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Do I add value? A mixed methods study comparing medical students’ experiences with patient documentation
Shannon Haines, Kari Nelson, Kaeli Samson, and Nathan Gollehon
Background
Clinical documentation is an essential skill for practicing physicians, yet many medical students are not prepared for the documentation demands required during residency.1,2 Recent CMS rule changes now allow medical students’ notes to be used for billing.3 Previous studies have shown positive perceptions of medical students whose notes were used in an outpatient setting.4 We utilized Constructivist Learning Theory to frame our work, where students construct their knowledge as faculty and residents facilitate the process.5
Objectives
To explore if using student documentation for billing impacts student perceptions and experiences during the pediatric clerkship.
Methods
Pediatric clerkship students were randomly assigned to one of two inpatient hospitalist teams: Control group students (n=28), whose daily notes were not addended or used for billing purposes, and Study group students (n=42) who wrote notes that were used for billing. After study group students signed the notes, they were addended and cosigned by a resident and subsequently a faculty member who submitted the note for billing. There was no specific feedback structure or documentation curriculum provided to either study arm. We utilized a sequential mixed methods approach (quant+qual), with a survey that included fixed response and open-ended questions, as well as an opportunity to participate in a focus group. Differences in Likert-type questions between groups were assessed with Wilcoxon Rank Sum tests. Open-ended survey responses and focus groups were analyzed using inductive thematic analysis, with consensus among 3 researchers and respondent validation.
Results
Study group students found their experience more valuable, rated the usefulness of feedback from residents higher, and spent more time reviewing edits to their notes than their peers in the control group (p=<0.05).In focus groups and open-ended survey responses, themes from the study group included feeling more useful to the team and receiving more one-on-one feedback. They also reported that there was feedback inherent in reviewing supervisors’ edits to their notes. Control group students reported they focused their time on tasks other than note writing. Both groups reported that the practice of writing notes helped organize their thoughts and plans.
Discussion
In this exploratory study, use of student notes for billing was associated with feelings of value and enhanced feedback compared to students whose notes were not used. These findings support the use of medical student notes for documentation as a worthwhile educational practice and highlight the need for further study to define curricular interventions that foster development of this essential professional skill.
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To addend or not to addend? Exploring pediatric residents' perceptions of using medical students’ notes for documentation, a mixed methods approach
Shannon Haines, Kari Nelson, Kaeli Samson, and Nathan Gollehon
Background
Clinical documentation is an essential skill for practicing physicians, yet many medical students are not prepared for documentation required during residency.1,2 CMS rule changes now allow medical students’ notes to be used for billing.3 Residents are often the primary authors of notes and provide medical student supervision and instruction. However, little is known about how the use of medical student notes in patient documentation would impact residents. We utilized Constructivist Learning Theory to frame our work, where students construct their knowledge as residents and subsequently faculty facilitate the process.4
Objectives
To evaluate how utilizing clerkship medical student notes for billing in the inpatient setting impacts resident learners.
Methods
Pediatric clerkship students were randomly assigned to one of two inpatient hospitalist teams: Control group students wrote daily notes that were not addended or used for billing purposes; and Study group students wrote notes that were used for billing. After study group students signed the notes, they were addended and cosigned by a resident and a faculty member who submitted the note for billing. There was no structured feedback or documentation curriculum provided to either study arm. We utilized a sequential mixed methods approach (quant + QUAL); junior and senior residents were given a survey with Likert-type items related to their satisfaction with the process, and an opportunity to participate in focus groups. Sixteen residents who supervised the control group and twenty residents who supervised the study group completed the survey, with responses analyzed using Wilcoxon Rank Sums tests. Focus groups were analyzed using inductive thematic analysis, with consensus among three researchers and respondent validation of participants.
Results
In surveys, residents supervising both groups reported similar satisfaction scores with medical student documentation. There was a trend towards increased time spent providing feedback on notes among the study group, but this did not reach statistical significance. In focus groups, emergent themes included the educational value for students and residents, positive impacts on student experience, minimal negative impacts on patient care, and possible impacts on team workflow.
Discussion
Medical students' notes are being increasingly used for EMR/billing; therefore, it is important to understand upstream effects on other learners. Recently published qualitative research has explored the resident perspective, but did not use a control group, and had varying results from our own with regard to workflow.5 If use of student notes for billing is to become common practice, more study is needed to understand the impacts on resident learners.
