Physicians' lifelong learning journeys: A narrative analysis of continuing professional development struggles

INTRODUCTION

Despite tenacious efforts of continuing professional development (CPD) developers and educators, physician engagement in CPD is fraught with challenges. Research suggests that these educational interventions and the maintenance of professional competence systems that mandate them are often seen as impractical, decontextualized and check-box activities by participants. This study explores physicians' learning post graduate medical education (GME) training across their CPD journey to understand how they (a) conceive of themselves as learners and (b) engage in lifelong learning across the course of their professional careers.

METHODS

Using narrative inquiry and holistic narrative analysis situated within a social constructivist orientation, we carried out individual interviews with physicians from across a large children's hospital network including academic hospitals, community hospitals and primary care practices. Timelines and story arcs were used to support the narrative analysis's re-storying.

RESULTS

Twelve physicians from six different sub-specialties were interviewed. We identified three noteworthy challenges as particularly salient across participants' re-storied narratives: (i) train-on-a-track to treading water, (ii) learning takes a backseat, and (iii) learning through foraging or hunting and gathering. Participants described significant change when transitioning from GME to CPD learning. While participants identified as learners, they described the disorienting impact of losing GME's formal supports and structures. They articulated that patient care trumped learning as their top priority. They lamented having limited insight into their learning needs (e.g. little feedback data) and so resorted to engaging in CPD activities that were readily at hand-but not necessarily relevant-and to finding learning resources that might not be formally recognised for CPD credit.

CONCLUSIONS

Physicians' learning journeys post-GME are challenging, and the systems created to support that learning are ill equipped to meet the needs of physicians transitioning from GME to CPD. To encourage meaningful learning, the complex interplay of factors impeding CPD engagement should inform future innovations.

Lifelong Learning Indicators in Medical Students After a Novel Communication Skills Session

CONTEXT

A growth mindset and mastery approach have gained attention as useful learning orientations in medical education, however few studies of interventions to foster these orientations exist.

OBJECTIVES

We sought to discover whether a communication skills session on delivering serious news could foster a communication growth mindset and/or a mastery approach in medical students.

METHODS

This was an interventional survey study of third-year medical students before and after a session on delivering serious news. Students were administered a communication mindset survey before and after the session; achievement goal and learning environment surveys were administered after the session. Chi-square tests were used to assess the difference in pre and post mindsets. Logistic regression was used to determine the odds of achieving a mastery approach with pre- and post-communication growth mindset as the independent variables.

RESULTS

Students' communication growth mindset increased from 79% (n = 186) before the intervention to 92% (n = 142) after the intervention. Achievement goal analysis demonstrated that 64% (n = 91) of students had a mastery approach, 14% (n = 20) had a performance approach and 22% (n = 32) had an avoidant approach. Ninety-nine percent (n = 151) felt the session provided a safe learning environment. The odds of having a mastery approach correlated with both pre and post-intervention growth mindset, with post-session growth mindset having the strongest correlation.

CONCLUSIONS

A novel communication skills session on delivering serious news fostered a communication growth mindset in third year medical students. Most students exhibited a mastery approach to learning; this approach was more likely when they had a growth mindset.

What Do You See? Signature Pedagogy in Continuous Electroencephalography Teaching

PURPOSE

Electroencephalography (EEG) is commonly used in neurology, but there is variability in how neurologists interpret EEGs, potentially from variability in EEG teaching. Little is known about how EEG teaching is done to prepare neurologists for professional practice.

METHODS

We interviewed a group of EEG experts to characterize their teaching practices around continuous EEG (cEEG). We used signature pedagogy as a framework to analyze and interpret the data.

RESULTS

We identified pervasive and characteristic forms of cEEG teaching. Teaching is based on apprenticeship, relying on "learning by doing" in the context of real-life clinical practice. There are habitual steps that learners take to anchor teaching, which typically occurs during rounds. There is a common language and core knowledge that trainees need to master early in their training.

CONCLUSIONS

There are pervasive characteristic forms of cEEG teaching. These findings can help facilitate instructional design and implementation of complementary or enhanced cEEG teaching practices.

Evaluation of a Palliative Care Longitudinal Curriculum for Medical Students Using the Context-Input-Process-Product Model

Palliative care (PC) longitudinal curricula are increasingly being recognized as important in Undergraduate Medical Education (UME). They are however, not yet commonplace, and where they do exist may be implemented without a systematic, prospective approach to curriculum evaluation. This paper describes an implementation of a new longitudinal curriculum at the Perelman School of Medicine (PSOM) at the University of Pennsylvania. We used the Context Input Process Product (CIPP) model, a holistic evaluation model, to assess the local environment, design the curriculum, guide the improvement process, and evaluate outcomes. Comprehensive models such as CIPP provide a more robust approach to curriculum evaluation than outcomes-only models and may be of use to other programs who are implementing new curricula or improving upon existing programs.

A Qualitative Exploration of Pediatric Resident Perceptions of Autonomy in the Era of Pediatric Hospital Medicine Fellowship

OBJECTIVE

Some pediatric residents report experiencing less autonomy when working clinically with pediatric hospital medicine (PHM) fellows than with attendings alone. We sought to explore pediatric senior resident (SR) experiences working clinically with PHM fellows, with a focus on characterizing fellow behaviors that could impact perceived resident autonomy.

METHODS

In this qualitative study, we conducted virtual semistructured interviews with pediatric SRs. We recorded, deidentified, and transcribed interviews for codebook thematic analysis, making iterative adjustments to our codebook and themes until reaching thematic sufficiency.

RESULTS

We conducted 17 interviews. A subanalysis identified key components of the resident mental model of autonomy, including independent clinical decision-making with 3 core qualifiers: 1) plan follow-through, 2) availability of a safety net, and 3) ownership. Our primary analysis identified 4 key themes (with a total of 7 contributory subthemes) describing resident experiences of autonomy, scaffolded based on an organizing framework adapted from Bronfenbrenner's ecological model including 1) microsystem factors (based on direct resident-fellow or resident-leadership team interactions), 2) mesosystem factors (based on fellow-attending interactions), 3) exosystem factors (based on fellow-intrinsic characteristics), and 4) macrosystem factors (cultural values, norms, and policies governing academic pediatrics).

