Hilary M. Haftel

Long-Term Gain After Team-Based Learning Experience in a Pediatric Clerkship

Background: Team-based learning (TBL) increases student engagement, value of teamwork, and performance on standardized evaluations. Purpose: The authors implemented a 3rd-year pediatric TBL curriculum, evaluating its effect on satisfaction, engagement, value of teamwork, and short-term and long-term academic performance. Method: Students evaluated the TBL curriculum and core lectures through satisfaction, engagement and value of team surveys. Scores on short-term and long-term examinations were compared to historical data. Results: The first implementation year, students were less likely to enjoy TBL sessions compared to lectures. The 2nd year, this difference lessened. Through both years, students reported dramatic increases in classroom engagement during TBL compared to lecture. Students developed a greater value for teams after participating in TBL. Short-term and long-term examination scores improved significantly. Conclusions: Both short-term and long-term performance improved with implementation of TBL, emphasizing the benefits of a curriculum that allows students to critically engage with material.

Is it Crohn's disease? A severe systemic granulomatous reaction to sulfasalazine in patient with rheumatoid arthritis

BackgroundSulfasalazine is a widely used anti-inflammatory agent in the treatment of inflammatory bowel disease and several rheumatological disorders. Although as many as 20% of treated patients may experience reversible, dose-dependent side effects, less frequent but potentially severe, systemic reactions have also been reported.Case PresentationA severe systemic reaction to sulfasalazine developed in a 21-year old female with rheumatoid arthritis characterized by eosinophilia, granulomatous enteritis and myelotoxicity, cholestatic hepatitis, and seizures. The clinical course and management of this patient are presented as well as a review of the incidence and outcome of severe systemic reactions to sulfasalazine.ConclusionsGranulomatous myelotoxicity and enteritis developed in a 21 year old female within 3 weeks of initiating sulfasalazine for rheumatoid arthritis. Following a short course of corticosteroids, the patient had resolution of her cholestatic hepatitis, rash, eosinophilia, and gastrointestinal symptoms with no residual manifestations at 7 months follow-up. Although severe reactions to sulfasalazine are rare and unpredictable, practicing physicians should be aware of unusual clinical presentations of toxicity when prescribing sulfasalazine.

Competency-based education: programme design and challenges to implementation.

Competency‐based education (CBE) has been widely cited as an educational framework for medical students and residents, and provides a framework for designing educational programmes that reflect four critical features: a focus on outcomes, an emphasis on abilities, a reduction of emphasis on time‐based training, and promotion of learner centredness. Each of these features has implications and potential challenges for implementing CBE.

Induction of the autoantigen proliferating cell nuclear antigen in T lymphocytes by a mycobacterial antigen

Mycobacteria have been implicated in the pathogenesis of autoimmunity. To determine the potential effect of mycobacterial antigens on peripheral blood mononuclear cells (PBMC), we analyzed PBMC incubated with the acetone-precipitable fraction of Mycobacterium tuberculosis (APMT) for changes in cellular protein expression. Two-dimensional gel analysis showed induction of a 36-kD polypeptide identified as proliferating cell nuclear antigen (PCNA), a known autoantigen, after incubation with AP-MT. PCNA plays a role in cell proliferation and is expressed as a late growth regulated factor. However, its synthesis in response to AP-MT was induced as an early event. The early induction of PCNA was regulated at a posttranscriptional level and was restricted to T cells. Treatment of PBMC with known T cell mitogens, namely PHA, anti-CD3 antibodies, and staphylococcal superantigens failed to induce an early PCNA increase. The distinct characteristics of the AP-MT effect on PCNA expression suggest a separate mechanism of induction in response to AP-MT, compared with the late increase observed in response to mitogens. The induction of PCNA in response to mycobacterial antigens may represent a pathogenically relevant mechanism in autoimmunity.

A validated search assessment tool: assessing practice-based learning and improvement in a residency program

OBJECTIVE The objective of this study was to validate an assessment instrument for MEDLINE search strategies at an academic medical center. METHOD Two approaches were used to investigate if the search assessment tool could capture performance differences in search strategy construction. First, data from an evaluation of MEDLINE searches from a pediatric residents longitudinal assessment were investigated. Second, a cross-section of search strategies from residents in one incoming class was compared with strategies of residents graduating a year later. MEDLINE search strategies formulated by faculty who had been identified as having search expertise were used as a gold standard comparison. Participants were presented with a clinical scenario and asked to identify the search question and conduct a MEDLINE search. Two librarians rated the blinded search strategies. RESULTS Search strategy scores were significantly higher for residents who received training than the comparison group with no training. There was no significant difference in search strategy scores between senior residents who received training and faculty experts. CONCLUSION The results provide evidence for the validity of the instrument to evaluate MEDLINE search strategies. This assessment tool can measure improvements in information-seeking skills and provide data to fulfill Accreditation Council for Graduate Medical Education competencies.

