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Inherent in every clinical preceptor's role is the ability to understand the learning needs of individual trainees, enabling them to meet their potential. Competency-based medical education frameworks have been developed to this end, but efforts to identify behaviours and activities that define competence are based on mapping knowledge, skills and ability, which can be difficult to integrate into a comprehensive picture of who the trainee is becoming. Professional identity formation, in contrast, prioritizes attention to who trainees are becoming, but provision of detailed guidance to preceptors on how to best support this form of development is challenging. The tension that results limits our ability to optimally support learners as strengths in competency development may mask professional identity development gaps and vice versa. To address this tension, this paper examines how the theory of threshold concepts - troublesome ideas that, once appreciated, fundamentally change how you understand and approach a particular activity - can shine light on professional identity formation and its relationship with developing competence. The recognition and identification of threshold concepts is offered as a means to improve our ability to identify, discuss and support behaviours and actions that impact the learner's capacity to act competently as they develop their identity at various stages of training., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Objectives: Data driven strategies for acute pancreatitis (AP) in pediatrics are limited; adult data suggests lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes, but has not been studied in pediatrics. Our objective was to evaluate the efficacy of LR during the first 48 h of an AP episode compared with NS., Study Design: A multisite randomized controlled clinical trial, from 2015 to 2020 (Clinical Trials.gov NCT03242473). Patients were randomized to exclusively LR or NS for the first 48 h. Primary outcomes were serial C-reactive protein (CRP) values. Secondary outcomes included other lab values, time to feeds, length of stay (LOS), systemic inflammatory response syndrome (SIRS) development, and progression to severe AP (SAP)., Results: We studied 76 patients (38 LR, 38 NS). CRP at 24 and 48 h were not significantly different between LR or NS group. Additionally, there were no differences in trends of BUN, amylase, lipase, SIRS status, or SAP development between the LR and NS group at 24 and 48 h. A higher proportion of LR patients (32%, 12/38) were discharged before 48 h compared to NS (13%, 5/38). The LR group had a significantly higher rate of discharge within the first 72 h compared to the NS group (p = 0.02)., Conclusion: The use of LR was associated with a faster rate of discharge during the intervention period and in the first 72 h, but no other differences compared to NS. This reduction in length of hospitalization has significant implications for patients and healthcare costs., (© 2023 The Authors. Journal of Pediatric Gastroenterology and Nutrition published by Wiley Periodicals LLC on behalf of European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Pain and depression are interrelated, and worse postpartum pain has been associated with postpartum depression. It remains unclear whether improved pain and mood after delivery can also improve maternal parenting. Few studies have examined relationships between postpartum pain and negative mood (anxiety or depression) or their effects on parent-infant relationship outcomes. The purpose of this study was to explore the relationships between postpartum pain, mood, parent-infant attachment, parenting self-efficacy, and infant development. This was a prospective longitudinal observational pilot study of nulliparous women enrolled at the third trimester and presenting for labor and delivery at term gestation. Baseline third trimester assessments included validated inventories of pain (the brief pain inventory, BPI), depression (the Edinburgh postnatal depression screen, EPDS), anxiety (the state trait anxiety inventory, STAI), multidimensional scale of perceived social support (perceived social support scale, MSPSS) and perceived stress scale (PSS). Demographic and labor characteristics were recorded. At 6 weeks and 3 months postpartum, self-reported assessments included EPDS, STAI, BPI, maternal parent infant attachment scale (MPAS), and perceived maternal parenting self-efficacy (PMP-SE). Child development outcomes were assessed at 6 weeks and 3 months using the Ages and Stages Questionnaire (ASQ). Univariable linear regression assessed the relationships between pain and parenting outcomes (MPAS and PMP-SE), including potential interactions between pain and mood for parenting outcomes. Generalized linear modeling was used to explore the relationships between postpartum pain, parenting outcomes, and child development outcomes. Of 187 subjects, 87 had complete data on parent-infant attachment and parenting self-efficacy data at 3 months. Lower "pain right now" scores (BPI) on postpartum day 1 was associated with higher maternal-infant attachment (MPAS) at 6 weeks postpartum (Estimate - 1.8, 95% CI - 3.4 to - 0.2, P < 0.03) but not at 3 months (Estimate 0.23 95% CI - 1.1 to 1.6, P = 0.7). Higher depression (EPDS) scores at 6 weeks were also associated with lower MPAS scores at 6 weeks (Estimate - 1.24, 95% CI - 2.07 to - 0.40, P = 0.004). However, there was no evidence that the relationship between pain and MPAS varied by depression score at 6 weeks (P = 0.42). Pain scores at baseline, six weeks, or three months did not correlate with parenting outcomes (MPAS, PMP-SE) at six weeks or three months. Results of the generalized linear modeling revealed relationships between pain, age, anxiety (STAI), and depression (EPDS) predictors, and the outcomes of parenting (MPAS, PMP-SE) and gross motor and personal-social (ASQ) aspects of infant development. There is a pattern of association between worse postpartum pain, anxiety, and depression with worse parenting outcomes. Depression and pain may also affect infant development, but future work is required to replicate and characterize these potential relationships., (© 2022. The Author(s).)

