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Abstract BackgroundScreening for risk behaviors is a routine and essential component of adolescent preventive health visits. Early identification of risks can inform targeted counseling and care. If stored in discrete fields in the electronic health record (EHR), adolescent screening data can also be used to understand risk behaviors across a clinic or health system or to support quality improvement projects. ObjectiveGoals of this pilot study were to adapt and implement an existing paper adolescent risk behavior screening tool for use as an electronic data capture tool (the eTeenQ), to evaluate acceptance of the eTeenQ, and to describe the prevalence of the selected risk behaviors reported through the eTeenQ. MethodsThe multidisciplinary project team applied an iterative process to develop the 29-item eTeenQ. Two unique data entry forms were created with attention to (1) user interface and user experience, (2) the need to maintain patient privacy, and (3) the potential to transmit and store data for future use in clinical care and research. Three primary care clinics within a large health system piloted the eTeenQ from August 17, 2020, to August 27, 2021. During preventive health visits for adolescents aged 12 to 18 years, the eTeenQ was completed on tablets and responses were converted to a provider display for teens and providers to review together. Responses to the eTeenQ were stored in a REDCap (Research Electronic Data Capture; Vanderbilt University) database, and for patients who agreed, responses were transferred to an EHR flowsheet. Responses to selected eTeenQ questions are reported for those consenting to research. At the conclusion of the pilot, the study team conducted semistructured interviews with providers and staff regarding their experience using the eTeenQ. ResultsAmong 2816 adolescents with well visits, 2098 (74.5%) completed the eTeenQ. Of these, 1811 (86.3%) agreed to store responses in the EHR. Of 1632 adolescents (77.8% of those completing the eTeenQ) who consented for research and remained eligible, 1472 (90.2%) reported having an adult they can really talk to and 1510 (92.5%) reported feeling safe in their community, yet 401 (24.6%) reported someone they lived with had a gun and 172 (10.5%) reported having had a stressful or scary event that still bothered them. In addition, 157 (9.6%) adolescents reported they were or wondered if they were gay, lesbian, bisexual, pansexual, asexual, or other, and 43 (2.6%) reported they were or wondered if they were transgender or gender diverse. Of 11 staff and 7 providers completing interviews, all felt that the eTeenQ improved confidentiality and willingness among adolescents to answer sensitive questions. All 7 providers preferred the eTeenQ over the paper screening tool. ConclusionsElectronic capture of adolescent risk behaviors is feasible in a busy clinic setting and well accepted among staff and clinicians. Most adolescents agreed for their responses to risk behavior screening to be stored in the EHR.

Wastewater-based epidemiology has emerged as a viable tool for monitoring disease prevalence in a population. This paper details a time series machine learning (TSML) method for predicting COVID-19 cases from wastewater and environmental variables. The TSML method utilizes a number of techniques to create an interpretable, hypothesis-driven framework for machine learning that can handle different nowcast and forecast lengths. Some of the techniques employed include: • Feature engineering to construct interpretable features, like site-specific lead times, hypothesized to be potential predictors of COVID-19 cases. • Feature selection to identify features with the best predictive performance for the tasks of nowcasting and forecasting. • Prequential evaluation to prevent data leakage while evaluating the performance of the machine learning algorithm.

