN. We therefore recommend limiting initial empiric CT imaging to the chest only in patients without localizing signs or symptoms and prolonged FN.

Siblings presenting with progressive congenital aleukemic leukemia cutis

Congenital leukemia is infrequent, occurring in <1% of pediatric leukemia patients, and mainly of myeloid lineage. Twenty-five to 30% of congenital leukemia cases present with cutaneous leukemic infiltrates. Rarely, infants will have aleukemic leukemia cutis, presenting with leukemic skin lesions but without systemic symptoms or bone marrow involvement. Few cases of congenital aleukemic leukemia cutis have been reported in the literature. The course of disease is variable as cases of spontaneous resolution have been described. Here we present the first report of siblings with progressive congenital aleukemic leukemia cutis, both treated successfully with myeloid leukemia chemotherapy.

An unusual phaeoid fungi: Ulocladium, as a cause of chronic allergic fungal sinusitis

Allergic fungal sinusitis (AFS) has been recognized as an important cause of chronic sinusitis commonly caused by Aspergillus spp. and various dematiaceous fungi like Bipolaris, Alternaria, Curvalaria, and etc. Ulocladium botrytis is a non pathogenic environmental dematiaceous fungi, which has been recently described as a human pathogen. Ulocladium has never been associated with allergic fungal sinusitis but it was identified as an etiological agent of AFS in a 35 year old immunocompetent female patient presenting with chronic nasal obstruction of several months duration to our hospital. The patient underwent FESS and the excised polyps revealed Ulocladium as the causative fungal agent.

Evaluation and optimization of preparative variables for controlled-release floating microspheres of levodopa/carbidopa

Levodopa, a prodrug of dopamine, is the first line drug in the treatment of Parkinson's disease. All current levodopa products are formulated in combination with aromatic amino acid decarboxylase inhibitors such as carbidopa or benserazide to prevent the peripheral metabolism of levodopa. The objective of the present investigation was to produce floating microspheres of carbidopa (CD)/levodopa (LD) to enhance their efficacy by increasing their gastric residence time, which is major technique to improve efficacy of narrow absorption window drugs. The microspheres were prepared by the o/w emulsion-solvent diffusion method using polymers hydroxypropylmethyl cellulose K15 M (HPMC K15 M) and ethyl cellulose (EC). The effects of various formulation and process variables on the particle size, in vitro floating behavior, percent drug entrapment, and in vitro drug release were studied. The size and surface morphology of prepared microspheres were characterized by optical and scanning electron microscopy, respectively. In vitro drug release studies were performed and drug release kinetics was evaluated using the linear regression analysis. The prepared microspheres exhibited prolonged drug release (approximately 10h) and remained buoyant for >12 h. Spherical and smooth-surfaced microspheres with encapsulation efficiency ranging from 43% to 80% were obtained. In vitro studies demonstrated diffusion-controlled drug release from the microspheres.

Development and characterization of in situ gel system for nasal insulin delivery

The objective of the present study was to develop a thermosensitive in situ gel system based on chitosan and poly vinyl alcohol (PVA) for nasal delivery of insulin. The hydrogel was prepared by mixing chitosan and PVA. The concentration of the components was optimized during formulation development. The prepared hydrogel was characterized for gelation temperature, gelation time, viscosity changes, degree of swelling, in vitro release and in vivo hypoglycemic effect. The prepared hydrogel was liquid at room temperature while underwent thermal transition from solution below or at room temperature to non-flowing hydrogel when incubated at 37 degrees C for approximately 12 minutes with increased viscosity. The in vitro release of insulin from gel network was observed spectrophotometrically which was good enough to maintain blood glucose level for six hour. Furthermore, the formulation when evaluated for their in vivo hypoglycemic effect, demonstrated its ability to reduce glucose level. The observed in vitro and in vivo results indicate that the proposed thermosensitive in situ gelling system has substantial potential as nasal delivery system for insulin.

Monitoring the trace metals concentration in rice by flame atomic absorption spectrometer and inductively coupled plasma atomic emission spectrometer

The objective of this study was to monitor the concentration of trace metals in rice. Eight different commercial rice samples were collected from retail market and among these samples Fe, Cd, Cr and Zn metal concentrations were determined by using Flame Atomic Absorption Spectrometer (FAAS) and Inductively Coupled Plasma Atomic Emission Spectrophotometer (ICP-AES). The powdered rice samples were digested by wet chemical method. The analytical results obtained by both the instruments were found comparable. The accuracy of the method has been confirmed by analyzing Certified Reference Material CRM No. 10-b of National Institute for Environmental Studies (NIES). The concentrations of Fe, Cd, Cr and Zn in different brands were found in the range of 15.4 +/- 1.1 to 57.7 +/- 2.5 mg/kg, 0.08 +/- 0.03 to 0.39 +/- 0.05 mg/kg, 0.16 +/- 0.03 to 0.58 +/- 0.08 mg/kg and 7.3 +/- 0.3 to 18.6 +/- 0.5 mg/kg respectively. The standard deviation of the measurements has been calculated for Fe, Cd, Cr and Zn in six replicates of each sample and was found to be less than +/- 3% by the method proposed.