CONCLUSIONS

Many factors impact perceived resident autonomy on PHM fellow-inclusive teams. Although some are related to direct resident-fellow interactions, many others are more complex and may reflect resident interactions with the leadership team, attending-fellow dynamics, and the influence of cultural context. Based on our analysis, we propose several best-practice recommendations directed at fellows, attendings, the fellow-attending dyad, and Graduate Medical Education programs overall.

Extending Arts-Based Interventions in Graduate Medical Education through the Positive Humanities: the Re-FRAME Workshop

BACKGROUND

Arts-and-humanities-based interventions are commonly implemented in medical education to promote well-being and mitigate the risk of burnout. However, mechanisms for achieving these effects remain uncertain within graduate medical education. The emerging field of the positive humanities offers a lens to examine whether and how arts-based interventions support well-being in internal medicine interns.

AIM

Through program evaluation of this visual art workshop, we used a positive humanities framework to elucidate potential mechanisms by which arts-based curricula support well-being in internal medicine interns.

SETTING

We launched the re-FRAME workshop at the Philadelphia Museum of Art in winter 2020.

PARTICIPANTS

Fifty-six PGY-1 trainees from one internal medicine residency program.

PROGRAM DESCRIPTION

The 3-h re-FRAME workshop consisted of an introductory session on emotional processing followed by two previously described arts-based interventions.

PROGRAM EVALUATION

Participants completed an immediate post-workshop survey (91% response rate) assessing attitudes towards the session. Analysis of open-ended survey data demonstrated 4 categories for supporting well-being among participants: becoming emotionally aware/expressive through art, pausing for reflection, practicing nonjudgmental observation, and normalizing experiences through socialization.

DISCUSSION

Our project substantiated proposed mechanisms from the positive humanities for supporting well-being-including reflectiveness, skill acquisition, socialization, and expressiveness-among medical interns.

Measuring the Learning Orientation Fostered by Pediatric Residency Programs With the Graduate Medical Education Learning Environment Inventory Instrument

INTRODUCTION

Mastery learning orientation, conceptualized as a growth mindset, can be beneficial to learners in medical education and is supported by a program...s learning environment. Currently, there are no instruments which reliably assess the learning orientation of a graduate medical education program...s learning environment.

OBJECTIVE

To explore the reliability and validity of the Graduate Medical Education Learning Environment Inventory (GME-LEI).

METHODS

Leaders of the Education in Pediatrics Across the Continuum (EPAC) project revised Krupat...s Educational Climate Inventory to create the GME-LEI. We investigated the GME-LEI...s reliability and validity through confirmatory factor and parallel factor analyses and calculated Cronbach...s alpha for each subscale. We compared mean subscale scores between residents in traditional programs and the EPAC project. As EPAC is known to foster a mastery-focused learning orientation, we hypothesized differences detected between resident groups would strengthen the instrument...s validity.

RESULTS

One hundred and twenty-seven pediatric residents completed the GME-LEI. The final 3-factor model was an acceptable fit to the data, and Cronbach...s alpha for each subscale was acceptable (Centrality: 0.87; Stress: 0.73; Support: 0.77). Mean scores on each subscale varied by program type (EPAC vs traditional) with EPAC residents reporting statistically significant higher scores in the Centrality of Learning subscale (2.03, SD 0.30, vs 1.79, SD 0.42; P.ß=.ß.023; scale of 1...4).

CONCLUSIONS

The GME-LEI reliably measures 3 distinct aspects of the GME learning environment with respect to learning orientation. The GME-LEI may be used to help programs better monitor the learning environment and make changes to support mastery-oriented learning.

Planning for Happenstance: Helping Students Optimize Unexpected Career Developments

INTRODUCTION

Planning for and responding to happenstance is an important but rarely discussed part of the professional development of medical students. We noted this gap while conducting a study of career inflection points of 24 physicians who frequently mentioned how luck had shaped their unfolding careers. A review of the career counseling literature led us to a body of work known as Planned Happenstance Learning Theory (PHLT). PHLT focuses on the attitudes and skills to make happenstance a positive force in one's life. We found no reference to this work in the medical education literature and resolved to address this gap.

METHODS

We created resources for an interactive, 90-minute faculty development workshop. In the workshop, the facilitator used a PowerPoint presentation, vignettes of happenstance, a student testimonial, and a reflection worksheet. We presented and formally evaluated the workshop at three national meetings for health science educators.

RESULTS

Workshop participants, mostly faculty (N = 45), consistently expressed positive regard for the workshop content, organization, and instructional methods, especially the opportunity for guided reflection. A retrospective pre/postevaluation revealed a meaningful increase in knowledge about PHLT attitudes and skills, as well as a commitment to use these skills in promoting professional development.

DISCUSSION

The skills and attitudes of PHLT are relevant to students' career development. A workshop designed to introduce PHLT skills and attitudes to faculty advisors and mentors can help prepare faculty to promote students' awareness and use of these attitudes and skills.

'Whispers and shadows': A critical review of the professional identity literature with respect to minority physicians

OBJECTIVES

Professional identity formation (PIF) is a growing area of research in medical education. However, it is unclear whether the present research base is suitable for understanding PIF in physicians considered to be under-represented in medicine (URM). This meta-ethnography examined the qualitative PIF literature from 2012 to 2019 to assess its capacity to shine light on the experiences of minoritised physicians.

METHODS

Data were gathered using a search of six well-known medical education journals for the term 'professional identit*' in titles, keywords, abstracts and subheadings, delineated with the date range of 2012-2019. All non-relevant abstracts were removed and papers were then further reduced to those that focused only on learners' experiences. This left 67 articles in the final dataset, which were analysed using a collaborative approach among a team of researchers. The team members used their professional expertise as qualitative researchers and personal experiences as minoritised individuals to synthesise and interpret the PIF literature.

RESULTS

Four conceptual categories were identified as impacting PIF: Individual versus Sociocultural Influences; the Formal versus the Hidden Curriculum; Institutional versus Societal Values; and Negotiation of Identity versus Dissonance in Identity. However, a major gap was identified; only one study explored experiences of PIF in URM physicians and there was an almost complete absence of critical stances used to study PIF. Combined, these findings suggest that PIF research is building on existing theories without questioning their validity with reference to minoritised physicians.