1. Englander R, et al(2016) Toward defining the foundation of the MD degree: Core entrustable professional activities for entering residency. Academic Medicine. 91(10):1352-1358.
2. Power D, Byerley J, Steiner B. (2018) Policy change from the centers for Medicare and Medicaid Services provides an opportunity to improve medical student education and recruit community preceptors. Academic Medicine,
3. Department of Health & Human Services. CMS Manual System Publication100-04 Medicare claims processing:
4. Bruner, J.S. (1961). The act of discovery. Harvard Educational Review, 31: 21-32.
5. Safdar K, Dombrosky EM, Kimberly C, et al. The One Note System: Implementation and Initial Perceptions of Student Documentation in the Electronic Health Records Under the New Centers for Medicare and Medicaid Services Guidelines. Cureus. 2020;12(8):e9702. Published 2020 Aug 12. doi:10.7759/cureus.9702
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Profound Neonatal Anemia Due to a Fetal to Maternal Hemorrhage: A Case Study
Margaret Hogan Smoot and Terrance Zach
A female infant was born by cesarean section at 36 weeks of gestation after the mother presented with perceived decreased fetal movement, blood-tinged mucous vaginal discharge, and a non-reactive non-stress test. Upon delivery, the infant appeared extremely pale and in mild respiratory distress. A complete blood count upon admission showed profound neonatal anemia, and a Kleihaur-Betke test confirmed fetomaternal hemorrhage as the cause. Transfusions corrected the infant’s hematocrit levels, and she was discharged on day 8 following a normal brain MRI. Fetal to maternal hemorrhage is a known cause of neonatal anemia, however the presentation is nonspecific leading to underdiagnosis which can cause serious complications including infant death. Fetomaternal hemorrhage is a rare and severe phenomenon which requires increased awareness, improved diagnostic testing, and further research.
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MiR-1253 Potentiates Cisplatin Response in Pediatric Medulloblastoma by Regulating Ferroptosis
Ranjana K. Kanchan, Naveenkumar Perumal, Pranita Atri, Ramakanth C. Venkata, Ishwor Thapa, Mohd W. Nasser, Surinder K. Batra, and Sidharth Mahapatra
Introduction Among CNS tumors, medulloblastoma (MB) is the most common malignant pediatric brain tumor. Of the four subgroups, group 3 (G3MB) tumors fare the worst. Haploinsufficiency of 17p13.3 is a hallmark of these high-risk tumors; included within this locus is miR-1253, which has tumor suppressive properties in medulloblastoma. Therapeutic strategies capitalizing on the anti-neoplastic properties of miRNAs can provide promising adjuncts that can improve efficacy while mitigating toxicity of current chemotherapeutic drugs.
Objective In this study, we explored the potentiation of miR-1253 on cisplatin cytotoxicity in group 3 MB.
Methods We used RNA Sequencing to isolate a putative target for miR-1253 that is upregulated in G3MB, has a poor prognostic profile, and is involved in iron balance/ferroptosis. Calein AM quenching, COX IV staining and multiple stains for iron were used to study mitochondrial vs. free cytosolic iron generation. Confocal microscopy and FACs analyses were used to examine ROS generation and lipid peroxidation. Using 2 classical group 3 MB cell lines, possessing c-Myc amplification and i17q, we determined the IC50 of cisplatin in the presence of miR-1253 expression using MTT assay. We also studied colony formation, apoptosis and oxidative stress, as cisplatin is an inducer of both. Finally, ROS and ferroptosis inhibitors were used to study effects on tumor cell rescue from miR-1253 and cisplatin therapy.
Results In silico and in vitro analyses revealed upregulation of ABCB7 in G3MB cancer cells and tumors. Overexpressing miR-1253, in turn, suppressed ABCB7, revealing it as a putative target with poor survival in high-expressing MB tumors. Overexpression also led to a suppression of GPX4, a ferroptosis regulator, consequently increasing labile iron pool within the mitochondria and resulting in mtROS induction. Cisplatin is reported as an inducer of both apoptosis and ferroptosis-mediated cancer cell death. In miR-1253-overexpressing cancer cells, we observed a cumulative effect on cell death and colony formation with cisplatin; treatment with ROS and ferroptosis inhibitors abrogated these effects.
