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Zuckerman A, Robinson KJ, Twichell SA, Bonenfant N, Naud S, Runte KE, Couser S, First LR, Flyer JN. Increasing Pediatric Morning Report Educational Value Through Quality Improvement. Pediatrics 2022; 150:188309. [PMID: 35730343 DOI: 10.1542/peds.2021-053103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Morning report (MR) is a common case-based conference in graduate medical education. Recent studies highlight participant dissatisfaction with the educational value of MR, but data are lacking on means for improvement. We aimed to increase MR quality and participant satisfaction at our academic pediatric residency program. METHODS Improvement science was used to develop and implement a new standardized pediatric MR process (intervention), with 5 core educational elements and structured resident-faculty mentorship. Educational elements were measured via feedback forms and tracked using a run chart. Residents and faculty were surveyed regarding MR quality and satisfaction at baseline and 6 months postintervention; responses were analyzed using mixed effects logistic regression. RESULTS The median of educational elements increased from 3 to 5 (5 maximum) during the 6-month study period and 12-months poststudy. Baseline and postintervention survey response rates were 90% (18 of 20) for residents and 66% (51 of 77) for faculty. Residents reporting high quality MR changed from 50% to 72% (P = .20), and faculty from 29% to 85% (P <.001). Satisfaction with MR content increased for both residents (50%-89%, P = .03) and faculty (25%-67%, P <.001). Resident satisfaction with faculty mentorship before MR increased from 28% to 78% (P = .01); satisfaction with faculty feedback after MR increased from 11% to 56% (P = .02). CONCLUSIONS Improvement science can be used to develop a new pediatric graduate medical education process. Requiring core educational elements and providing structured mentorship were associated with improvements in pediatric MR quality and participant satisfaction.
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Affiliation(s)
- Anna Zuckerman
- Department of Pediatrics.,Montefiore Bronx Health Collective, Bronx, New York
| | - Keith J Robinson
- Department of Pediatrics.,University of Vermont Children's Hospital, Burlington, Vermont
| | - Sarah A Twichell
- Department of Pediatrics.,University of Vermont Children's Hospital, Burlington, Vermont
| | - Nicholas Bonenfant
- Department of Pediatrics.,University of Vermont Children's Hospital, Burlington, Vermont
| | - Shelly Naud
- Biomedical Statistics Research Core, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - K Elisabeth Runte
- Department of Pediatrics.,University of Vermont Children's Hospital, Burlington, Vermont
| | - Sarah Couser
- Department of Pediatrics.,University of Vermont Children's Hospital, Burlington, Vermont
| | - Lewis R First
- Department of Pediatrics.,University of Vermont Children's Hospital, Burlington, Vermont
| | - Jonathan N Flyer
- Department of Pediatrics.,University of Vermont Children's Hospital, Burlington, Vermont
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Runte KE, Flyer JN, Edwards EM, Soll RF, Horbar JD, Yeager SB. Variation of Patent Ductus Arteriosus Treatment in Very Low Birth Weight Infants. Pediatrics 2021; 148:peds.2021-052874. [PMID: 34675131 DOI: 10.1542/peds.2021-052874] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA) treatment is common among very low birth weight (VLBW) infants. Given limitations in evidence, controversy exists regarding treatment risks and benefits. In this study, we describe PDA treatment trends and variation in a large, US, multicenter VLBW infant cohort. METHODS Data were collected through Vermont Oxford Network on 291 292 VLBW infants born 2012-2019 at 806 US NICUs. PDA diagnosis and treatment rates, further categorized as pharmacologic, invasive, or combined, were determined. NICUs were classified as capable versus noncapable of invasive PDA treatment. Infant and hospital characteristics were examined by NICU type and treatment quartile. Geographic NICU distribution and treatment rates were described in 9 US census divisions. RESULTS Of all infants, 24.6% were diagnosed with and 20.5% were treated for PDA. Diagnosis and treatment rates decreased over the study period. Treatment was predominantly pharmacologic. Treatment rates varied widely among NICUs (0% to 67%) despite similar infant characteristics. The median treatment rate was higher at NICUs capable of pharmacologic and invasive treatment (20.3%, interquartile range 13.3-28.6) than at NICUs capable of only pharmacologic treatment (8.9%, interquartile range 2.9-14.8). Treatment rates were highest in the northeast and lowest in the west. Invasive treatment was more common in the west. CONCLUSIONS PDA diagnosis and treatment rates are trending downward. Wide variation exists in PDA treatment despite a largely uniform VLBW infant population. This variation correlates with differences in hospital treatment capabilities and geography. Further understanding of the effects of treatment disparity could aid in guiding clinical management.