CONCLUSIONS

From a post-colonial perspective, the fact that race and ethnicity have been largely absent, invisible or considered irrelevant within PIF research is problematic. A new line of inquiry is needed, one that uses alternative frameworks, such as critical theory, to account for the ways in which power and domination influence PIF for URM physicians in order to foreground how larger sociohistorical issues influence and shape the identities of minoritised physicians.

Implementing an interprofessional narrative medicine program in academic clinics: Feasibility and program evaluation

Interprofessional education (IPE) is a critical component of medical education and is affected by the characteristics of the clinical teams in which students and residents train. However, clinical teams are often shaped by professional silos and hierarchies which may hinder interprofessional collaborative practice (IPCP). Narrative medicine, a branch of health humanities that focuses on close reading, reflective writing, and sharing in groups, could be an innovative approach for improving IPE and IPCP. In this report, we describe the structure, feasibility, and a process-oriented program evaluation of a narrative medicine program implemented in interprofessional team meetings in three academic primary care clinics. Program evaluation revealed that a year-long narrative medicine program with modest monthly exposure was feasible in academic clinical settings. Staff members expressed engagement and acceptability as well as support for ongoing implementation. Program success required administrative buy-in and sustainability may require staff training in narrative medicine.

Teamwork on Rounds on an Inpatient Ward Team: An Ethnographic Study

BACKGROUND AND OBJECTIVES

Pediatric hospitalists are expected to be adept at effective teamwork; yet, studies in which researchers describe teamwork practices in general pediatric inpatient settings are lacking. Our aim in this study was to examine the roles that general pediatric team members assume in real-life settings and how team members conduct teamwork practices on family-centered rounds.

METHODS

In the ethnographic tradition, we observed a general pediatric team on a hospitalist service, focusing on family-centered rounds, and conducted in-depth interviews with interns, senior residents, and faculty. We collected data in the form of field notes from observations and transcribed interviews and used constant comparison methods to create codes and generate themes. We used Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) as an analytic lens and organizing framework.

RESULTS

Communication occurred in both structured and unstructured ways. Situation monitoring happened during routines, such as running the list, and led to creating a plan of patient care through shared decision-making. Some leadership characteristics were not exclusive to 1 team member. Finally, mutual support occurred through task completion and empowering learners; for example, attending physicians empowered senior residents, who also helped interns.

CONCLUSIONS

Our findings aligned with some, but not all, teamwork principles from TeamSTEPPS; misalignment may be due to contextual factors, such as the need to provide medical education and the development of grassroots routines (eg, running the list). Context is a key consideration when developing interventions to enhance teamwork on inpatient medical wards.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance

Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.

Objective

To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.

Design, Setting, and Participants

We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.

Main Outcomes and Measures

Error and AE rates.

Results

Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.

Conclusions and Relevance

Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

The greater good: how supervising physicians make entrustment decisions in the pediatric emergency department

BACKGROUND

Graduate medical education is transitioning to the use of entrustable professional activities to contextualize educational competencies. Factors influencing entrustment decisions have been reported in adult medicine. Knowing how such decisions are made in pediatrics is critical to this transition.

PURPOSE

To understand how supervisors determine the level of procedural supervision to provide a resident, taking into consideration simulation performance; to understand factors that affect supervisors' transparency to parents about residents' procedural experience.

METHODS

We conducted 18 one-on-one interviews with supervisors in a tertiary care pediatric emergency department, iteratively revising interview questions as patterns in the data were elucidated. Two researchers independently coded transcripts and then met with the investigative team to refine codes and create themes.

RESULTS

Five factors influenced supervisors' entrustment decisions: 1) resident characteristics that include self-reported confidence, seniority, and prior interactions with the resident; 2) supervisor style; 3) nature of the procedure/characteristics of the patient; 4) environmental factors; and 5) parental preferences. Supervisors thought that task-based simulators provided practice opportunities but that simulated performance did not provide evidence for entrustment. Supervisors reported selectively omitting details about a resident's experience level to families to optimize experiential learning for residents they entrusted to perform a procedure.

CONCLUSIONS

In pediatrics, supervisors consider various factors when making decisions regarding resident procedural readiness, including parental preferences. An educational system using entrustable professional activities may facilitate holistic assessment and foster expertise-informed decisions about residents' progression toward entrustment; such a system may also lessen supervisors' need to omit information to parents about residents' procedural readiness.

Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs

Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education-Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.

Family-centered rounds in theory and practice: an ethnographic case study

BACKGROUND

Family-centered rounds (FCR) seek to incorporate principles of family-centered care-including clear and open information sharing, respect, participation and collaboration-into inpatient settings. Although potential models designed to translate these principles into everyday clinical practice have been reported, few studies explore how FCR practices align with principles of family-centered care.

METHODS

We conducted an ethnographic study, observing over 200 hours of FCR on a general pediatrics inpatient service from January to August 2010 (185 distinct rounding events). To complement observation, we conducted interviews with 6 family members. Qualitative analysis entailed applying codes to data from observation and interviews and deriving themes using the principles of family-centered care as an interpretive lens.

RESULTS

Four themes emerged that suggested incomplete alignment between FCR practices and principles of family-centered care. 1) FCR provided a forum for information sharing; nonetheless, medical jargon sometimes limited communication. 2) Medical teams approached families with practices intended to demonstrated respect, but contextual factors served to undermine this intent. 3) FCR gave family members the opportunity to participate in care but did not guarantee their involvement. 4) FCR were a starting point for collaboration around plan making, but did not guarantee that collaboration occurred.

CONCLUSIONS

Although FCR practices may set the stage for family-centered care, they do not necessarily ensure that the principles of family-centered care are upheld. Efforts to more effectively deliver FCR should consider physical, organizational, and cultural factors that influence both patient/family and medical team behavior.

Sounding narrative medicine: studying students' professional identity development at Columbia University College of Physicians and Surgeons

PURPOSE

To learn what medical students derive from training in humanities, social sciences, and the arts in a narrative medicine curriculum and to explore narrative medicine's framework as it relates to students' professional development.

METHOD

On completion of required intensive, half-semester narrative medicine seminars in 2010, 130 second-year medical students at Columbia University College of Physicians and Surgeons participated in focus group discussions of their experiences. Focus group transcriptions were submitted to close iterative reading by a team who performed a grounded-theory-guided content analysis, generating a list of codes into which statements were sorted to develop overarching themes. Provisional interpretations emerged from the close and repeated readings, suggesting a fresh conceptual understanding of how and through what avenues such education achieves its goals in clinical training.