Conclusions We conclude that miR-1253 potentiates the ferroptotic effects of cisplatin via targeting miR-1253/ABCB7/GPX4 axis.
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Direct Hyperbilirubinemia in Infants with Trisomy 13 and 18
Jeffrey Kepple and Eric Peeples
Background: Survival in trisomy 13 (T13) and 18 (T18) has increased in recent years, but little is known about the prevalence and management of the non-lethal complications in these populations.
Significance of Problem: A subjectively high rate of direct hyperbilirubinemia (DH) was noted at Children’s Hospital & Medical Center compared to the general population. Defining the prevalence, timing, and risk factors for DH will allow for the development of screening and management guidelines.
Hypothesis, Problem or Question: We hypothesized that infants with T13 and T18 would have high rates of DH, with no significant difference in prevalence between the two populations.
Experimental Design: Retrospective cohort study of infants born between Jan 1, 2012 and March 1, 2020 and admitted to the NICU at Children’s or the Nebraska Medical Center within the first month of life. Data collected included bilirubin, ALT, AST, and GGT levels, liver imaging, and any treatment administered. DH is defined as conjugated bilirubin >1 mg/dL, but the cutoff of >2 mg/dL has a higher association with underlying pathology. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous variables in DH for both cutoffs.
Results/Data: Thirty-five patients met inclusion criteria: 13 with T13 and 22 with T18. When using the >1 mg/dL cutoff, DH was seen in 7/13 (53.8%) patients with T13 and 9/22 (40.9%) with T18, which was not significantly different between the two diagnoses. Twelve of the 16 infants with DH developed DH in the first two weeks of life and, although it did not reach significance, patients with T13 tended to present with DH earlier than those with T18 (median 5 vs. 12 days of life). DH occurred more often in infants who received TPN (81.3 vs. 36.8%, p=0.016). DH was associated with higher peak AST (p=0.004), ALT (p=0.002), but not GGT (p=0.176) levels. The presence of an abnormal ultrasound was not associated with DH. Six infants were treated with phenobarbital or ursodiol, and 5/6 normalized their conjugated bilirubin levels within one week of starting therapy.
Conclusions: DH was common in infants with T13 and T18, and at a qualitatively higher prevalence than what has previously been reported in the general population, even if excluding those infants who received TPN. Clinicians should consider screening for DH starting within the first week of life in both trisomy 13 and 18, continuing weekly if <1 mg>/dL until discharge from hospital.
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Perceptions of Pediatricians on the SARs-CoV2 Vaccine
Karl Khandalavala, Kari Simonsen, and Jeffrey A. Robinson
Introduction: The novel SARs-CoV2 coronavirus has infected approximately 30,000,000 people in the USA. To date, approximately 146 million doses of SARs-CoV2 vaccines have been administered. Perceptions of rapid vaccine development have resulted in reported vaccine hesitancy and refusal. Though not currently FDA approved for use in pediatric populations, but pediatric vaccination may contribute to herd immunity. Previous study demonstrates that physician recommendations significantly impact perceptions of routine pediatric immunizations among parents. Given this historical data, this study aimed to describe the strength of recommendation by pediatricians for the SARs-CoV2 vaccine for pediatric patients and their parents.
Methods: A 10-question single-institution anonymous survey was distributed to physicians in the Department of Pediatrics, consisting of 2 demographic questions, 5 Likert-style survey questions on vaccine recommendations, and 2 free-responses for comments on current vaccine development for thematic analysis.
Results: There were 90 survey responses, and no responses were excluded from analysis. The most common sources of vaccine information among pediatricians were peer-reviewed journals (51%) and major broadcast or print materials (30%). A majority of pediatricians indicated that they read about vaccine information either weekly (44%) or monthly (27%). Of the survey respondents, 99% indicated that they had personally received a SARs-CoV2 vaccine. For pediatric vaccine recommendations, 69% responded that they strongly encouraged their pediatric patients to receive a SARs-CoV2 vaccine, compared to 87% recommending SARs-CoV2 vaccine for parents and 96% recommending the annual influenza vaccine. Thematic analysis of free response questions demonstrated that physicians cited the need for herd immunity (42%) and the protection of their patients (41%) as reasons for recommending the vaccine, and cited lack of research or FDA approval of vaccine use in pediatric populations (61%) as reasons for recommending against receiving the vaccine.