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Affiliation(s)
- K Elisabeth Runte
- Department of Pediatrics, Robert Larner, MD, College of Medicine, The University of Vermont and The University of Vermont Children's Hospital, Burlington, Vermont
| | - Jonathan N Flyer
- Department of Pediatrics, Robert Larner, MD, College of Medicine, The University of Vermont and The University of Vermont Children's Hospital, Burlington, Vermont
| | - Erika M Edwards
- Department of Pediatrics, Robert Larner, MD, College of Medicine, The University of Vermont and The University of Vermont Children's Hospital, Burlington, Vermont.,Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, The University of Vermont, Burlington, Vermont.,Vermont Oxford Network, Burlington, Vermont
| | - Roger F Soll
- Department of Pediatrics, Robert Larner, MD, College of Medicine, The University of Vermont and The University of Vermont Children's Hospital, Burlington, Vermont.,Vermont Oxford Network, Burlington, Vermont.,Neonatology
| | - Jeffrey D Horbar
- Department of Pediatrics, Robert Larner, MD, College of Medicine, The University of Vermont and The University of Vermont Children's Hospital, Burlington, Vermont.,Vermont Oxford Network, Burlington, Vermont.,Neonatology
| | - Scott B Yeager
- Department of Pediatrics, Robert Larner, MD, College of Medicine, The University of Vermont and The University of Vermont Children's Hospital, Burlington, Vermont
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Runte KE, Bell SP, Selby DE, Häußler TN, Ashikaga T, LeWinter MM, Palmer BM, Meyer M. Relaxation and the Role of Calcium in Isolated Contracting Myocardium From Patients With Hypertensive Heart Disease and Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004311. [PMID: 28784688 DOI: 10.1161/circheartfailure.117.004311] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Relaxation characteristics and Ca2+ homeostasis have not been studied in isolated myocardium from patients with hypertensive heart disease (HHD) and heart failure with preserved ejection fraction (HFpEF). Prolonged myocardial relaxation is believed to play an important role in the pathophysiology of these conditions. In this study, we evaluated relaxation parameters, myocardial calcium (Ca2+), and sodium (Na+) handling, as well as ion transporter expression and tested the effect of Na+-influx inhibitors on relaxation in isolated myocardium from patients with HHD and HFpEF. METHODS AND RESULTS Relaxation characteristics were studied in myocardial strip preparations under physiological conditions at stimulation rates of 60 and 180 per minute. Intracellular Ca2+ and Na+ were simultaneously assessed using Fura-2 and AsanteNATRIUMGreen-2, whereas elemental analysis was used to measure total myocardial concentrations of Ca, Na, and other elements. Quantitative polymerase chain reaction was used to measure expression levels of key ion transport proteins. The lusitropic effect of Na+-influx inhibitors ranolazine, furosemide, and amiloride was evaluated. Myocardial left ventricular biopsies were obtained from 36 control patients, 29 HHD and 19 HHD+HFpEF. When compared with control patients, half maximal relaxation time (RT50) at 60 per minute was prolonged by 13% in HHD and by 18% in HHD+HFpEF (both P<0.05). Elevated resting Ca2+ levels and a tachycardia-induced increase in diastolic Ca2+ were associated with incomplete relaxation and an increase in diastolic tension in HHD and HHD+HFpEF. Na+ levels were not increased, and expression levels of Ca2+- or Na+-handling proteins were not altered. Na+-influx inhibitors did not improve relaxation or prevent incomplete relaxation at high stimulation rates. CONCLUSIONS Contraction and relaxation are prolonged in isolated myocardium from patients with HHD and HHD+HFpEF. This leads to incomplete relaxation at higher rates. Elevated calcium levels in HFpEF are neither a result of an impaired Na+ gradient nor expression changes in key ion transporters and regulatory proteins.
