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Due to the changing complex healthcare environment, educational innovation is essential to meet the needs of current and future neonatal-perinatal medicine (NPM) leaders. Greater clinical demands, decreased academic funding, and expanded graduate medical education program requirements have negatively impacted time for teaching and educational scholarship potentially limiting innovation in the field. By focusing on adult learning principles, embracing technology, and promoting collaboration, today's educators are preparing the next generation of neonatologists. Current innovations include regionalizing simulation boot camps, leveraging virtual learning to increase accessibility, developing niche training opportunities, and incorporating population health principles within existing quality initiatives. Areas in need of additional innovation include faculty and fellow development for teaching skills, expansion of educational networks, and dissemination and financial support of educational scholarship. These efforts and future innovations will require medical institutions and national NPM organizations to further invest in the medical educator as part of their missions.

Academic physicians must teach elements in an Accreditation Council for Graduate Medical Education (ACGME)-mandated curriculum while balancing career development and clinical workload. Exploring educator perceptions on the learning environment and comparing two instructional methods (traditional didactics [TD] vs. flipped classroom [FC]) in one pediatric subspecialty may elucidate current challenges, barriers, and strategies to optimize learning and educator satisfaction. A randomized trial comparing effectiveness and learner preference for FC versus TD physiology teaching was conducted in ACGME-accredited neonatal-perinatal medicine (NPM) fellowship programs in 2018 to 2019. Educator preferences were elicited through online surveys pre- and postintervention. Free-text comments were provided for questions exploring strengths, challenges, and opportunities in fellowship education. Statistical analysis included comparisons of demographics and pre-post-intervention educator responses between groups. Thematic analysis of text responses was conducted to identify common subthemes. From 61 participating programs, 114 FC educators and 130 TD educators completed surveys. At baseline, all educators experienced professional satisfaction from teaching fellows, but noted challenges with time available to create and/or deliver educational content, limited content expertise amongst faculty, colleagues' limited enthusiasm toward educating fellows, and lack of perceived value of education by institutions given limited protected time or credit toward promotion. Postintervention, educators in both groups noted a preference to teach physiology using FC due to interactivity, learner enthusiasm, and learner-centeredness. FC educators had a 17% increase in preference to teach using FC ( Overall, NPM educators in a trial evaluating a standardized, peer-reviewed curriculum report professional satisfaction from teaching, but described logistical challenges with developing/delivering content. Educators preferred instruction using FC, but identified challenges with learner preparedness and ensuring adequate educator time and skill. Future efforts should be dedicated to addressing these barriers.· Many challenges exist for educators teaching neonatal-perinatal medicine fellows, including time, support, and recognition.. · Many educators preferred using flipped classroom methodology with a standardized curriculum due to interactivity and learner-centeredness.. · Benefits of a standardized, peer-reviewed curriculum include reduced preparation time, adaptability of content, and learning environment enhancement..

Abnormalities in pain processing have been observed in patients with chronic pain conditions and in individuals who engage in self-harm, specifically nonsuicidal self-injurious behaviors (NSSI). Both increased and decreased pain sensitivity have been described in chronic pain patients, while decreased pain sensitivity is consistently observed in individuals with NSSI. The objective of the study was to identify the differential effects of chronic pain and NSSI on experimental pain sensitivity, specifically pressure pain threshold, in depressed patients. Moreover, the role that hopelessness may play between depression severity and pain sensitivity was also examined. Depressed patients with and without chronic pain, and with and without lifetime self-harm behaviors were analyzed into four groups. Group 1 (N = 42) included depressed patients with both Chronic pain ( +) and Self-harm ( +), Group 2 (N = 53) included depressed patients with Chronic pain ( +) but no Self-harm (−), Group 3 (N = 64) included depressed patients without Chronic pain (−), but Self-harm ( +), and Group 4 (N = 81) included depressed patients with neither Chronic pain (−) nor Self-harm (−). Healthy controls (N = 45) were also recruited from the community. Depressed patients with both Chronic pain ( +) and Self-harm ( +) reported higher pressure pain threshold measures when compared with the other groups. Mediation analysis indicated that hopelessness mediates the relationship between depression severity and pressure pain threshold. Our findings suggest that a multiprong approach including adequate mental health services and pain control for depressed patients with comorbid chronic pain and nonsuicidal self-harm is needed to yield effective outcomes.