Conclusions: This single-center survey study demonstrated that a majority of pediatricians strongly encourage their pediatric patients to receive a SARs-CoV2 vaccine, though not as strongly as they recommend vaccination to their patients’ parents or vaccination against influenza. Thematic analysis indicated that physicians cite the need for population-level herd immunity as well as individual-level protection from SARs-CoV2 infection as a basis for their vaccine recommendations.
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Computer-Assisted Analysis of Soccer Ball Trauma of the Eye
Matthew Lam, Pengfei Dong, Yasin Shokrollahi, Donny Suh, and Linxia Gu
Purpose: Sports-related eye injuries are common in the United States and around the world, particularly in youth. Over half of patients presenting with these injuries are of 18 years or younger, and sports and recreation account for nearly a quarter of all pediatric eye injuries treated in US emergency departments. Soccer is the most popular game in the world and is the leading source of sports-related eye injury in Europe and Israel. Soccer injuries cause visual impairment at a disproportionately higher rate than other sports. This study investigates the mechanisms of injury. Methods: A finite element simulation was developed to study the distribution of stresses in the eye following the impact of a soccer ball. The eye model was composed of sclera, vitreous, and retina. The retina was simulated as three layers: preretinal, intraretinal, and subretinal. Vitreoretinal adhesions were incorporated along retinal vessels. Results: The anterior pole experienced a peak stress of 69.8 kPa following impact of the soccer ball. The impact induced a pressure wave within the vitreous that traveled latitudinally along the anterior-posterior axis and repeatedly reflected from the intraocular tissue. Oscillations of high and negative pressure in the vitreous resulting from the pressure wave were greatest at the posterior pole. Stresses within the retina were highest along the retinal vasculature, especially at the distal bifurcations where the peak stress was 15.4 kPa. The subretinal layer experienced more stress than the preretinal and intraretinal layers except along the vasculature, at which the preretinal layer experienced more stress. Conclusions: The distribution of stresses within the eye quantify and expand on frequently proposed biomechanical bases for ocular injuries resulting from soccer ball trauma. High stress near the point of impact may account for commonly observed anterior segment injuries. Negative pressures within the vitreous adjacent to the posterior retina provide further support for the anterior pulling of the retina as a potential mechanism for posteriorly localized retinal lesions. These patterns of stress throughout the eye highlight the importance of eye protection in soccer and other sports, which have been demonstrated to prevent up to 90% of ocular injury.
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Food Protein Induced Enterocolitis Syndrome Triggers at Children’s Hospital
Rachel Nelson and Russell Hopp
Background
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food disease characterized by delayed vomiting and diarrhea, often at the first ingestion of the food. The clinical phenotype of FPIES, including trigger food and disease course, varies by region. A literature review of the most common FPIES foods in children in the United States and worldwide includes cow’s milk, soy, oats, rice, and egg.
Objective:
We sought to survey the most common FPIES foods seen at Children’s hospital in the past five years.
Methods:
A data search of the EPIC electronic medical record using FPIES codes ICD-10 (K52.21) and ICD-9 (558.3) as the primary diagnosis revealed 40 cases and 23 foods.
Results:
The five most common foods seen in FPIES cases presenting at Children’s Hospital are oat, rice, sweet potato, milk and egg. Fish was much more common in our cohort than in the previously studied populations.
We also report the most recently diagnosed FPIES cases at Children’s hospital. One case with two less common food triggers, and a case of FPIES with concomitant IgE positivity to the food (atypical FPIES).
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Spring
Olufemi Oladokun
This original piece, "Spring" using chalk pastel on textured paper evokes a sense of warmth, life and playfulness. The art-work (13"x11") depicting an infant playing with a stethoscope makes use of vibrant strokes and a color scheme that I believe captures some of the more endearing features of children, a certain courage and curiosity frequently encountered by professionals within pediatrics. The infant stares back, briefly yet frozen in time, offering its attention as a gift to the viewer.