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Affiliation(s)
- K Elisabeth Runte
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington
| | - Stephen P Bell
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington
| | - Donald E Selby
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington
| | - Tim N Häußler
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington
| | - Takamuru Ashikaga
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington
| | - Martin M LeWinter
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington
| | - Bradley M Palmer
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington
| | - Markus Meyer
- From the Division of Cardiology, Department of Medicine (K.E.R., S.P.B., D.E.S., T.N.H., M.M.L., M.M.), Biostatistics Unit (T.A.), and Department of Molecular Physiology and Biophysics (M.M.L., B.M.P.), Larner College of Medicine at the University of Vermont, Burlington.
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Klein FJ, Bell S, Runte KE, Lobel R, Ashikaga T, Lerman LO, LeWinter MM, Meyer M. Heart rate-induced modifications of concentric left ventricular hypertrophy: exploration of a novel therapeutic concept. Am J Physiol Heart Circ Physiol 2016; 311:H1031-H1039. [PMID: 27591220 DOI: 10.1152/ajpheart.00301.2016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/26/2016] [Indexed: 01/20/2023]
Abstract
Lowering the heart rate is considered to be beneficial in heart failure (HF) with reduced ejection fraction (HFrEF). In a dilated left ventricle (LV), pharmacological heart rate lowering is associated with a reduction in LV chamber size. In patients with HFrEF, this structural change is associated with better survival. HF with preserved ejection fraction (HFpEF) is increasingly prevalent but, so far, without any evidence-based treatment. HFpEF is typically associated with LV concentric remodeling and hypertrophy. The effects of heart rate on this structural phenotype are not known. Analogous with the benefits of a low heart rate on a dilated heart, we hypothesized that increased heart rates could lead to potentially beneficial remodeling of a concentrically hypertrophied LV. This was explored in an established porcine model of concentric LV hypertrophy and fibrosis. Our results suggest that a moderate increase in heart rate can be used to reduce wall thickness, normalize LV chamber volumes, decrease myocardial fibrosis, and improve LV compliance. Our results also indicate that the effects of heart rate can be titrated, are reversible, and do not induce HF. These findings may provide the rationale for a novel therapeutic approach for HFpEF and its antecedent disease substrate.