Although anti-inflammatory effects of American ginseng metabolites have been investigated at systemic and cellular levels, the biological signatures of ginseng microbial metabolite-induced bioactivities are still unknown. To fill this knowledge gap and to support the findings published in the companion research article entitled “American ginseng microbial metabolites attenuated DSS-induced colitis and abdominal pain” (Wang et al., 2018), we are here to provide datasets of enteric microbiome biotransformation and fecal metabolomics. For the microbiome biotransformation study, data were obtained from C57BL6 mice treated with a broad-spectrum antibiotic metronidazole. After oral administration of ginseng extract, we observed that compound K (CK) was undetectable in metronidazole-treated mouse stools but was detected in stools from vehicle-treated mice, suggesting biotransformation of CK is gut microbial dependent. In the fecal metabolomic study, three small molecules which were associated with gut inflammation were identified. In the DSS mice, the levels of lactate, linoleic acid, and malic acid increased significantly in the model group. After ginseng treatment, the expressions of these metabolites reduced significantly. Thus, the selective fecal endogenous metabolites could be used as biological signatures reflecting severity of enteric inflammation and ginseng treatment outcomes. Our results showed the enteric microbiome plays a key role for CK conversion, and the effects of CK on enteric inflammation can be demonstrated by the metabolomics data. Keywords: American ginseng, Biological signature, Colitis, Enteric microbiome, Gut inflammation, Metabolomics, Microbial metabolites

Objective:  Neonatal resuscitation is a high-acuity, low-occurrence event and many rural pediatricians report feeling underprepared for these events. We piloted a longitudinal telesimulation (TS) program with a rural hospital's interprofessional delivery room teams aimed at improving adherence to Neonatal Resuscitation Program (NRP) guidelines and teamwork., Study Design:  A TS study was conducted monthly in one rural hospital over a 10-month period from November 2020 to August 2021. TS sessions were remotely viewed and debriefed by experts, a neonatologist and a simulation educator. Sessions were video recorded and assessed using a scoring tool with validity evidence for NRP adherence. Teamwork was assessed using both TeamSTEPPS 2.0 Team Performance Observation Tool and Mayo High-Performance Teamwork Scale., Results:  We conducted 10 TS sessions in one rural hospital. There were 24 total participants, who rotated through monthly sessions, ensuring interdisciplinary team composition was reflective of realistic staffing. NRP adherence rate for full code scenarios improved from a baseline of 39 to 95%. Compared with baseline data for efficiency, multiple NRP skills improved (e.g., cardiac lead placement occurred 12× faster, 0:31 seconds vs. 6:21 minutes). Teamwork scores showed improvement in all domains., Conclusion:  Our results demonstrate that a TS program aimed at improving NRP and team performance is possible to implement in a rural setting. Our pilot study showed a trend toward improved NRP adherence, increased skill efficiency, and higher-quality teamwork and communication in one rural hospital. Additional research is needed to analyze program efficacy on a larger scale and to understand the impact of training on patient outcomes., Key Points: · Optimal newborn outcomes depend on skillful implementation of NRP.. · Telesimulation can deliver medical education that circumvents challenges in rural areas.. · A longitudinal NRP TS program is possible to implement in a rural setting.. · A rural NRP telesimulation program may improve interprofessional resuscitation performance.. · A rural NRP telesimulation program may improve interprofessional resuscitation teamwork.., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction Neonatal resuscitation is a high-acuity, low-occurrence event that requires ongoing practice by interprofessional teams to maintain proficiency. Simulation provides an ideal platform for team training and evaluation of team performance. Our simulation center supports a longitudinal in situ simulation training program for delivery room teams. In addition to adherence to the Neonatal Resuscitation Program standards, team performance assessment is an essential component of program evaluation and participant feedback. Multiple published teamwork assessment tools exist. Our objective was to select the tool with the best validity evidence for our program's needs. Methods We used Messick's framework to assess the validity of evidence for potential teamwork assessment tools. Four possible tools were identified from the literature: the Mayo High Performance Teamwork Scale (Mayo), Team Performance Observation Tool (TPOT), Clinical Teamwork Scale (CTS), and Team Emergency Assessment Measure (TEAM). Relevant context included team versus individual focus, external evaluator versus self-evaluation, and ease of use (which included efficiency, clarity of interpretation, and overall assessment). Three simulation experts identified consensus anchors for each tool and independently reviewed and scored 10 pre-recorded neonatal resuscitation simulations. Raters assigned each tool a rating according to efficiency, ease of interpretation, and completeness of teamwork assessment. Interrater reliability (IRR) was calculated using intraclass correlation for each tool across the three raters. Average team performance scores for each tool were correlated with neonatal resuscitation adherence scores for each video using Spearman's rank coefficient. Results There was a range of IRR between the tools, with Mayo having the best (single 0.55 and multi 0.78). Each of the three raters ranked Mayo optimally in terms of efficiency (mean 4.66 + 0.577) and ease of use (4+1). However, TPOT and CTS scored highest (mean 4.66 ± 0.577) for overall completeness of teamwork assessment. There was no significant correlation to NRP adherence scores for any teamwork tool. Conclusion Of the four tools assessed, Mayo demonstrated moderate IRR and scored highest for its ease of use and efficiency, though not completeness of assessment. The remaining three tools had poor IRR, which is not an uncommon problem with teamwork assessment tools. Our process emphasizes the fact that assessment tool validity is contextual. Factors such as a relatively narrow (and high) performance distribution and clinical context may have contributed to reliability challenges for tools that offered a more complete teamwork assessment., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. MaineHealth Institutional Review Board (IRB) issued approval 2050668-3. This project was deemed exempt by the MaineHealth IRB. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Soghikian et al.)