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3D Printed Adjustable Glasses: A New Model of Corrective Lens Delivery for Pediatric Refractive Error in Underserved Communities
Nathan Ostlie, Mari Ogino, Donny Suh, Gabe Linke, and James Hermsen
Purpose:
Uncorrected refractive error (URE) remains a major cause of preventable vision impairment in the pediatric population with large inequities in disease burden. The present study aims to elucidate the global burden of pediatric URE and explore the current lens delivery systems which address this problem. Within this framework, we introduce a new model of corrective lens delivery that may improve upon existing models.
Methods:
The present study involved an extensive literature review of epidemiological data to determine the global prevalence of URE. Prevalence data was then compared against WHO data on refractionist coverage gaps divided by region. Four current models for corrective lens delivery, plus our newly proposed model, were compared across five general categories (Fit, Appearance, Pathologies Corrected, Cost to Patient, Distribution System).
Results:
In children, the estimated pooled prevalence (EPP) of myopia, hyperopia, and astigmatism was 11.7% (95% CI: 10.5–13.0), 4.6% (95% CI: 3.9–5.2), and 14.9% (95% CI: 12.7–17.1), respectively. The highest prevalence of astigmatism and hyperopia occurs in The Americas at double and triple the global average respectively. The regions with the poorest coverage of URE were Sub-Saharan Africa, Southeast Asia and The Americas. Existing solutions delivering coverage to these areas often lacks the ability to correct for astigmatism. Our modular glasses design provides a one-size-fits-all frame with circular lens mounts to accommodate any axis of astigmatism. 3D printed materials allow these frames to be constructed at a fraction of the cost of conventional frames.
Discussion:
While corrective lenses are made available through a variety of distribution models, the infrastructure to fit and deliver these glasses to remote and resource poor areas remains a major challenge leading to inequities in URE treatment. The flexibility of our glasses design allows for these glasses to be distributed in rural and urban environments alike, with minimal training required to fit and assemble, at a low cost to patients.
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Postnatal Diagnosis of Dandy Walker Malformation with Encephalocele
Heerali Patel
Encephalocele is a defect of the neural tube. Dandy Walker malformation (DWM) is a defect involving agenesis or hypoplasia of the cerebellar vermis, cystic dilation of the fourth ventricle, and enlargement of the posterior fossa. This is a case of a female preterm infant born at 36 weeks’ gestation who presented with DWM and an encapsulated occipital encephalocele at birth. The pregnancy was complicated by poorly controlled maternal diabetes. Prenatal ultrasound indicated a central nervous system anomaly. Amniocentesis did not show chromosomal abnormality. The infant also presented with polydactyly of the right thumb. MRI showed evidence of soft tissue within the defect and confirmed the presence of DWM. Renal ultrasound was normal. Whole exome sequencing revealed three variants of possible pathologic or unknown significance. No variants of known clinical significance were found. The encephalocele was repaired by ventriculoperitoneal shunt and cranioplasty at 18 days of age.
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Relationship between miR-335 and sterol levels after in vitro hypoxia-ischemia of primary brain cells
Namood-E Sahar, Zeljka Korade, and Eric Peeples
Background/Purpose: Cholesterol homeostasis is vital for synaptogenesis and myelination during fetal and neonatal brain development. Both brain and plasma sterol levels have been shown to be associated with outcomes in adult stroke, and animal studies have suggested brain and plasma sterol changes in neonatal hypoxic-ischemic brain injury. MicroRNA-335 (miR-335) has been associated with brain sterol metabolism and our preliminary data showed that sterol metabolism is dysregulated in the brain after hypoxic-ischemic injury in a mouse model. This study sought to describe the effect of oxygen-glucose deprivation in vitro on individual brain cell populations and to validate the associations between sterol levels and miR-335 levels. Lastly, we assessed the feasibility of transfecting miR-335 mimics or miRNA antagonists (antagomiRs) in these brain cell cultures to set up future experiments to alter miR-335 levels for neuroprotection.
Methods: Primary cells were isolated from embryonic day 18 CD1 mouse brains. Cells were maintained in DMEM for mixed glial culture and Neurobasal media with B27 for neurons. Once astrocytes were confluent, microglia were separated from the mixed glial culture by shaking to provide pure cell populations. Each of the three cell types underwent oxygen and glucose deprivation (OGD: glucose/pyruvate/B27-free media, 1% O2, 5% CO2) for 4 hours followed by replacement of glucose/pyruvate/B27 and resumption of normoxia. At 24 hours after OGD, cells (n=12 wells OGD and 12 normoxia) were washed, counted, and sterols analyzed by LC-MS/MS, normalized to the number of cells/well. Additional cells underwent measurement of miR-335 expression using quantitative PCR and/or transfection with miR-335 mimic or antagomiR.