RESULTS

Students' comments articulated the known features of narrative medicine--attention, representation, and affiliation--and endorsed all three as being valuable to professional identity development. They spoke of the salience of their work in narrative medicine to medicine and medical education and its dividends of critical thinking, reflection, and pleasure. Critiques constituted a small percentage of the statements in each category.

CONCLUSIONS

Students report that narrative medicine seminars support complex interior, interpersonal, perceptual, and expressive capacities. Students' lived experiences confirm some expectations of narrative medicine curricular planners while exposing fresh effects of such work to view.

Health-related quality of life in children with sickle cell disease using the child health questionnaire

INTRODUCTION

This study sought to determine if changes in parent-reported health-related quality of life (HRQOL) in children with sickle cell disease (SCD-SS) occurred after participation in a nutritional supplementation study and to compare HRQOL responses with normative scores from non-White children.

METHOD

Parents of children with SCD-SS between the ages of 5 and 13 years completed the Child Health Questionnaire (CHQ-PF50) at baseline and at 12 months.

RESULTS

For the 47 children (8.6 ± 2.4 yrs, 43% female), baseline Child Health Questionnaire scale scores were significantly lower than normative scale scores for parental emotional impact, general health, and overall physical health, but they were higher for mental health. After the nutritional supplementation study, overall physical health and parental emotional impact improved to normative levels. Furthermore, physical role functioning significantly improved.

DISCUSSION

Participation in a nutritional study had a positive impact on parent-reported HRQOL physical scores in children with SCD-SS. More research is necessary to develop care providers' awareness and adequate HRQOL interventions for this population.

Medical students as teachers at CoSMO, Columbia University's student-run clinic: a pilot study and literature review

BACKGROUND

Although medical students are expected to teach as soon as they begin residency, medical schools have just recently begun adding teacher training to their curricula. Student-run clinics (SRCs) may provide opportunities in clinical teaching before residency.

AIM

The aim of this pilot study was to examine students' experiences in clinical teaching at Columbia Student Medical Outreach (CoSMO), Columbia University's SRC, during the 2009-2010 school year.

METHODS

A mixed-methods approach was used. Data included closed and open-ended surveys (n = 34), combined interviews with preclinical and clinical student pairs (n = 5), individual interviews (n = 10), and focus groups (n = 3). The transcripts were analyzed using the principles of grounded theory.

RESULTS

Many students had their first clinical teaching experience while volunteering at CoSMO. Clinical students' ability to teach affected the quality of the learning experience for their preclinical peers. Preclinical students who asked questions and engaged in patient care challenged their clinical peers to balance teaching with patient care. Clinical students began to see themselves as teachers while volunteering at CoSMO.

CONCLUSION

The practical experiences in clinical teaching that students have at SRCs can supplement classroom-based trainings. Medical schools might revisit their SRCs as places for exposure to clinical teaching.

How mentoring relationships evolve: a longitudinal study of academic pediatricians in a physician educator faculty development program

INTRODUCTION

Mentoring is increasingly recognized as central to career development. Less attention has been paid, however, to how mentoring relationships evolve over time. To provide a more complete picture of these complex relationships, the authors explored mentoring from a mentee's perspective within the context of a three-year faculty development program in which the mentor provided specific expertise to assist the mentee in completing a scholarly educational project.

METHODS

Using an evolving focus group design, the authors interviewed mentee groups in 2007-2009 inclusive. Transcripts were coded inductively; codes were revised as data patterns became more apparent. Preliminary assertions about the answers to guiding questions were made; the trustworthiness of the assertions was assessed via member check.

RESULTS

Mentees offered a variety of reasons for choosing their project mentor, including proximity, familiarity, and mentor expertise. There was a dyadic relationship with the project mentor in year 1, a broader collaboration with multiple senior mentors in year 2, and mentoring among program peers in year 3. Mentees benefitted from mentors' supportive behaviors and, to a lesser extent, mentors' challenging behaviors.

CONCLUSION

Mentoring relationships, in the context of this faculty development program, tended not to be an exclusive dyadic connection but rather a constellation of relationships that evolved over time and included peer mentoring. The complex reality of these relationships challenges the application of traditional mentoring models and suggests unique considerations in developing mentoring programs designed to meet the needs of faculty in academic medicine.

Evaluating the performance of medical educators: a novel analysis tool to demonstrate the quality and impact of educational activities

PURPOSE

Traditional promotion standards rely heavily on quantification of research grants and publications in the curriculum vitae. The promotion and retention of educators is challenged by the lack of accepted standards to evaluate the depth, breadth, quality, and impact of educational activities. The authors sought to develop a practical analysis tool for the evaluation of educator portfolios (EPs), based on measurable outcomes that allow reproducible analysis of the quality and impact of educational activities.

METHOD

The authors, 10 veteran educators and an external expert evaluator, used a scholarly, iterative consensus-building process to develop the tool and test it using real EPs from educational scholars who followed an EP template. They revised the template in parallel with the analysis tool to ensure that EP data enabled valid and reliable evaluation. The authors created the EP template and analysis tool for scholar and program evaluation in the Educational Scholars Program, a three-year national certification program of the Academic Pediatric Association.

RESULTS

The analysis tool combines 18 quantitative and 25 qualitative items, with specifications, for objective evaluation of educational activities and scholarship.

CONCLUSIONS

The authors offer this comprehensive, yet practical tool as a method to enhance opportunities for faculty promotions and advancement, based on well-defined and documented educational outcome measures. It is relevant for clinical educators across disciplines and across institutions. Future studies will test the interrater reliability of the tool, using data from EPs written using the revised template.

Learning behind the scenes: perceptions and observations of role modeling in pediatric residents' continuity experience

OBJECTIVE

Little is known about what residents learn from "everyday" physician role models, who, in the course of their ordinary work, serve as real-life examples of residents' future roles. The purpose of this research was to analyze what and how pediatric residents learn through role modeling during their continuity experience.

DESIGN

We conducted a case study of 10 third-year pediatric residents and their 10 continuity clinic preceptors (CCP) in a community-based continuity clinic. Data were derived from 5 months (100 hours) of direct observation in clinic; semistructured interviews with residents before and after observation; and semistructured interviews with CCPs after resident data were collected. Interview transcripts and notes from observation were inductively coded and thematically analyzed.