Phenomenon For most medical students, clerkship represents a transitional phase into the 'real world' of medicine. This transition is often accompanied by significant mental stressors, burnout, and empathy decline. Educator led resilience curricula designed to support students during this critical period often focus on teaching generalized strategies to promote wellness and lack the student input and perspective in their development. Thus, they may be of minimal value when learners are faced with acute moments of challenge and distress in their day-to-day work. The following project seeks to provide an insider view on the experience, interpretation, and response to these moments of challenge and distress from the frontline perspective of clinical clerks. Approach: Using collaborative autoethnography, two medical students documented 85 reflections on their emerging professional identity over the course of a core clerkship year. A narrative analysis was conducted iteratively in partnership with a staff internist and a medical education researcher experienced in autoethnography, allowing for robust multi-perspective input. Reflections were analyzed and coded thematically; disagreements were resolved by consensus discussion. Findings: A key theme of the reflections was self-preservation, conceptualized within two principal contexts: (i) Clerk-patient relationships, wherein we found ourselves in emotionally difficult situations; and (ii) Clerk-preceptor relationships, in which self-preservation manifested through a series of self-protective mechanisms. Insights: The practice of self-preservation is understood as the conscious act of boundary-setting and psychological defense in situations that pose a real (or perceived) threat to the clerk's wellbeing. At best, self-preservation serves as a temporary compromise to the stressors and burnout of clerkship. We speculate, however, that, left unchecked, acts of self-preservation may lead to habitual selfishness and apathy, qualities that are in diametric opposition to those expected of future physicians, and may manifest later (when these learners progress through the hierarchy) as the unprofessional behaviors that perpetuate the cycle of the hidden curriculum.

Background: Longitudinal faculty development (LFD) may allow for increased uptake of teaching skills, especially in a forum where teachers can reflect individually and collectively on the new skills. However, the exact processes by which such interventions are effective need further exploration., Methods: This qualitative study examined an LFD initiative teaching a novel feedback approach attended by five family practice physicians. The initiative began with two 1.5-hour workshops: Goal-Oriented Feedback (as the teaching skill to be developed) and Narrative Reflection (as the tool to support personal reflection on the skill being learned). Over the subsequent six-months, the five participants iteratively applied the feedback approach in their teaching and engaged in narrative reflection at four 1-hour group sessions. Transcripts from the group discussions and exit interviews were analyzed using thematic analysis., Results: Iteratively trialing, individually reflecting on, and collectively exploring efforts to implement the new feedback approach resulted in the development of a learning community among the group. This sense of community created a safe space for reflection, while motivating ongoing efforts to learn the skill. Individual pre-reflection prepared individuals for group co-reflection; however, written narratives were not essential., Conclusion: LFD initiatives should include an emphasis on ensuring opportunities for iterative attempts of teaching skills, guided self-reflection, and collaborative group reflection and learning to ensure sustainable change to teaching practices., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (© 2021 Farrell, Buydens, Bourgeois-Law, Regehr; licensee Synergies Partners.)