Results: Although lanosterol is increased after OGD in neurons, desmosterol and cholesterol levels were decreased. In microglia and astrocytes, cholesterol levels were lower than in neurons but increased after OGD. MiR-335 expression in neurons and astrocytes were inverse to cholesterol level changes, though this association was not seen in microglia. Lastly, red fluorescent protein-labelled miR-335 mimic was visualized in both neurons and astrocytes after transfection and miR-335 expression changes were seen after transfection in astrocytes.
Conclusions: Sterol levels are altered after OGD and may be associated with OGD changes. Transfection of miR-335 mimic and antagomiR is feasible and future studies using these tools will allow for better understanding of the effects of neonatal HIBI on sterol levels. This approach could allow for identification of targets to aid in developing therapeutics.
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Expanding the phenotype of HNRNPU-related disorders to include brief, resolved, unexplained events (BRUE)
Jonah Scheffler, Kristen P. Fishler, and Lois J. Starr
hnRNP-U deficiency is caused by pathogenic variants in HNRNPU, which encodes the heterogeneous nuclear ribonucleoprotein U (HNRNPU), a highly conserved protein responsible for assisting spliceosomes in mediating transcription and alternative splicing activity. HnRNPs are responsible for the regulation of translation at the presynaptic sites as well as the transportation of stabilized mRNAs along the axonal cytoskeleton. Here, we report a 2-year-old-male with a HNRNPU variant with a new presentation of apparent recurrent apneic spells with an underlying epileptic origin. These were described as apnea followed by desaturation and tachycardia in the 180's-200 range prior to resolution of symptoms. He also had autistiform behaviors, hypotonia, global developmental delay, heart defects, and unique facial features. The anesthetist professional parents describe multiple BRUE. At 26 months, he presented to the hospital with hypotonia and unique facial features, global developmental delay, autistiform behaviors, dyspraxia with cognitive disability and a change in mental status. On physical exam, the proband had telecanthus, a broad nasal bridge, short palpebral fissures, mild nevus flammeus changes on his face, a single right palmar crease, and a modified single crease on the left. EKG showed a sinus rhythm with intermittent 1st degree AV block, blocked premature atrial contractions, left axis deviation, right bundle branch block, and an ejection fraction of 67%. Echocardiography re-identified an atrial septal defect. Brain MRI showed a T2/FLAIR hyperintense signal in the white matter of the parietal lobes, left greater than right. EEG identified generalized slowing indicative of a mild nonspecific encephalopathy. History of episodes were determined to be consistent with partial onset seizures with eye opening, deviation, and tachycardia with apnea and medical treatment ensued.
Genetic testing including microarray and an epilepsy panel that identified no genomic dosage anomalies and a de novo nonsense mutation (c.803+2T>C; p. unknown in HNRNPU), classified as pathogenic. The study of hnRNP complexes have gained momentum in neurodegenerative and tumorigenesis disease research. hnRNPs have a key role in mediating transcription, alternative splicing, and translation activity. Recently, Durkin et al, 2020 (PMID: 32319732) reported 21 previously unreported probands; nearly doubling the recorded patient population. Probands in the literature to date have had variable presentation, but usually with hypotonia, global developmental delays, and seizures. This suggests the addition of HNRNPU to all seizure-related diagnostic panels. We would also recommend including the HNRNPU-related disorders in a differential diagnosis of BRUE and recurrent apneic episodes as any underlying clonic activity may be profoundly subtle.
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Comparison of Third Year Medical Student Wellness Before and During the SARS-CoV2 Pandemic
Jenna Scholl, Oladapo Akinmoladun, Amissabah Kanley, Nathan Gollehon, and Jason Burrows
Introduction
Depression and suicidal ideation have a higher prevalence in medical students when compared to other age-matched populations.1,2 The SARS-CoV2 pandemic has further threatened medical trainee well-being with increased stress and risk of mental illness.3,4
Objective
To compare medical student well-being at a single institution before and during the SARS-CoV2 pandemic.