Background A vital element of the Next Accreditation System is measuring and reporting educational Milestones. Little is known about changes in Milestones levels during the transition from residency to fellowship training. Objective Evaluate the Accreditation Council for Graduate Medical Education (ACGME) Milestones' ability to provide a linear trajectory of professional development from general pediatrics residency to neonatal-perinatal medicine (NPM) fellowship training. Methods We identified 11 subcompetencies that were the same for general pediatrics residency and NPM fellowship. We then extracted the last residency Milestone level and the first fellowship Milestone level for each subcompetency from the ACGME's Accreditation Data System on 89 subjects who started fellowship training between 2014 and 2018 at 6 NPM fellowship programs. Mixed-effects models were used to examine the intra-individual changes in Milestone scores between residency and fellowship after adjusting for the effects of the individual programs. Results A total of 1905 subcompetency Milestone levels were analyzed. The average first fellowship Milestone levels were significantly lower than the last residency Milestone levels (residency, mean 3.99 [SD = 0.48] vs fellowship 2.51 [SD = 0.56]; P < .001). Milestone levels decreased by an average of -1.49 (SD = 0.65) from the last residency to the first fellowship evaluation. Significant differences in Milestone levels were seen in both context-dependent subcompetencies (patient care and medical knowledge) and context-independent subcompetencies (professionalism). Conclusions Contrary to providing a linear trajectory of professional development, we found that Milestone levels were reset when trainees transitioned from general pediatrics residency to NPM fellowship.

Neonatal-perinatal medicine (NPM) fellowship programs in the United States support800 learners annually. Understanding variations in the programmatic structure, challenges, and needs is essential to optimize the educational environment and ensure the specialty's future. NPM fellowship program directors (PDs) and associate program directors (APDs) were invited to complete an electronic survey on their program administration, recruitment, clinical training, assessment methods, scholarly program, and career pathways. Each participant identified individual programmatic strengths, challenges, opportunities, and threats to the field. Representatives from 59 NPM fellowships provided data (response rate 59/96 = 61%). In total, 30% of PDs received less than the Accreditation Council for Graduate Medical Education -recommended protected time for administrative duties, and 44% of APDs received no protected time. Fellow clinical service assignments varied widely from 13 to 18 months and 90 to 175 call nights over 3 years. Recruitment practices varied across programs; 59% of respondents raised concerns over the pipeline of applicants. Conflicts between fellows and advanced practice providers were identified by 61% of responders. Programs varied in their scholarly offerings, with 44% of NPM fellowships interested in adding broader research opportunities. NPM fellowship leaders identified a need for improved programmatic support, enhanced measures to assess competency, opportunities to strengthen scholarly programs, shared curricular resources, and strategies to balance education with clinical demands. PDs and APDs identified threats to the future of NPM training programs including the diminishing pipeline of applicants into neonatology, challenges with clinical exposure and competence, inadequate support for the educational mission, issues supporting high-quality scholarship, and fewer graduates pursuing physician-investigator pathways. National organizations and academic institutions should take action to address these challenges so that fellowships can optimally prepare graduates to meet their patients' needs.· Numerous challenges exist for current program directors in NPM including balancing clinical work with scholarly activities, accurately assessing competency, optimizing the culture of the learning environment, and ensuring that fellows are adequately prepared for a range of postgraduate positions.. · Significant variation exists across NPM fellowship programs in clinical service/calls assigned over 3 years of fellowship training, as well as opportunities to pursue scholarly activities across a variety of areas.. · Challenges exist related to ensuring an adequate number of future applicants into the specialty, including those from backgrounds traditionally underrepresented in medicine, as well as those seeking to pursue careers as physician-investigators..

Neonatal-perinatal medicine fellows must achieve a meaningful accomplishment in scholarly activity as part of their training. Despite the requirement for scholarly training in fellowship, there is a vanishingly small number of MD-only physician-scientists pursuing a research-oriented career. Recent neonatal trainees have identified several factors that preclude their careers in research-focused academic neonatology, including lower pay in academic positions, inadequate training in research techniques, and the perception that individuals in research careers have a poor work-life balance. High competition for limited pediatric research funds also contributes to a diminishing pool of physician-scientists in neonatology. This small number of physician-scientists is threatened by a high rate of attrition among physicians who enter this career path. In order to prevent further declines in the number of neonatal physician-scientists, we need improvements in funding and strong intra- and cross-institutional mentorship to foster individuals interested in a career as a physician-scientist.