Background: Data linking labor pain and postpartum depression are emerging. Robust, prospective evaluations of this relationship while factoring other important variables are lacking. We assessed perinatal pain and other factors predicting postpartum depression (PPD) symptoms., Methods: Third trimester women, stratified by a priori plan to receive or avoid labor epidural analgesia, were longitudinally followed from the prenatal period through labor and delivery, until 6 weeks and 3 months postpartum. Electronic pain data was collected hourly during labor in real time, capturing pain unpleasantness, intensity, pain management satisfaction, and expectations. Prenatal and postpartum data included anxiety, depression, the Brief Pain Inventory (BPI), pain catastrophizing, resiliency, and perceived social support and stress. The primary outcome was Edinburgh Postnatal Depression Score (EPDS) as a marker of PPD symptoms. The primary pain variable of interest was labor pain emotional valence (unpleasantness burden, area under the curve for entire labor duration). Single and multivariable linear regressions examined perinatal pain variables in relation to EPDS., Results: Of 72 subjects included, 55 planned/received labor epidural analgesia and 17 planned avoidance/avoided it. In the planned epidural group, the emotional valence of labor pain independently predicted six-week EPDS (labor pain unpleasantness burden, R 2  = 0.42, P = 0.002). In addition to labor pain, prenatal and postpartum pain variables from the BPI independently predicted six-week EPDS. Three-month depression scores were linked to labor and acute pain (6 weeks postpartum), but not to chronic (3 months postpartum) pain variables. Intrapartum pain management satisfaction and expectations were largely met or exceeded and did not differ between analgesia groups., Conclusion: For susceptible women, pain at all perinatal time points-prenatal, labor, and postpartum-appear to be independently linked to depression scores at 6 weeks postpartum. The relationships are true, even though satisfaction and expectations regarding labor pain management were met or exceeded. These data support the concept that labor and acute postpartum pain influences both acute and long-term PPD symptoms, although additional data are needed to assess how analgesia preference interacts with these relationships.

Objective: The aim of the study was to evaluate lactated ringers (LR) versus normal saline (NS) in pediatric acute pancreatitis (AP)., Methods: This retrospective study used Pediatric Health Information System database of primary AP patients, 2013 to 2017., Results: The study included 1581 first time AP patients with exclusive use of a single fluid (111 LR, 1470 NS) for the first 48 hours. The LR cohort had a significantly shorter length of stay (P < 0.001) compared with NS. A multivariable logistic regression analysis suggests use of NS in the first 48 hours (after controlling for total parenteral nutrition, operation, and infection during the admission) had a significantly increased likelihood of requiring a hospitalization for 4 days or more compared with the LR group (odds ratio, 3.31; 95% confidence interval, 1.95-5.62). The overall cost was significantly less in the LR group. There was no statistical difference observed in risk factors for AP, intensive care transfer, organ dysfunction, or mortality., Conclusions: This represents the first large data set analysis of LR versus NS in pediatric AP. The use of LR was associated with a shorter length of stay and reduced cost compared with NS. Future randomized trials will help determine the ideal fluid choice for pediatric AP.

Foraging behavior is a critical adaptation by insects to obtain appropriate nutrients from the environment for development and fitness. Bumble bees ( Bombus spp.) form annual colonies which must rapidly increase their worker populations to support rearing reproductive individuals before the end of the season. Therefore, colony growth and reproduction should be dependent on the quality and quantity of pollen resources in the surrounding landscape. Our previous research found that B. impatiens foraging preferences to different plant species were shaped by pollen protein:lipid nutritional ratios (P:L), with foragers preferring pollen species with a ~5:1 P:L ratio. In this study, we placed B. impatiens colonies in three different habitats (forest, forest edge, and valley) to determine whether pollen nutritional quality collected by the colonies differed between areas that may differ in resource abundance and diversity. We found that habitat did not influence the collected pollen nutritional quality, with colonies in all three habitats collecting pollen averaging a 4:1 P:L ratio. Furthermore, there was no difference in the nutritional quality of the pollen collected by colonies that successfully reared reproductives and those that did not. We found however, that "nutritional intake," calculated as the colony-level intake rate of nutrient quantities (protein, lipid, and sugar), was strongly related to colony growth and reproductive output. Therefore, we conclude that B. impatiens colony performance is a function of the abundance of nutritionally appropriate floral resources in the surrounding landscape. Because we did not comprehensively evaluate the nutrition provided by the plant communities in each habitat, it remains to be determined how B. impatiens polylectic foraging strategies helps them select among the available pollen nutritional landscape in a variety of plant communities to obtain a balance of key macronutrients.