Methods
Third year medical students at a single institution voluntarily completed a survey during pediatric clerkship orientation as part of an ongoing, non-pandemic longitudinal wellness study. The survey instrument includes basic demographic information, the validated World Health Organization (WHO) (FIVE) Well-Being Index (WHO-5), and questions about physical activity. Data from mid-academic year students rotating on the pediatric clerkship in the 2019-2020 (two cohorts, pre-pandemic) and 2020-21 (three cohorts, during pandemic) academic years were compared across compositive survey scores and sub-question scores.
Results
Study participation was 81% pre-pandemic (n=34) and 59% during the pandemic (n=39) with no statistically significant differences in age or gender. Mean WHO-5 well-being scores trended up from the pre-pandemic to pandemic groups without reaching statistical significance (16.3 vs 17.5, p=0.13). The mean individual survey question on feeling fresh and rested significantly improved from pre-pandemic to pandemic groups (2.74 vs 3.23, p<0.05). Remaining question mean scores were similar or trended toward improved well-being from pre-pandemic to pandemic groups; cheerful/good spirits (3.62 vs 3.82, p=0.15), calm/relaxed (3.32 vs 3.33, p=0.48), active/vigorous (3.18 vs 3.31, p=0.28), and interest in daily life (3.41 vs 3.79, p=0.08). Based on using the composite WHO-5 survey as a validated tool to screen for depression, there was a trend towards less students screening positive for depression in the pandemic group (26.5% pre-pandemic vs 10.5% pandemic, p=0.07).
Discussion
From our small sample of third year medical students at a single institution, we find that well-being is stable when comparing matched groups across academic years before and during the SARS-CoV2 pandemic. Interestingly, survey subsection data demonstrates improved subjective feelings of being rested in the pandemic group and suggests lower rates of depression based on screening cutoffs (WHO-5). We suspect this may be related to changes in the educational environment such as transitioning from the clinical environment to virtual rotations, or time away from rotations entirely which may have allowed for increased personal wellness time. Focus groups and further investigation are necessary to identify which factors are altering levels of student well-being.
References
- Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med J Assoc Am Med Coll. 2006;81(4):354-373. doi:10.1097/00001888-200604000-00009
- Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016;316(21):2214-2236. doi:10.1001/jama.2016.17324
- Kannampallil TG, Goss CW, Evanoff BA, Strickland JR, McAlister RP, Duncan J. Exposure to COVID-19 patients increases physician trainee stress and burnout. PLOS ONE. 2020;15(8):e0237301. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237301. Accessed Oct 5, 2020. doi: 10.1371/journal.pone.0237301.
- Wu S, Li Z, Li Z, et al. The mental state and risk factors of chinese medical staff and medical students in early stages of the COVID-19 epidemic. Compr Psychiatry. 2020;102:152202. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437442/. Accessed Oct 21, 2020. doi: 10.1016/j.comppsych.2020.152202.
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Patchwork Pericardium
Sarah Small
"Patchwork Pericardium" is a reflection into what we see and don't see in medicine as a whole picture. From my lens as third-year medical students, I learned how it important it was to be observant to the world around me.
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Severe Colitis and Malnutrition in Association with Neonatal Hemophagocytic Lymphohistiocytosis
Laura Tarantino
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome of overwhelming immune activation causing multiorgan dysfunction that may be genetic and/or acquired. Patients with familial HLH often present by one year of age, though most are asymptomatic in the first month of life. We present the case of a neonate with diarrhea and malnutrition who developed signs and symptoms consistent with a clinical diagnosis of HLH.
Case: A neonate born at 35 5/7 weeks was transferred to a Level IV neonatal intensive care unit at 39 4/7 weeks for failure to thrive. Though feeding adequately and non-dysmorphic, he had persistent diarrhea on multiple formulas and only gained small amounts of weight via total parental nutrition. He was the first child of consanguineous parents of South Asian descent. Evaluation was inconsistent with milk soy protein intolerance and malabsorption syndromes. Very-early-onset inflammatory bowel disease and congenital diarrheas/enteropathies were considered. Intestinal biopsy was concerning for an underlying primary immunodeficiency. Additional studies showed a mild increase in T cells and low IgM. Lymphocyte proliferation to mitogens and expression of FOXP3, XIAP, and SAP by flow cytometry were unremarkable. At age 44 weeks, he acutely became lethargic, with fevers to 40°C and metabolic acidosis, further developing anemia, thrombocytopenia, lymphocytosis, transaminitis, and hepatosplenomegaly. Hypofibrinogenemia, hyperferritinemia (>10,000), and elevated Soluble IL-2R level led to HLH diagnosis. Per HLH-94 protocol, he began dexamethasone and etoposide; he also received emapalumab. Despite treatment, fulminant liver failure with uncontrollable DIC ensued. Life-sustaining treatments were withdrawn and he died at 46 3/7 weeks.