A 3-year experiment was conducted to evaluate the performance and playability of 24 coarse-textured zoysiagrass (Zoysia spp. Willd.) experimental genotypes in comparison to five commercially available cultivars maintained as a low-maintenance turf across multiple climates (Indiana, North Carolina, Georgia, Arizona, and California). Following establishment in 2018, plots were maintained under low-maintenance regimes and evaluated for quality, density, uniformity, color, winterkill damage, drought resistance, and golf ball lie in 2019 and 2020. A turf performance index (TPI) was calculated for each treatment at each site, which represented the number of times the treatment occurred in the top statistical group. The unique climate for each site led to differences in TPI scores. For instance, the arid climates of Arizona and California resulted in distinct differences in performance among treatments compared to the other sites. However, consistencies in performance across sites were also observed. For example, the 2018−2019 winter resulted in winterkill differences among entries in both Indiana and North Carolina, which led to some similarities in TPI. Furthermore, the southern humid climates of North Carolina and Georgia produced consistencies in overall TPI. Under the minimal inputs and the hot-humid or arid climates evaluated in this study, all of the check cultivars were some of the poorest performing treatments, which clearly illustrates there is a need for breeding programs to develop zoysiagrass genotypes for these climates. However, experimental lines that exhibited excellent persistence under these conditions were identified indicating the genetic potential for wider adaptation to lower input environments exists within the species.

Shade caused by trees or buildings can affect the quality and growth of turfgrasses. Thus, breeding for shade tolerance is an essential component of most turfgrass improvement programs. The objective of this study was to evaluate the performance of seashore paspalum (Paspalum vaginatum Sw.) breeding lines under shade in multi-environment trials. Germplasm sources were 20 lines from the University of Georgia seashore paspalum breeding program and two checks, the cultivars 'SeaDwarf' and 'SeaStar'. Field trials were conducted from 2016 to 2019 under shade structures designed to reduce ambient sunlight at three locations: Citra (FL), Tifton (GA), and Raleigh (NC). The response variables evaluated were percent living ground cover (%GC), dark green color index (DGCI), canopy height (CH) and turfgrass quality (TQ). Data were analyzed by mixed model approaches using ASReml-R, and the t-statistics were used to group the entries. Significant genetic variances were observed in the single-location-repeated-measures analysis for CH and DGCI at Citra and Tifton, %GC at Citra, and TQ at Raleigh. Spearman correlations of the predicted values for entries between locations ranged from low to moderate, with the exception of between Citra and Tifton (0.76) for CH. There were a few breeding lines with superior performance to the entry average for all traits for which the entry variance was significant. In conclusion, genetic variability was observed for all traits and superior seashore paspalum breeding lines for multiple traits were identified under shade.

Objective This study aimed to determine the value, strengths, and challenges of implementing an e-learning based flipped classroom (FC) educational modality as part of the standardized physiology National Neonatology Curriculum (NNC), created for neonatal-perinatal medicine (NPM) fellow learners and faculty educators. Study Design This is a cross-sectional study of NPM fellows and faculty educators who utilized at least one of the e-learning based NNC FC respiratory physiology programs between May and September 2018. Participants were surveyed anonymously regarding their experiences participating in the NNC, including measures of preparation time. A combination of descriptive statistics and proportion comparisons were used for data analysis. Results Among 172 respondents, the majority of fellow and faculty respondents reported positive attitudes toward the educational content and case discussions, and the majority supported national standardization of NPM physiology education (92%). Fellows reported greater preclass preparation for their FC compared with previous didactic lectures (30–60 vs. 0–15 minutes, p Conclusion Fellows and faculty educators supported the FC learning, reporting peer-to-peer learning, and the establishment of a learning community which promotes adult learning and critical thinking skills. A national physiology curriculum creates equitable and engaging educational experiences for all NPM fellows while reducing individual program burden of content creation. Our findings further supported the development of an NNC using a flipped classroom modality.