RESULTS

From the residents' perspective, role modeling was an implicit and intentional learning strategy that was linked to routine clinical practice in continuity clinic. Residents learned, through modeling their CCPs, "how to talk" and "how to think things through." Residents did not directly report modeling professional behavior. For residents, learning through modeling was not contingent on CCPs' awareness of being a role model.

CONCLUSIONS

Role modeling is a nuanced, deliberate learning strategy that provides pediatric residents with templates for interpersonal communication and clinical decision making that have both immediate and long-term relevance. Understanding residents' perspective on role modeling, and how it aligns with their CCPs' perspective, presents opportunities for improving residents' learning experiences, faculty development, and future research.

Pediatric Residents’ and Continuity Clinic Preceptors’ Perceptions of the Effects of Restricted Work Hours on Their Learning Relationship

OBJECTIVE

The effects of the Work Hour Standard (WHS) on continuity of care and quality of education has stimulated much discussion, yet little is known about how it affects the resident-continuity clinic preceptor (CCP) dyad, the only longitudinal learning relationship in pediatric residency. This case study explored residents' and CCPs' perceptions of the effects of restricted work hours on their learning relationship.

METHODS

Direct observation of third-year pediatric residents (n = 10) and their CCPs (n = 10) was carried out in continuity clinic (CC) for 5 months; both groups attended clinic before and after the WHS. Semistructured, audiotaped interviews were conducted with residents before and after observation, and with CCPs after resident data were collected. Data from interview transcripts and observational notes were analyzed for major themes.

RESULTS

To comply with the WHS, postcall clinic was eliminated and residents were rescheduled to another afternoon CC. The consequence of eliminating postcall clinic, disruption in the resident-CCP relationship, was perceived differently by residents and CCPs. From the residents' perspective, rescheduling CC in response to the WHS benefited their learning because it exposed them to different CCPs with different practice styles. From the CCPs' perspective, rescheduling CC frustrated their efforts to be learner-centered teachers and effective mentors.

CONCLUSIONS

Intended changes to limit excessive work hours had unintended effects that were viewed more favorably by residents than by CCPs. Understanding the shared and different perspectives of residents and preceptors regarding WHS-related changes in CC extends the discussion of the effect of restricted work hours.

Learning About Systems-Based Practice in the Informal Curriculum: A Case Study in an Academic Pediatric Continuity Clinic

OBJECTIVE

Pediatric residents learn about systems-based practice (SBP) explicitly in the formal curriculum and implicitly in the informal curriculum as they engage in practice alongside physician faculty. Recent studies describe innovative ways to address SBP in the formal curriculum for SBP, but the informal curriculum has not been explored. We examined what, and how, third-year pediatric residents learn about SBP in the informal curriculum at one continuity clinic, and to consider how this learning aligns with the formal curriculum.

METHODS

A case study involving 10 third-year pediatric residents and 10 continuity preceptors was conducted at one continuity clinic, housed in a community-based, pediatric primary care center. Data were derived from 5 months (100 hours) of direct observation in the precepting room at the case clinic, semistructured interviews with residents (before and after observation) and with preceptors (after observation). Interview transcripts and notes from observation were inductively coded and analyzed for major themes.

RESULTS

Two themes emerged in the informal curriculum. Residents perceived "our system," the academic health system in which they trained and practiced as separate and distinct from the "real system," the larger, societal context of health care. Residents also understood SBP as a commitment to helping individual patients and families navigate the complexities of "our system," dealing with issues that concerned them.

CONCLUSIONS

Residents learn important lessons about SBP in the informal curriculum in continuity clinic. These lessons may reinforce some elements of the competency-based formal curriculum for SBP, but challenge others.

In vivo properties of the urinary bladder wall and their modulation by estradiol and raloxifene in a rat model

OBJECTIVES

Urinary incontinence is a common symptom of urogenital aging that affects a considerable proportion of postmenopausal women. Morphological and morphometrical modulation of the bladder by estrogen are known. Yet data showing that this translates into changes of in vivo function of the urinary bladder are missing.

METHODS

We measured urodynamic parameters in anaesthetized, surviving rats. Following ovariectomy animals were divided into three groups and fed either an estradiol-, raloxifene-, or unsupplemented soy-free formula for ten weeks. Via a transurethral catheter the intravesical pressure was recorded during a stretch period (the urinary bladder was filled), and a one-minute isometric accommodation period immediately after the filling period. Upon termination of the experiment upper and lower halves of the bladder were processed histologically.

RESULTS

The estrogen-, and raloxifene-treated animals showed significantly higher pressures in responses to rapid stretch. Bladder compliance during the isometric period on the other hand was not significantly affected by these treatments. Thickness of the epithelial layer, collagen content and muscle bundles were significantly increased by estrogen and raloxifene treatment.

CONCLUSIONS

This is a good animal model to investigate modulation of detrusor muscle contractility and stiffness. Both estradiol and raloxifene increase bladder contractility. Urinary bladder morphology indicates that estrogen acts primarily in the upper half of this organ since significant effects on collagen content and muscle fibers are only found in this part.

Quantitative localization of heterogeneous methyl-CpG-binding protein 2 (MeCP2) expression phenotypes in normal and Rett syndrome brain by laser scanning cytometry

Rett syndrome (RTT) is an X-linked, dominant neurodevelopmental disorder caused by mutations in MECP2, encoding the methyl-CpG-binding protein 2 (MeCP2). A major paradox in the pathogenesis of RTT is how mutations in ubiquitously transcribed MECP2 result in a phenotype specific to the central nervous system (CNS) during postnatal development. To address this question, we have used a novel approach for quantitating the level and distribution of wild-type and mutant MeCP2 in situ by immunofluorescence and laser scanning cytometry. Surprisingly, cellular heterogeneity in MeCP2 expression level was observed in normal brain with a subpopulation of cells exhibiting high expression (MeCP2(hi)) and the remainder exhibiting low expression (MeCP2(lo)). MeCP2 expression was significantly higher in CNS compared with non-CNS tissues of human and mouse by automated quantitation of MeCP2 on multiple tissue arrays. Quantitative localization of MeCP2 expression phenotypes in normal human brain showed a mosaic, but distinct, distribution pattern, with MeCP2(hi) neurons highest in layer IV of the cerebrum and MeCP2(lo )neurons highest in the granular layer of the cerebellum. In female RTT brains, MECP2 mutant-expressing cells were identified as cells negative for the MeCP2 C-terminal epitope. MECP2 mutant-expressing cells were randomly localized in Rett cerebrum and cerebellum and showed normal MeCP2 expression with N-terminal-specific anti-MeCP2. These results demonstrate a CNS-specific cellular phenotype of MeCP2 high expression and suggest that MECP2 mutations in RTT are only manifested in MeCP2(hi) cells. In addition, our results demonstrate the power of laser scanning cytometry in examining complex cellular phenotypes in disease pathogenesis.