Background: Using labor, epidural analgesia has been linked to a reduced risk of postpartum depression, but the role of labor pain relief in this association remains unclear. The goal of this study was to test the hypothesis that effective epidural analgesia during labor is associated with reduced postpartum depression symptomatology., Methods: A single, institutional, retrospective, observational cohort design was chosen. The primary outcome was Edinburgh postnatal depression scale (EPDS) score, measured at the 6-week postpartum visit. Subjects included in the final analysis had (1) received labor epidural analgesia; (2) pain assessed during labor both before and during initiation of labor epidural analgesia by 0-10 numeric rating scores; and (3) depression risk assessed by the EPDS and documented at their 6-week postpartum visit. Simple and multiple linear regression was used to identify the best model for assessing the association between pain improvement, defined as percent improvement in pain (PIP), and depression, after adjusting for a history of anxiety or depression, other psychiatric history, abuse, trauma, mode of delivery, and other maternal or fetal comorbid diseases., Results: Two hundred one patients were included in the final analysis. Women with higher improvements in pain were associated with lower EPDS scores (r = 0.025; P = .002). Variables known to be associated with depression (body mass index, anxiety and/or depression, third- and fourth-degree perineal lacerations, and anemia) were significantly correlated with EPDS score and included in the final model. After we adjusted for these covariates, PIP remained a significant predictor of EPDS score (r = 0.49; P = .008), accounting for 6.6% of the variability in postpartum depression scores. The full model including pain, body mass index, anxiety and/or depression, perineal lacerations, and anemia explained 24% of the variability in postpartum depression scores., Conclusions: Although the extent of labor pain relief by epidural analgesia predicts lower postpartum depression scores, the relative contribution of PIP to risk for postpartum depression symptoms may be less than other established risk factors for depression. These data support that the clinical significance of labor analgesia in the development of postpartum depression needs to be more clearly defined.

Background: Previous research suggests a negative stereotype toward people with fluency disorders (i.e. stuttering and/or cluttering), although recent findings suggest that exposure to an actual person who stutters (e.g. a live or video presentation) leads to more positive perceptions of some personality traits. However, there is a paucity of research examining perceptions of a person who clutters and whether these perceptions can be modified via video exposure to cluttering., Aims: To examine the effects of video exposure to cluttering on university students' perceptions of a person who clutters. It was hypothesized that participants in the video condition would rate personality traits more positively than those who did not view the video clip., Methods & Procedures: A total of 105 undergraduate students served as participants; 54 were provided with written definition of cluttering, whereas 51 were provided with both a definition and short segment of an instructional DVD on cluttering. Students then rated a person who clutters on a variety of speech skills and personality scales., Outcomes & Results: Independent samples t-tests yielded no significant group differences in ratings of any speech skills or personality traits. However, a significantly greater number of students who viewed the video clip reported a reluctance to hire a person who clutters specifically because of the individual's fluency disorder. Additionally, participants who did not view the video clip reported having more previous instructors who cluttered than those who did view the video clip; this increased familiarity with persons who clutter may have impacted perceptions of a person who clutters., Conclusions & Implications: The present results indicate that viewing the brief video clip did not significantly influence ratings towards more positive perceptions, but also did not influence ratings to be significantly more negative on any traits. Further research is needed to compare the differences in the perceptions of listeners who have had long-term exposure to cluttered speech with those of listeners who have had brief exposure. Implications discussed include the impact of prior exposure to fluency disorders, as well as potential confusion between cluttering and 'fast speech'. These two factors may have influenced the identification rate of individuals with who clutter in the present study, which may have affected perceptions of a person who clutters., (© 2014 Royal College of Speech and Language Therapists.)

Objectives: To ascertain the views of trainees and recently graduated Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on their experiences of taking parental leave during specialist training., Design: An anonymous online survey, conducted over a 1-month period from 16 August 2012 to 14 September 2012, of participants' experiences of taking parental leave and of the effects of parental leave taken by trainee colleagues on participants' own training., Setting and Participants: All trainees undertaking training for the Fellowship of the College, and all Fellows who had graduated in the past 6 years were invited to take part. Of the total 1051 invitees, 261 responded to the survey., Main Outcome Measures: Ease with which parental leave was granted, ability to return to a training post after taking leave, and participants' experiences of views expressed about parental leave in the work environment., Results: Most participants requesting parental leave were able to access it and return to a training post; however, a small proportion experienced difficulties. Among female respondents who had taken parental leave, 28 (26.2%) reported being asked about their intentions for future pregnancy during the training application process, and 45 (42.1%) reported receiving negative comments about this in the work environment., Conclusions: While in most instances parental leave is accessible automatically, a small but significant number of trainees reported encountering difficulties. These matters are being addressed within our own College, and our results are likely to be relevant to all bodies involved in postgraduate medical training, particularly given the increasing feminisation of the medical workforce.

The Pantex Plant significantly revised its Radiological Control Manual to improve its usability, streamline plant procedures, and clarify conflicting guidance. This article overviews the process used to develop the new Radiological Control Manual.

The Pantex Plant, located in the Texas panhandle near Amarillo, is a major Department of Energy (DOE) participant in maintaining the safety of the nation's nuclear weapons resources and protecting the employees, public, and environment. With more than 168,000 person-years of operations involving nuclear materials, explosives, and hazardous chemicals, Pantex has maintained a notable safety record. This article overviews the nuclear weapon activities at Pantex and describes their safety culture.