The demand for bromelian and pineapple fruit has been increasing substantially in the world because of their benefits for the human health and use in diverse areas. In this context, this work aimed to study the capacity of higher retention (concentration); bromelain activity underwent ultrafiltration from pineapple juice (Ananas comusus L. Merrill). All assays were carried out at pH 7.0 and 7.5, and at 0.05 and 0.40 bar of transmembrane pressures. Results have shown that at the best operating conditions, between 85 and 87% of bromelain activity was recovered using the plain membrane separation process at 0.05 bar. The ultrafiltration has shown the capacity to retain 100% of proteolytic activity of the bromelain extracted. The samples have kept the same physics properties after ultrafiltration, and the result was verified via electrophoresis. The bromelain enzyme obtained was characterized, and pH 7 and between 30 and 40 °C were the best conditions. Therefore, this work shows that the use of both polymeric membranes has shown high efficiency, and can be used in the purification of bromelain enzymes.

Positive end-expiratory pressure (PEEP) is a key mechanical ventilator setting in infants with bronchopulmonary dysplasia (BPD). Excessive PEEP can result in insufficient carbon dioxide elimination and lung damage, while insufficient PEEP can result in impaired gas exchange secondary to airway and alveolar collapse. Determining PEEP settings based on clinical parameters alone is challenging and variable. The purpose of this study was to describe our experience using dynamic airway CT to determine the lowest PEEP setting sufficient to maintain expiratory central airway patency of at least 50% of the inspiratory cross-sectional area in children with BPD requiring long-term ventilator support. We retrospectively identified all infants with BPD who underwent volumetric CT with a dynamic airway protocol for PEEP optimization from December 2014 through April 2019. Sixteen infants with BPD underwent 17 CT exams. Each CT exam consisted of acquisitions spanning the trachea and mainstem bronchi. We measured cross-sectional area of the trachea and mainstem bronchi and qualitatively assessed the amount of atelectasis. We documented changes in management as a result of the CT exam. The average effective dose was 0.1–0.8 mSv/scan. Of 17 CT exams, PEEP was increased in 9, decreased in 3 and unchanged after 5 exams. Dynamic airway CT shows promise to assist the clinician in determining PEEP settings to maintain airway patency in infants with BPD requiring long-term ventilator support. Further evaluation of the impact of this maneuver on gas exchange, cardiac output and other physiological measures is needed.

Objective This study aimed to report on Neonatal-Perinatal Medicine (NPM) fellows' views of self-preparedness upon starting postresidency training. Study Design We conducted a national survey of first-year NPM fellows in the United States. The validated survey had five major areas: professionalism, psychomotor ability, independence/graduated responsibility, clinical evaluation, and academia. Survey responses were analyzed using descriptive statistics, and the free-text answers were categorized. Results Of 228 potential first-year NPM fellows, 140 (61%) initially responded to the survey. Overall, the fellows perceived themselves positively in professionalism and independence/graduated responsibility domains. Marked variability was observed in perceived preparedness in psychomotor ability, with confidence in neonatal intubation and arterial line placement of 86 and 49%, respectively. Lack of confidence in performing neonatal intubation procedures correlates with lack of attempts. The majority (75%) of fellows reported being interested in academia, but less than half felt capable of writing an article. Conclusion First-year NPM fellows identified deficiencies in the domains of psychomotor ability and academia. Residency and fellowship programs should partner to address these deficiencies.

Background: Active, learner-centric educational methods in graduate medical education are infrequently used despite evidence suggesting they are more effective for adult learners. The Organization of Neonatal-Perinatal Medicine (NPM) Training Program Directors developed a National Neonatology Curriculum to teach neonatal physiology incorporating andragogic principles. Using American Board of Pediatrics content specifications, NPM faculty developed peer-reviewed online videos and discussion guides for flipped classroom (FC) sessions. Objective: To determine NPM fellow (learner) preferences for FC vs. TD modalities in a large, randomized controlled trial. We hypothesized that fellows would prefer FC compared to TD. Methods: NPM fellowships were prospectively cluster randomized to FC or TD …

The Accreditation Council for Graduate Medical Education (ACGME) Pediatric Subspecialty Milestone Project competencies are used for Neonatal-Perinatal Medicine (NPM) fellows. Milestones are longitudinal markers that range from novice to expert (levels 1-5). There is no standard approach to the required biannual evaluation of fellows by fellowship programs, resulting in significant variability among programs regarding procedural experience and exposure to pathology during clinical training. In this paper, we discuss the opportunities that Milestones provide, potential strategies to address challenges, and future directions.