Race, Income, and Disease Outcomes in Juvenile Dermatomyositis

Objective To determine the relationships among race, income, and disease outcomes in children with juvenile dermatomyositis (JDM). Study design Data from 438 subjects with JDM enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry were analyzed. Demographic data included age, sex, race, annual family income, and insurance status. Clinical outcomes included muscle strength, presence of rash, calcinosis, weakness, physical function, and quality of life measures. Disease outcomes were compared based on race and income. Results Minority subjects were significantly more likely to have low annual family income and significantly worse scores on measures of physical function, disease activity, and quality of life measures. Subjects with lower annual family income had worse scores on measures of physical function, disease activity, and quality of life scores, as well as weakness. Black subjects were more likely to have calcinosis. Despite these differences in outcome measures, there were no significant differences among the racial groups in time to diagnosis or duration of disease. Using calcinosis as a marker of disease morbidity, black race, annual family income <

Developing Leaders in Pediatric Graduate Medical Education: The APPD LEAD Program

50 000 per year, negative antinuclear antibody, and delay in diagnosis >12 months were associated with calcinosis. Conclusion Minority race and lower family income are associated with worse morbidity and outcomes in subjects with JDM. Calcinosis was more common in black subjects. Further studies are needed to examine these associations in more detail, to support efforts to address health disparities in subjects with JDM and improve disease outcomes.

A multi-source feedback tool for measuring a subset of Pediatrics Milestones

From the Department of Pediatrics, University of South Alabama College of Medicine, Mobile, Alabama (Dr Trimm); Department of Medical Education, Phoenix Children’s Hospital, Phoenix, Arizona (Dr Caputo); Department of Pediatrics, Weill Cornell Medical College, New York, New York (Dr Bostwick); Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Dr Frohna); Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, Michigan (Dr Haftel); Division of Infectious Diseases, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia (Dr Waggoner-Fountain); and Department of Pediatrics, University of California, Davis, Sacramento, California (Dr Li) The authors declare that they have no conflict of interest. Address correspondence to Franklin Trimm,MD, Department of Pediatrics, 1700 Center St, University of South Alabama, USAChildren’s and Women’s Hospital, Mobile, AL 36604 (e-mail: rftrimm@health.southalabama.edu).

Assessing Interpersonal Communications Skills: The Use of Standardized Patients in Graduate Medical Education

Abstract Background: The Pediatrics Milestones Assessment Pilot employed a new multisource feedback (MSF) instrument to assess nine Pediatrics Milestones among interns and subinterns in the inpatient context. Objective: To report validity evidence for the MSF tool for informing milestone classification decisions. Methods: We obtained MSF instruments by different raters per learner per rotation. We present evidence for validity based on the unified validity framework. Results: One hundred and ninety two interns and 41 subinterns at 18 Pediatrics residency programs received a total of 1084 MSF forms from faculty (40%), senior residents (34%), nurses (22%), and other staff (4%). Variance in ratings was associated primarily with rater (32%) and learner (22%). The milestone factor structure fit data better than simpler structures. In domains except professionalism, ratings by nurses were significantly lower than those by faculty and ratings by other staff were significantly higher. Ratings were higher when the rater observed the learner for longer periods and had a positive global opinion of the learner. Ratings of interns and subinterns did not differ, except for ratings by senior residents. MSF-based scales correlated with summative milestone scores. Conclusion: We obtain moderately reliable MSF ratings of interns and subinterns in the inpatient context to inform some milestone assignments.

Microscopic polyangiitis in an adolescent presenting as severe anemia and syncope

All authors are at the University of Michigan Medical School. Sarah Middlemas, MPH, is Training Specialist and Director of Graduate Medical Education and Pharmacy Standardized Patient Assessments; Hilary Haftel, MD, MHPE, is Associate Chair and Director of Pediatric Education and Pediatric Residency Director; Paula T. Ross, MA, is Project Manager; Monica L. Lypson, MD, MHPE, is Assistant Dean for Graduate Medical Education and Associate Professor of Internal Medicine.