Clonal maintenance of imprinted expression of SNRPN and IPW in normal lymphocytes: correlation with allele-specific methylation of SNRPN intron 1 but not intron 7

DNA methylation is a heritable and reversible modification to CpG sites in the mammalian genome. Parental allele-specific methylation is hypothesized to be important in the establishment and maintenance of imprinted gene expression; however, dynamic changes in allele-specific patterns have been observed. The upstream regulatory region of the small nuclear riboprotein N gene (SNRPN) is an important imprinting control region (ICR) for establishing and maintaining the methylation imprint in the locus on 15q11-13 associated with Prader-Willi and Angelman syndromes (PWS). To compare directly the role of allele-specific methylation patterns and the maintenance of imprinted expression in the PWS region, clonal populations of normal T lymphocytes were cultured for 22-25 generations. A novel long-range semi-nested polymerase chain reaction (PCR) strategy was utilized in order to span two different methylation sites, and a polymorphism within SNRPN was used so that allele-specific methylation of both sites could be determined. Reverse transcription/PCR followed by polymorphism analysis was also performed in order to determine parental allele-specific transcription. Exclusive paternal expression at both SNRPN and IPW was maintained in all T cell clones and correlated with maternal methylation of the intron 1 NotI site. In contrast, biallelic methylation was observed in all clones at the previously described paternally methylated HpaII site in intron 7. These results demonstrate that the maintenance of paternal expression of SNRPN and IPW correlates with a strict clonal maintenance of allele-specific methylation at the CpG-dense 5' end of SNRPN. Differential maintenance of methylation sites within imprinted genes may depend on the density and chromatin organization of surrounding CpG sites.

Parental origin and mechanisms of formation of triploidy: a study of 25 cases

Triploidy is one of the most frequently observed chromosome abnormalities in spontaneous abortions in humans. The parental origin of the additional chromosome set is known to have a major impact on the phenotype of the foetuses and to result in differences in size and structure of the placenta. Early studies based on cytogenetic polymorphisms indicated a preponderant diandric origin of the triploidies; such detection method, however, is known to be prone to error. Other studies revealed a predominant digynic origin in cases with longer intrauterine survival. It is now thought that, to some extent, a detection bias in favour of cases with associated partial hydatidiform moles may account for the high incidences of diandric cases reported in some studies. Furthermore, depending on the gestational age of the cases analysed there may indeed be differences in the proportion of diandric and digynic triploidies. We investigated the parental origin and mechanisms of formation of triploidy in a group of 25 probands with gestational ages ranging from 8 to 37 weeks. DNA samples were extracted from foetal material and from blood samples of the parents, and were analysed using microsatellite markers. The parental origin of the triploidies was found to be maternal in 20 cases and paternal in 5. Regarding the digynic cases, an error at meiosis I was inferred in 10 cases, whereas in the other half an error occurred at meiosis II. All five diandric cases included in this study were found to be due to dispermy. No significant differences in the average maternal ages were found amongst the different subgroups of patients.

Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania

BACKGROUND

Access to HIV-1 voluntary counselling and testing (VCT) is severely limited in less-developed countries. We undertook a multisite trial of HIV-1 VCT to assess its impact, cost, and cost-effectiveness in less-developed country settings.

METHODS

The cost-effectiveness of HIV-1 VCT was estimated for a hypothetical cohort of 10000 people seeking VCT in urban east Africa. Outcomes were modelled based on results from a randomised controlled trial of HIV-1 VCT in Tanzania and Kenya. Our main outcome measures included programme cost, number of HIV-1 infections averted, cost per HIV-1 infection averted, and cost per disability-adjusted life-year (DALY) saved. We also modelled the impact of targeting VCT by HIV-1 prevalence of the client population, and the proportion of clients who receive VCT as a couple compared with as individuals. Sensitivity analysis was done on all model parameters.

FINDINGS

HIV-1 VCT was estimated to avert 1104 HIV-1 infections in Kenya and 895 in Tanzania during the subsequent year. The cost per HIV-1 infection averted was US$249 and $346, respectively, and the cost per DALY saved was $12.77 and $17.78. The intervention was most cost-effective for HIV-1-infected people and those who received VCT as a couple. The cost-effectiveness of VCT was robust, with a range for the average cost per DALY saved of $5.16-27.36 in Kenya, and $6.58-45.03 in Tanzania. Analysis of targeting showed that increasing the proportion of couples to 70% reduces the cost per DALY saved to $10.71 in Kenya and $13.39 in Tanzania, and that targeting a population with HIV-1 prevalence of 45% decreased the cost per DALY saved to $8.36 in Kenya and $11.74 in Tanzania.

INTERPRETATION

HIV-1 VCT is highly cost-effective in urban east African settings, but slightly less so than interventions such as improvement of sexually transmitted disease services and universal provision of nevirapine to pregnant women in high-prevalence settings. With the targeting of VCT to populations with high HIV-1 prevalence and couples the cost-effectiveness of VCT is improved significantly.