Abnormalities in pain processing have been observed in patients with chronic pain conditions and in individuals who engage in self-harm, specifically nonsuicidal self-injurious behaviors (NSSI). Both increased and decreased pain sensitivity have been described in chronic pain patients, while decreased pain sensitivity is consistently observed in individuals with NSSI. The objective of the study was to identify the differential effects of chronic pain and NSSI on experimental pain sensitivity, specifically pressure pain threshold, in depressed patients. Moreover, the role that hopelessness may play between depression severity and pain sensitivity was also examined. Depressed patients with and without chronic pain, and with and without lifetime self-harm behaviors were analyzed into four groups. Group 1 (N = 42) included depressed patients with both Chronic pain ( +) and Self-harm ( +), Group 2 (N = 53) included depressed patients with Chronic pain ( +) but no Self-harm (-), Group 3 (N = 64) included depressed patients without Chronic pain (-), but Self-harm ( +), and Group 4 (N = 81) included depressed patients with neither Chronic pain (-) nor Self-harm (-). Healthy controls (N = 45) were also recruited from the community. Depressed patients with both Chronic pain ( +) and Self-harm ( +) reported higher pressure pain threshold measures when compared with the other groups. Mediation analysis indicated that hopelessness mediates the relationship between depression severity and pressure pain threshold. Our findings suggest that a multiprong approach including adequate mental health services and pain control for depressed patients with comorbid chronic pain and nonsuicidal self-harm is needed to yield effective outcomes.

Several reports indicate either increased or decreased pain sensitivity associated with psychiatric disorders. Chronic pain is highly prevalent in many of these conditions. We reviewed the literature regarding experimental pain sensitivity in patients with major depression, bipolar disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder, panic disorder, obsessive-compulsive disorder and schizophrenia. Electronic searches were performed to identify studies comparing experimental pain in patients with these conditions and controls. Across 31 depression studies, reduced pain threshold was noted except for ischemic stimuli, where increased pain tolerance and elevated sensitivity to ischemic pain was observed. A more pervasive pattern of low pain sensitivity was found across 20 schizophrenia studies. The majority of PTSD studies (n = 20) showed no significant differences compared with controls. The limited number of bipolar disorder (n = 4) and anxiety (n = 9) studies precluded identification of clear trends. Wide data variability was observed. Awareness of psychiatric patients' pain perception abnormalities is needed for active screening and addressing physical comorbidities, in order to enhance quality of life, life expectancy and mental health.

Background Recent studies showed that psychological safety is important to resident perception of the work environment, and improved psychological safety improves resident satisfaction survey scores. However, there is no evidence in medical education literature specifically addressing relationships between psychological safety and learning behaviors or its impact on learning outcomes. Objective We developed and gathered validity evidence for a group learning environment assessment tool using Edmondson's Teaming Theory and Webb's Depth of Knowledge model as a theoretical framework. Methods In 2018, investigators developed the preliminary tool. The authors administered the resulting survey to neonatology faculty and trainees at Baylor College of Medicine morning report sessions and collected validity evidence (content, response process, and internal structure) to describe the instrument's psychometric properties. Results Between December 2018 and July 2019, 450 surveys were administered, and 393 completed surveys were collected (87% response rate). Exploratory factor analysis and confirmatory factor analysis testing the 3-factor measurement model of the 15-item tool showed acceptable fit of the hypothesized model with standardized root mean square residual = 0.034, root mean square error approximation = 0.088, and comparative fit index = 0.987. Standardized path coefficients ranged from 0.66 to 0.97. Almost all absolute standardized residual correlations were less than 0.10. Cronbach's alpha scores showed internal consistency of the constructs. There was a high correlation among the constructs. Conclusions Validity evidence suggests the developed group learning assessment tool is a reliable instrument to assess psychological safety, learning behaviors, and learning outcomes during group learning sessions such as morning report.