Introduction: Medical mis- and disinformation are on the rise and impact patient health outcomes. The complexity of modern medicine and health care delivery necessitates that care be delivered by an interprofessional team of providers well versed in addressing this increased prevalence of medical misinformation. Health professions educational curricula often lack opportunities for students to learn how to address medical misinformation, employ advanced communication techniques, and work collaboratively., Methods: Based on literature and our previous qualitative research, we created a module offering prework learning on COVID-19 and addressing misinformation through advanced communication techniques and interprofessional collaboration. After completing prework, students participated in a standardized patient encounter addressing COVID misinformation. Health professions student dyads completed a preencounter planning huddle and together interviewed a standardized patient. Students received global and checklist-based feedback from standardized patients and completed pre- and postsession self-assessments., Results: Twenty students participated (10 third-year medical, nine third-year pharmacy, one fourth-year pharmacy). Key findings included the following: Nine of 15 survey questions demonstrated statistically significant improvement, including all three questions assessing readiness to have difficult conversations and six of 10 questions assessing interprofessional collaboration and team function., Discussion: Students participating in this novel curriculum advanced their readiness to address medical misinformation, including COVID-19 vaccine disinformation, with patients and coworkers to improve health decision-making and patient care. These curricular methods can be customized for use with a range of health professions learners., (© 2024 Hayman et al.)

Introduction: Simulation is an ideal tool for interprofessional (IP) team training. Debriefing after simulation is key to IP learning, although engagement and participation may be adversely influenced by cultural and hierarchical barriers. This mixed-methods study explored factors influencing learner engagement and participation in IP debriefing and the experience of "silent but apparently engaged" participants., Methods: Semistructured profession-specific focus groups were conducted with participants from a weekly IP pediatric simulation program. Focus groups were recorded, transcribed, and thematically analyzed. Eligible participants were assigned to "silent" or "verbal" groups according to observed behavior and received a questionnaire. Participants' self-rated engagement scores were compared using a t test., Results: Thirty-six of 81 eligible participants were included, 13 completed a questionnaire, and 23 (8 physicians, 10 nursing staff, 4 pharmacists, 1 respiratory therapist) participated in 13 focus groups. Twenty-two subthemes were grouped into 6 themes: psychological safety, realism, distractors, stress, group characteristics, and facilitator behavior, with differences in perspective according to profession. Of the 36 respondents, 18 were "silent" and 18 "verbal." Self-rated engagement scores differed between groups (3.65 vs. 4.17, P = 0.06); however, "silent" participants described themselves as engaged., Conclusions: Themes identified that influenced learner engagement in debriefing included aspects of prebriefing and the simulation. Some aligned with general simulation best practices, such as psychological safety, prebriefing, and facilitator behavior. Findings unique to IP simulation included importance of realism to nonphysician professions, protecting time for training, group composition, and direct probing by cofacilitators to decrease physician bias and emphasize IP contributions. Silent participants reported engagement., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Society for Simulation in Healthcare.)

Summary Statement: A decade ago, at the time of formation of the International Network for Pediatric Simulation-based Innovation, Research, and Education, the group embarked on a consensus building exercise. The goal was to forecast the facilitators and barriers to growth and maturity of science in the field of pediatric simulation-based research. This exercise produced 6 domains critical to progress in the field: (1) prioritization, (2) research methodology and outcomes, (3) academic collaboration, (4) integration/implementation/sustainability, (5) technology, and (6) resources/support/advocacy. This article reflects on and summarizes a decade of progress in the field of pediatric simulation research and suggests next steps in each domain as we look forward, including lessons learned by our collaborative grass roots network that can be used to accelerate research efforts in other domains within healthcare simulation science., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Society for Simulation in Healthcare.)