Maternal uniparental disomy 7--review and further delineation of the phenotype

Uniparental disomy (UPD) is defined as the inheritance of both homologous chromosomes from only one parent. So far, maternal UPD 7 has been described in 28 cases. Here, we report 4 new cases, present clinical information of 5 cases previously reported by us, and review the clinical and molecular findings of all 32 cases. We found a phenotype characterized by pre- and postnatal growth retardation, occipitofrontal head circumference in the lower normal range, a triangular face, and retarded bone maturation. Findings of the facial gestalt included a high and broad forehead and a pointed chin. A broad mouth with down-turned corners, prominent ears, café-au-lait spots, hemihypotrophy, or clinodactyly were rarely present. Psychomotor development was delayed in 6 cases. The clinical findings strikingly resemble the phenotype of the heterogeneous Silver-Russell syndrome (SRS). Other anomalies were less frequently found than in SRS. Molecular investigations revealed 11 cases with isodisomy and 17 cases with heterodisomy. In 4 cases this information was not available. From the allelic distribution of the microsatellites investigated, 9 cases might be the consequence of an error at maternal meiosis I, and 6 cases might be due to non-disjunction at maternal meiosis II. Three of the 17 heterodisomic cases had trisomy 7 in chorionic villi, in the remaining cases no prenatal diagnosis through chorionic villus sampling was reported.

CONCLUSION

Maternal UPD 7 should investigated in children with pre- and postnatal growth retardation anda facial gestalt characterized by a high and broad forehead and a pointed chin, as well as in cofined placental mosaicism for trisomy 7.

A supernumerary marker chromosome originating from two different regions of chromosome 18

By random amplification of a microdissected chromosome using the degenerate oligonucleotide primed polymerase chain reaction (DOP-PCR) and forward painting (microFISH), we characterised an extra structurally abnormal chromosome (ESAC) or supernumerary marker chromosome in a mentally retarded girl with a pattern of dysmorphic features. It could be clearly shown that the small marker chromosome originates from two different regions of chromosome 18, 18p11.1-->18q11.1 and 18q12.3-->18q21.1 respectively. Maternal origin of the de novo ESAC and biparental origin of the normal homologues of chromosome 18 were shown by PCR of several highly polymorphic microsatellites. In this case, application of microFISH was a prerequisite for rapid and precise characterisation of an ESAC. A definite identification of this discontinuous supernumerary marker chromosome would not have been possible using FISH with centromere specific probes or multicolour FISH approaches.

Screening for UBE3A gene mutations in a group of Angelman syndrome patients selected according to non-stringent clinical criteria

The Angelman syndrome (AS) is caused by genetic abnormalities affecting the maternal copy of chromosome region 15q12. Until recently, the molecular diagnosis of AS relied on the detection of either a deletion at 15q11-13, a paternal uniparental disomy (UPD) for chromosome 15 or imprinting mutations. A fourth class of genetic defects underlying AS was recently described and consists of mutations of the UBE3A gene. The vast majority of mutations reported so far are predicted to cause major disruptions at the protein level. It is unclear whether mutations with less drastic consequences for the gene product could lead to milder forms of AS. We report on our results obtained by screening 101 clinically diagnosed AS patients for mutations in the UBE3A gene. Non-stringent clinical criteria were purposely applied for inclusion of AS patients in this study. The mutation search was carried out by single-strand conformation polymorphism (SSCP), and SSCP/restriction fragment length polymorphism (RFLP) analyses and revealed five novel UBE3A gene mutations as well as three different polymorphisms. All five mutations were detected in patients with typical features of AS and are predicted to cause frameshifts in four cases and the substitution of a highly conserved residue in the fifth. The results we obtained add to the as yet limited number of reports concerning UBE3A gene mutations. Important aspects that emerge from the data available to date is that the four classes of genetic defects known to underlie AS do not appear to cover all cases. The genetic defect underlying approximately 10% of AS cases, including some familial cases, remains unknown.

Recombinant balanced and unbalanced translocations as a consequence of a balanced complex chromosomal rearrangement involving eight breakpoints in four chromosomes

We report on a family with a balanced complex chromosomal rearrangement (CCR) involving eight breakpoints between chromosomes 6, 7, 18, and 21 in the father. All three sons inherited one derivative chromosome from the father and in addition each inherited a different recombinant chromosome resulting in a partial trisomy 6q in the first, an apparently balanced karyotype in the second, and a partial trisomy 7q in the third son. Fluorescence in situ hybridisation (FISH) and microsatellite analysis were essential for the identification of the breakpoints. In addition, the results were confirmed by a 24-colour FISH experiment using the spectral karyotyping (SKYtrade mark) system. Paternal origin of the de novo CCR in the father was demonstrated for the first time by haplotype analysis. This is the second report of a CCR leading to simpler but unbalanced translocations in offspring as a consequence of recombination during gametogenesis, and the first report of a family case of CCR exhibiting as many as eight breakpoints in the transmitting carrier. The initial prediction that viable offspring would be quite unlikely had to be revised after the birth of three children. Genetic counselling of carriers of balanced complex rearrangements has to consider a higher probability for unbalanced recombinations than has been so far commonly assumed.

Severe intra-uterine growth retardation in a patient with maternal uniparental disomy 22 and a 22-trisomic placenta

We report on a maternal uniparental disomy of chromosome 22 in a patient with severe intra-uterine growth retardation. Karyotyping of a placental tissue revealed non-mosaic trisomy 22, whereas lymphocyte chromosomes from the newborn were normal 46,XY. Microsatellite analysis using DNA extracted from white blood cells showed maternal uniparental heterodisomy for chromosome 22. Thus, the conceptus started as maternal trisomy due to meiotic non-disjunction, and trisomy rescue occurred subsequently through loss of the paternal homologue resulting in maternal uniparental disomy. Normal phenotypes in previous reports have suggested that maternal UPD 22 has no impact on the phenotype. Thus, growth retardation in this patient was probably caused by dysfunction of the trisomic placenta.

Molecular and clinical correlation study of Williams-Beuren syndrome: No evidence of molecular factors in the deletion region or imprinting affecting clinical outcome

Williams-Beuren syndrome (WBS) results from a deletion of 7q11.23 in 90-95% of all clinically typical cases. Clinical manifestation can be variable and therefore, deletion size, inherited elastin (ELN) and LIM kinase 1 (LIMK1) alleles, gender, and parental origin of deletion have been investigated for associations with clinical outcome. In an analysis of 85 confirmed deletion cases, no statistically significant associations were found after Bonferroni's correction for multiple pairwise comparisons. Furthermore, the present data do not support presence of imprinted genes in the WBS common deletion despite a nonsignificant excess of maternal over paternal deletions. Maternal deletion cases were more likely to have a large head circumference in the present data. Also, pairwise comparisons between individual WBS clinical features have been conducted and revealed significant associations between (1) low birth weight and poor postnatal weight gain (<10th percentile at the time of examination) and (2) transient infantile hypercalcemia and a stellate iris pattern. The latter association could indicate a common underlying etiology.