Discussion: Though colitis is not classically a feature of most primary HLH syndromes, it has been described in one subset of familial HLH. However, sequencing of the associated gene (STXBP2) was normal in our patient. Similarly, among EBV-driven HLH, X-linked lymphoproliferative disease and XIAP deficiency are associated with hypogammaglobulinemia and colitis respectively, but expression of these was normal without evidence of EBV. Perforin/granzyme B expression was increased. Whole-exome sequencing (WES) revealed several variants of unknown significance but was ultimately nondiagnostic. While neonates are more likely to have genetic causes for HLH, around 40% of neonates do not have established genetic diagnoses after WES.
Conclusion: Timely recognition of HLH maximizes the potential for effective treatment like hematopoietic stem cell transplantation. Recognition of colitis as a presenting symptom may facilitate this challenging diagnosis. Rapid and inclusive genetic evaluation, including WES, may help identify the underlying etiology and guide treatment for neonatal HLH.
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The Blessings of Human Connection
Taylor Thieman
For my best friend, a healthcare hero, who herself spent several weeks in the NICU as a premature baby and is now helping other babies and their families as a NICU nurse.
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Homer
John Walburn
Because of the importance of pets in children's lives, I submit a black-and-white head and shoulders photographic portrait of Homer, a beloved neighborhood dog from when children were younger. Photographed by me and developed and printed in my own darkroom. Every family in the neighborhood had a copy of this photographic portrait prominently displayed in their homes, and some might remember this photograph from my old office.
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Klinefelter’s Syndrome: A fortuitously diagnosed by non-invasive prenatal testing
Steven V. Yackley and Terence L. Zach
Case Report: A male infant born at 37 weeks gestation. His mother was a 29-year-old, gravida 4 para 3 woman. During her pregnancy she was curious as to the gender of the fetus and requested a non-invasive prenatal test (NIPT) rather than fetal ultrasound. The NIPT returned with a karyotype of XXY. The male infant was born vaginally with a birth weight of 2670 grams. Apgar scores were 8 and 9 at one and five minutes respectively. He was admitted to the newborn intensive care unit secondary to respiratory distress. He had no obvious dysmorphic features. He had normal appearing male genitalia with testes descended bilaterally. Fluorescent in situ hybridization and blood chromosomes confirmed an XXY karyotype. He was discharged from the newborn intensive care unit with follow up by genetic counselors and close monitoring for developmental delays
Background: Klinefelter Syndrome (KS), a genetic disorder caused by the presence of supernumerary sex chromosomes. An additional X chromosome(s) and hypogonadism are the two defining features of KS. The excess of genes from the additional X chromosome drives the pathogenesis of the disease and distinguishing features of the affected individuals. The increase in the prevalence of prenatal testing has led to the earlier recognition of fetal chromosomal abnormalities. Early detection of KS through NIPT has given the family much needed information and allowing for early diagnosis and intervention, to promote the best outcome for the child. This case shows a patient that will benefit from the early diagnosis of a KS to implement early and timely interventions upon delivery and then later in the developing years. The neonate presented with no distinct, characteristic signs of KS, common in many individuals. Two findings, other than the NIPT results, weakly suggest any possible abnormality. Klinefelter neonates report mildly higher incidences of respiratory distress and low birth weight necessitating need for NICU admission. The underwhelming clinical presentation of the neonate shows that if NIPT wasn’t conducted, neither our patient nor his family would have known he was 47,XXY, until much later in life.
IMPLICATIONS: Timely hormonal intervention is possible for our patient because of NIPT. This demonstrates a need of a standard KS screen. With the technology of NIPT advancing and improving in its ability to detect a variety of other conditions outside of the traditional autosomal aneuploidy, it should be considered a technique for screening for clinically silent conditions, such as mild KS phonotypes.
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