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Affiliation(s)
- Franziska J Klein
- Cardiology Division, University of Vermont College of Medicine, Burlington, Vermont
| | - Stephen Bell
- Cardiology Division, University of Vermont College of Medicine, Burlington, Vermont
| | - K Elisabeth Runte
- Cardiology Division, University of Vermont College of Medicine, Burlington, Vermont
| | - Robert Lobel
- Cardiology Division, University of Vermont College of Medicine, Burlington, Vermont
| | - Takamuru Ashikaga
- Biostatistics Unit, University of Vermont College of Medicine, Burlington, Vermont; and
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Martin M LeWinter
- Cardiology Division, University of Vermont College of Medicine, Burlington, Vermont
| | - Markus Meyer
- Cardiology Division, University of Vermont College of Medicine, Burlington, Vermont;
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Lin B, Govindan S, Lee K, Zhao P, Han R, Runte KE, Craig R, Palmer BM, Sadayappan S. Cardiac myosin binding protein-C plays no regulatory role in skeletal muscle structure and function. PLoS One 2013; 8:e69671. [PMID: 23936073 PMCID: PMC3729691 DOI: 10.1371/journal.pone.0069671] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 06/11/2013] [Indexed: 12/19/2022] Open
Abstract
Myosin binding protein-C (MyBP-C) exists in three major isoforms: slow skeletal, fast skeletal, and cardiac. While cardiac MyBP-C (cMyBP-C) expression is restricted to the heart in the adult, it is transiently expressed in neonatal stages of some skeletal muscles. However, it is unclear whether this expression is necessary for the proper development and function of skeletal muscle. Our aim was to determine whether the absence of cMyBP-C alters the structure, function, or MyBP-C isoform expression in adult skeletal muscle using a cMyBP-C null mouse model (cMyBP-C((t/t))). Slow MyBP-C was expressed in both slow and fast skeletal muscles, whereas fast MyBP-C was mostly restricted to fast skeletal muscles. Expression of these isoforms was unaffected in skeletal muscle from cMyBP-C((t/t)) mice. Slow and fast skeletal muscles in cMyBP-C((t/t)) mice showed no histological or ultrastructural changes in comparison to the wild-type control. In addition, slow muscle twitch, tetanus tension, and susceptibility to injury were all similar to the wild-type controls. Interestingly, fMyBP-C expression was significantly increased in the cMyBP-C((t/t)) hearts undergoing severe dilated cardiomyopathy, though this does not seem to prevent dysfunction. Additionally, expression of both slow and fast isoforms was increased in myopathic skeletal muscles. Our data demonstrate that i) MyBP-C isoforms are differentially regulated in both cardiac and skeletal muscles, ii) cMyBP-C is dispensable for the development of skeletal muscle with no functional or structural consequences in the adult myocyte, and iii) skeletal isoforms can transcomplement in the heart in the absence of cMyBP-C.
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MESH Headings
- Animals
- Blotting, Western
- Carrier Proteins/genetics
- Carrier Proteins/metabolism
- In Vitro Techniques
- Mice
- Mice, Inbred C57BL
- Mice, Inbred mdx
- Mice, Knockout
- Microscopy, Electron
- Muscle Contraction
- Muscle Fibers, Fast-Twitch/metabolism
- Muscle Fibers, Fast-Twitch/physiology
- Muscle Fibers, Slow-Twitch/metabolism
- Muscle Fibers, Slow-Twitch/physiology
- Muscle, Skeletal/metabolism
- Muscle, Skeletal/physiology
- Myocardium/metabolism
- Promoter Regions, Genetic/genetics
- Protein Isoforms/genetics
- Protein Isoforms/metabolism
- Sarcomeres/metabolism
- Sarcomeres/physiology
- Sarcomeres/ultrastructure
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Affiliation(s)
- Brian Lin
- Department of Cell and Molecular Physiology, Health Sciences Division, Loyola University Chicago, Maywood, Illinois, United States of America
| | - Suresh Govindan
- Department of Cell and Molecular Physiology, Health Sciences Division, Loyola University Chicago, Maywood, Illinois, United States of America
| | - Kyounghwan Lee
- Department of Cell Biology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Piming Zhao
- Department of Cell and Molecular Physiology, Health Sciences Division, Loyola University Chicago, Maywood, Illinois, United States of America
| | - Renzhi Han
- Department of Cell and Molecular Physiology, Health Sciences Division, Loyola University Chicago, Maywood, Illinois, United States of America
| | - K. Elisabeth Runte
- Department of Molecular Physiology and Biophysics, University of Vermont, Burlington, Vermont, United States of America
| | - Roger Craig
- Department of Cell Biology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Bradley M. Palmer
- Department of Molecular Physiology and Biophysics, University of Vermont, Burlington, Vermont, United States of America
| | - Sakthivel Sadayappan
- Department of Cell and Molecular Physiology, Health Sciences Division, Loyola University Chicago, Maywood, Illinois, United States of America
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