Terminal deletion, del(1)(p36.3), detected through screening for terminal deletions in patients with unclassified malformation syndromes

We report on a 4 year-old girl with a 1p36.3-pter deletion. Clinical findings included minor anomalies of face and distal limbs, patent ductus arteriosus, the Ebstein heart anomaly, and brain atrophy with seizures. Conventional GTG-banded chromosome analysis revealed a normal (46,XX) result. Subsequent analysis by fluorescent in situ hybridization (FISH) using distal probes demonstrated a deletion of 1p36.6-pter. Molecular investigations with microsatellite markers showed hemizygosity at three loci at 1p36.3 with loss of the paternal allele. The deletion of 1p36.3 is difficult to identify by banding alone; indeed, our patient represents the third reported case with a del(1)(p36.3) that was detected only after more detailed analysis. In all three cases the deletion was detected through screening of patients with multiple congenital anomalies/mental retardation syndromes suggestive of autosomal chromosome aberrations for subtelomeric submicroscopic deletions by means of FISH or microsatellite marker analysis. On the basis of these observations we highly recommend that FISH with a subtelomeric 1p probe be routinely performed in patients with similar facial phenotype, severe mental retardation and seizures, and a heart malformation, particularly the Ebstein anomaly.

Duplication of segment 1p21 following paternal insertional translocation, ins(6;1)(q25;p13.3p22.1)

A moderately mentally retarded 3 year old boy showed minor anomalies including a prominent forehead and flat occiput, exophthalmos, large and prominent ears, high arched palate, umbilical hernia, sacral dimple, and irregular position of the toes. Cardiac sonography disclosed a chorda running through the left ventricle. Cytogenetic investigation of the family showed a balanced insertional translocation of segment 1p13-->p22 into distal 6q in the father which had led, through unbalanced segregation, to duplication of 1p13.3-->p22.1 in the proband. Familial duplication of such a small interstitial segment of 1p has not been reported previously, and the paucity of abnormal physical findings in the proband compared to previous patients with a similar aberration is remarkable.

High level of unequal meiotic crossovers at the origin of the 22q11. 2 and 7q11.23 deletions

Interstitial chromosomal deletions at 22q11.2 and 7q11.23 are detected in the vast majority of patients affected by CATCH 22 syndromes and the Williams-Beuren syndrome, respectively. In a group of 15 Williams-Beuren patients, we have shown previously that a large number of 7q11.23 deletions occur in association with an interchromosomal rearrangement, indicative of an unequal crossing-over event between the two homologous chromosomes 7. In this study, we show that a similar mechanism also underlies the formation of the 22q11.2 deletions associated with CATCH 22. In eight out of 10 families with a proband affected by CATCH 22, we were able to show that a meiotic recombination had occurred at the critical deleted region based on segregation analysis of grandparental haplotypes. The incidences of crossovers observed between the closest informative markers, proximal and distal to the deletion, were compared with the expected recombination frequencies between the markers. A significant number of recombination events occur at the breakpoint of deletions in CATCH 22 patients (P = 2.99x10(-7)). The segregation analysis of haplotypes in three-generation families was also performed on an extended number of Williams-Beuren cases (22 cases in all). The statistically significant occurrence of meiotic crossovers (P = 4.45x10(-9)) further supports the previous findings. Thus, unequal meiotic crossover events appear to play a relevant role in the formation of the two interstitial deletions. The recurrence risk for healthy parents in cases where such meiotic recombinations can be demonstrated is probably negligible. Such a finding is in agreement with the predominantly sporadic occurrence of the 22q11.2 and 7q11. 23 deletions. No parent-of-origin bias was observed in the two groups of patients with regard to the origin of the deletion and to the occurrence of inter- versus intrachromosomal rearrangements.

Isochromosomes 12p and 9p: parental origin and possible mechanisms of formation

In a recent study Bugge et al and Kotzot et al reported that isochromosomes 18p originate mainly from maternal meiosis II nondisjunction, followed by misdivision. In order to determine if there is a common mechanism for isochromosome formation, three cases with mosaicism for an additional isochromosome 12p and three cases with tetrasomy 9p were studied. Two probands with isochromosomes 12p and the three cases with isochromosome 9p showed 3 alleles (two different maternal alleles and one paternal allele) at several loci mapping to distal 12p and 9p, respectively. Maternal heterozygosity for distal markers was reduced to homozygosity for markers closer to the centromere in both i(12p) cases and in one i(9p) case. For one patient with isochromosome 12p, the maternal band was clearly stronger than the paternal one at some loci, but two distinct maternal alleles were never seen. For one foetus and the patient with tetrasomy 9p, distal markers showed maternal heterozygosity. All proximal markers were not informative in these two i(9p) cases. Our findings indicate common features in different autosomal isochromosomes: the origin of the isochromosomes analysed in predominantly maternal; and a common mechanism appears to underlie their formation, namely due to meiosis II nondisjunction followed by a rearrangements leading to duplication of the short and loss of the long arm.

Management of the gastrointestinal tract and nutrition in patients with cloacal exstrophy

Cloacal exstrophy is a rare condition in which there is a complex set of congenital anomalies that affect multiple-organ systems, including the gastrointestinal tract. Twenty-six patients with cloacal exstrophy have been treated at the authors' institution during the last 20 years. Gastrointestinal features usually included omphalocele, exstrophy of an everted cecal plate, a short blind-ending distal colon, imperforate anus, and, occasionally, a shortened small bowel. Additional gastrointestinal anomalies included four cases of colonic duplication, one duodenal web, and one malrotation. The average time until the initiation of enteral feeding after initial surgery was 15.6 days, and the time until discontinuation of total parenteral nutrition (TPN) was 36 days. One patient with short bowel syndrome died of TPN-associated liver failure. Five other patients exhibited short bowel physiology, but ultimately each was weaned from supplemental intravenous hyperalimentation. Four patients have undergone posterior sagittal anorectoplasty, and one has had perineal anoplasty. Of these patients, two are continent and one is free of soilage on a bowel management program. In the authors' experience with management of the gastrointestinal tract and nutrition in patients born with cloacal exstrophy, many patients initially exhibited short bowel physiology, although most eventually adapted. However, very few patients have been able to achieve bowel control.