espanolEste trabajo se enfoco en validar el simulador Aspen HYSYS para resolver dos casos representativos del ciclo Rankine regenerativo con recalentamiento intermedio. La interpretacion del ciclo Rankine por el metodo manual es complejo y requiere extenso tiempo. El primer caso comprendio el ciclo con un calentador abierto y uno cerrado con una extraccion de vapor en la turbina de baja presion. El segundo caso abarco el ciclo con tres extracciones de vapor, dos en la turbina de alta presion, una en la turbina de baja presion y tres calentadores abiertos. La validacion del simulador Aspen HYSYS alcanzo discrepancias del 1.2% con relacion a los calculos manuales. El simulador Aspen HYSYS mostro versatilidad para evaluar diversas variables que pueden afectar la eficiencia termica del ciclo. En conclusion, el simulador Aspen HYSYS puede ser utilizado para la ensenanza y comprension del ciclo Rankine. EnglishThis work focused on validating the Aspen HYSYS simulator for interpreting the regenerative Rankine cycle with intermediate overheating. Manual methods for interpreting the Rankine cycle are complex and are time consuming. Two representative cases were examined to validate the Aspen HYSYS simulator. The first case had a Rankine cycle with: 1) an open heater and 2) a closed heater with steam extraction in the low pressure turbine. The second case had three open heaters and three steam extractions: two in the high pressure turbine and one in the low pressure turbine. Validation of the Aspen HYSYS simulator showed discrepancies of 1.2% in relation to manual calculations. The Aspen HYSYS simulator was versatile for evaluating variables that can affect the thermal efficiency of the cycle. In conclusion, the Aspen HYSYS simulator can be employed for teaching and for analyzing the Rankine cycle

Effective suicide prevention is hindered by a limited understanding of the natural progression and neurobiology of the suicidal process. Our objective was to characterize the duration of the suicidal process and its relation to possible determinants: time judgment and cognitive impulsivity. In four groups of adults of both sexes including recent suicide attempters (n=57), suicidal ideators (n=131), non-suicidal depressed controls (n=51) and healthy controls (n=48) we examined time estimation and production, impulsivity and other cognitive variables. Duration of the suicidal process was recorded in suicide attempters. The suicide process duration, suicide contemplation and action intervals, had a bimodal distribution, ~40% of attempters took less than 5 minutes from decision to attempt. Time slowing correlated negatively with the suicidal action interval (time from the decision to kill oneself to suicide attempt) (p=.003). Individuals with suicide contemplation interval shorter than three hours showed increased time slowing, measured as shorter time production at 35 seconds (p=.011) and 43 seconds (p=.036). Delay discounting for rewards correlated with time estimation at 25 minutes (p=0.02) and 90 seconds (p=.01). Time slowing correlated positively with suicidal ideation severity, independently of depression severity (p

Suicidal behavior is frequently triggered by social crises, such as familial, romantic, social or work-related conflict. A variety of cognitive and social functioning impairments has been associated with suicidal thoughts and acts. One of the precipitating and perpetuating factors of social conflict is the desire for retribution after a perceived offense, even at one's own detriment. We utilized the Ultimatum Game-a behavioral economic task which examines the behavioral response to perceived unfairness-in order to characterize the response to unfairness across the acute suicide risk spectrum. We examined five groups of adult individuals of both genders (n = 204): High- and Low-Lethality recent Suicide Attempters, Suicidal Ideators, Non-Suicidal Depressed Patients; and Healthy Controls. We also measured demographic and clinical variables. Even though all depressed groups showed similar rejection rates in the Ultimatum Game, there was a higher likelihood of rejecting offers in the low stakes condition in all acutely suicidal groups compared with healthy controls. Stake size, offer, education, and gender of the proposer were significantly associated with rejection rates. Acutely suicidal patients may be more vulnerable to adverse interpersonal interactions. Further characterization of social behavior may provide targets for secondary and tertiary prevention for high-risk individuals.

Purpose: The learning environment encompasses the diverse physical locations, contexts, instructional methods, and cultures where learning occurs. Effective learning environments require preparation, promote collaboration, improve critical thinking, and increase learner engagement and knowledge retention. The Organization of Neonatal-Perinatal Medicine Training Program Directors (ONTPD) National Neonatology Curriculum (NNC) Randomized Controlled Trial (RCT) explored the impact of instructional methods on perceptions of the learning …