Objective: Children entering foster care after discharge from the hospital are at risk for adverse events associated with the hospital-to-home transition. Education of foster caregivers regarding transitional care needs is key. However, little is known about the unique needs of foster caregivers as they transition from hospital to home with a new foster child or how hospital-based health care teams can better support foster caregivers. We aimed to examine the experiences and preferences of foster caregivers' regarding hospital-to-home transitions of children newly discharged into their care and to identify opportunities for inpatient providers to improve outcomes for these children., Methods: We conducted semistructured telephone interviews of foster caregivers who newly assumed care of a child at the time of hospital discharge between May 2016 and June 2017. Interviews were continued until thematic saturation was reached. Interviews were audio recorded, transcribed, and analyzed to identify themes using a general inductive approach., Results: Fifteen interviews were completed. All subjects were female, 87% were Caucasian, and 73% were first-time foster caregivers. Thirteen themes were identified and grouped into the following domains: 1) knowing the child, 2) medicolegal issues, 3) complexities of multistakeholder communication, and 4) postdischarge preparation and support., Conclusions: Caregivers of children newly entering foster care following hospital discharge face unique challenges and may benefit from enhanced care processes to facilitate successful transitions. Hospitalization provides an opportunity for information gathering and sharing, clarification of custodial status, and facilitation of communication among multistakeholders, including child protective services and biological parents., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Hospital-to-home transitions present safety risks for patients. Children discharged with new foster caregivers may be especially vulnerable to poor discharge outcomes. With this study, our objective is to identify differences in discharge quality and outcomes for children discharged from the hospital with new foster caregivers compared with children discharged to their preadmission caregivers., Methods: Pediatric patients discharged from the Barbara Bush Children's Hospital at Maine Medical Center between January 2014 and May 2017 were eligible for inclusion in this retrospective cohort study. Chart review identified patients discharged with new foster caregivers. These patients were compared with a matched cohort of patients discharged with preadmission caregivers for 5 discharge quality process measures and 2 discharge outcomes., Results: Fifty-six index cases and 165 matched patients were identified. Index cases had worse performance on 4 of 5 discharge process measures, with significantly lower use of discharge readiness checklists (75% vs 92%; P = .004) and teach-back education of discharge instructions for caregivers (63% vs 79%; P = .02). Index cases had twice the odds of misunderstandings needing clarification at the postdischarge call; this difference was not statistically significant (26% vs 13%; P = .07)., Conclusions: Hospital-to-home transition quality measures were less often implemented for children discharged with new foster caregivers than for the cohort of patients discharged with preadmission caregivers. This may lead to increased morbidity, as suggested by more frequent caregiver misunderstandings. Better prospective identification of these patients and enhanced transition improvement efforts targeted at their new caregivers may be warranted., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objectives: Medications prescribed at hospital discharge can lead to patient harm if there are access barriers or misunderstanding of instructions. Filling prescriptions before discharge can decrease these risks. We aimed to increase the percentage of patients leaving the hospital with new discharge medications in hand to 70% by 18 months., Methods: We used sequential plan-do-study-act cycles from January 2015 to September 2016. We used statistical process control charts to track process measures, new medications filled before discharge, and rates of bedside delivery with pharmacist teaching to the inpatient pediatric unit. Outcome measures included national patient survey data, collected and displayed quarterly, as well as caregiver understanding, comparing inaccuracy of medication teach-back with and without medications in hand before discharge., Results: Rates of patients leaving the hospital with medications in hand increased from a baseline of 2% to 85% over the study period. Bedside delivery reached 71%. Inaccuracy of caregiver report during a postdischarge phone call decreased from 3.3% to 0.7% ( P < .05) when medications were in hand before discharge. Patient satisfaction with education of new medication side effects increased from 50% to 88%., Conclusions: By using an engaged interprofessional team, we optimized use of our on-site outpatient pharmacy and increased the percentage of pediatric patients leaving the hospital with new discharge medications in hand to >80%. This, accompanied by increased rates of bedside medication delivery and pharmacist teaching, was associated with improvements in caregiver discharge-medication related experience and understanding., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background and Objectives: To improve hospital to home transitions, a 4-element pediatric patient-centered transition bundle was developed, including: a transition readiness checklist; predischarge teach-back education; timely and complete written handoff to the primary care provider; and a postdischarge phone call. The objective of this study was to demonstrate the feasibility of bundle implementation and report initial outcomes at 4 pilot sites. Outcome measures included postdischarge caregiver ability to teach-back key home management information and 30-day reuse rates., Methods: A multisite, observational time series using multiple planned sequential interventions to implement bundle components with non-technology-supported and technology-supported patients. Data were collected via electronic health record reviews and during postdischarge phone calls. Statistical process control charts were used to assess outcomes., Results: Four pilot sites implemented the bundle between January 2014 and May 2015 for 2601 patients, of whom 1394 had postdischarge telephone encounters. Improvement was noted in the implementation of all bundle elements with the transitions readiness checklist posing the greatest feasibility challenge. Phone contact connection rates were 69%. Caregiver ability to teach-back essential home management information postdischarge improved from 18% to 82%. No improvement was noted in reuse rates, which differed dramatically between technology-supported and non-technology-supported patients., Conclusions: A pediatric care transition bundle was successfully tested and implemented, as demonstrated by improvement in all process measures, as well as caregiver home management skills. Important considerations for successful implementation and evaluation of the discharge bundle include the role of local context, electronic health record integration, and subgroup analysis for technology-supported patients., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: To determine which of the 21 general pediatrics milestone subcompetencies are most difficult to assess using traditional methodologies and which are best suited to simulation-based assessment., Methods: We surveyed 2 samples: pediatric simulation experts and pediatric program directors. Respondents were asked about current use of simulation for assessment and to select 5 of the 21 pediatric subcompetencies most difficult to assess using traditional methods and the 5 best suited to simulation-based assessment. Spearman rank correlation was used to determine a correlation between how the 2 samples ranked the subcompetencies., Results: Forty-eight percent (29 of 60) simulation experts and 20% (115 of 571) program directors completed the survey. Few respondents reported using simulation for summative assessment. There are clear differences across the pediatric subcompetencies in perceived difficulty of assessment and suitability to simulation-based assessment. The 3 most difficult to assess subcompetencies were "recognize ambiguity," "demonstrate emotional insight," and "identify one's own strengths and deficiencies." The subcompetencies most suitable to assessment using simulation were "interprofessional teamwork," "clinical decision making," and "effective communication." Program directors and simulation experts had high agreement for both questions: difficult to assess (rho = 0.76, P < .001) and suitable to simulation-based assessment (rho = 0.94, P < .001)., Conclusions: Several general pediatrics milestone subcompetencies were identified by pediatric simulation experts and pediatric program directors as difficult to assess using current methodologies and as amenable to simulation-based assessment. The pediatric simulation community should target development of simulation-based assessment tools to these areas., (Copyright © 2016 Academic Pediatric Association. All rights reserved.)

Objective: Effective communication between inpatient and outpatient providers may mitigate risks of adverse events associated with hospital discharge. However, there is an absence of pediatric literature defining effective discharge communication strategies at both freestanding children's hospitals and general hospitals. The objectives of this study were to assess associations between pediatric primary care providers' (PCPs) reported receipt of discharge communication and referral hospital type, and to describe PCPs' perspectives regarding effective discharge communication and areas for improvement., Methods: We administered a questionnaire to PCPs referring to 16 pediatric hospital medicine programs nationally. Multivariable models were developed to assess associations between referral hospital type and receipt and completeness of discharge communication. Open-ended questions asked respondents to describe effective strategies and areas requiring improvement regarding discharge communication. Conventional qualitative content analysis was performed to identify emergent themes., Results: Responses were received from 201 PCPs, for a response rate of 63%. Although there were no differences between referral hospital type and PCP-reported receipt of discharge communication (relative risk 1.61, 95% confidence interval 0.97-2.67), PCPs referring to general hospitals more frequently reported completeness of discharge communication relative to those referring to freestanding children's hospitals (relative risk 1.78, 95% confidence interval 1.26-2.51). Analysis of free text responses yielded 4 major themes: 1) structured discharge communication, 2) direct personal communication, 3) reliability and timeliness of communication, and 4) communication for effective postdischarge care., Conclusions: This study highlights potential differences in the experiences of PCPs referring to general hospitals and freestanding children's hospitals, and presents valuable contextual data for future quality improvement initiatives., (Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Although a diagnosis of pyridoxine-dependent seizures may commonly be delayed, this case involves an extremely late diagnosis with associated morbidity. Our patient received pyridoxine during the neonatal period, in conjunction with other antiepileptic drugs that masked its effect. This patient also underwent ventriculoperitoneal shunting, which complicated the diagnosis. Pyridoxine was continued with other antiepileptic drugs, without definite recognition of its therapeutic relationship. Pyridoxine-dependent seizures were finally recognized at age 19 years when the patient manifested refractory status epilepticus, several days after wisdom tooth removal (and discontinuing oral medications including pyridoxine and phenobarbital before surgery). The diagnosis was only established via genetic testing. Our patient highlights the difficulty in diagnosing this rare seizure type and its potential importance in refractory epilepsy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Congenital myasthenic syndrome is difficult to diagnose, especially in the neonate when classic myasthenic signs may not be present. Congenital myasthenic syndrome with episodic apnea is a rare cause of recurrent apnea in infancy. We present an infant with nine severe episodes of apnea in her first 6 months who underwent a prolonged evaluation before ptosis was evident, leading to a diagnosis of choline acetyltransferase deficiency, a form of congenital myasthenic syndrome. Midazolam appeared to resolve the apnea on five occasions. The diagnosis was supported by edrophonium testing and repetitive nerve stimulation. Mutation analysis demonstrated compound heterozygous p.T354M and p.A557T mutations, the latter of which is novel. The patient's respiratory status stabilized on pyridostigmine, and she is ambulatory at age 3 years. Pyridostigmine is the primary therapy for choline acetyltransferase deficiency, but the efficacy of midazolam during this patient's episodes of apnea is interesting, and warrants further study.