Screening for congenital and acquired deafness and hearing loss (HL) represents a significant responsibility for clinicians in all newborn units and medical homes. Approximately 1 to 3 infants of 1,000 born in a well infant nursery setting and 2 to 4 of 100 born in a NICU have significant bilateral HL. Outcomes in various developmental domains depend on the early recognition and subsequent intervention for HL. Developmental delay is present in 30% to 40% of children with HL; the goal of hearing screening (HS) and prompt intervention is to optimize a child's language acquisition, cognitive development, literacy, social-emotional maturity and academic success. This article reviews the most up-to-date standards and practices to aid medical providers in the early detection and intervention for pediatric HL.In the United States, universal screening begins in the neonatal period. According to the American Academy of Pediatrics (AAP) Joint Commission on Infant Hearing (JCIH), all infants should be screened for congenital HL before 1 month of age. Most infants are screened in nursery or NICU settings, except for those born outside of a medical facility. For the latter population or for infants with no documented HS, screening should be completed by the medical home before 1 month of age.In a well nursery setting, most HSs are performed by otoacoustic emission (OAE) testing. During an OAE screen, a sensitive microphone in the ear canal records the cochlear responses ("acoustic emissions") to acoustic stimuli, thereby testing the peripheral auditory system from the outer/middle ear (conduction zones) to the cochlear outer hair cells (sensory organ). A "pass" indicates that hearing is functional to the level of the cochlea. Children may fail this test if the system is impeded along any point. Thus, a "fail" will not distinguish between true congenital HL and reversible or transient abnormalities of the outer/middle ear (a false-positive). Excess wax buildup in the outer ear, middle ear effusions, or cochlear dysfunction may all result in a failed screen. A failed initial screen by OAE may be repeated before hospital discharge or followed by a complementary test known as an auditory brainstem response (ABR). ABR screening records neural activity generated in the cochlea and sent via neural pathways through the auditory nerve (cranial nerve VIII) to the brain stem in response to acoustic stimuli via an earphone. Because the cochlea is involved with both OAE and ABR, each screen can detect cochlear (sensory) HL; similarly, each test is also affected by outer/middle ear dysfunction that may be present. Infants who pass the ABR after a failed OAE have passed their newborn HS. However, ABR alone detects neural dysfunction of the auditory nerve and/or brainstem auditory pathway. A failed initial ABR may be repeated before discharge with another ABR. Rescreen by OAE after ABR is inappropriate because the child may have neural HL that will not be identified on OAE. Compared with ABR, OAE screening is less costly, takes less time to complete, and is less invasive (because it does not require electrode placement), making it the most widely used initial screen for HL in a nursery setting.All infants admitted to the NICU for more than 5 days are considered to be at high risk for neural HL and are screened by ABR. Failed ABR screening in the NICU should result in immediate referral to an audiologist for diagnostic evaluation of bilateral hearing ability, even if ABR detected unilateral HL. Notably, if an infant is readmitted to an inpatient setting (well nursery or NICU) before 1 month of age and has a condition that may be associated with HL (Table 1), that infant should have repeated HS by ABR before discharge.Any failed newborn HS should result in a comprehensive audiological evaluation before 3 months of age, and early intervention services should commence no later than 6 months of age for those who are found to have HL.Outside of the newborn period, the JCIH recommends that infant HS should occur regularly in the medical home. Clinicians should assess for the presence of risk factors for congenital or delayed-onset HL that may not have been picked up by the newborn HS. Infants who pass initial newborn HS but have risk factors for HL (Table 1) should have a diagnostic audiology evaluation no later than 24 to 30 months of age. In addition, routine in-office HS should include objective screening of developmental milestones at ages 9, 18, 24, and 30 months by a validated global screening tool (such as the Ages & Stages Questionnaires), middle ear examination (with pneumatic otoscopy as necessary to establish diagnosis of effusion), evaluation of apparent hearing skills in the examination room through observation, and consideration of any caregiver concerns about hearing, language, or communication. Objective communication delay as well as physician or parental concern should prompt immediate referral for speech-language pathology and audiologic evaluation to rule out HL. Because otitis media and effusion are associated with low-frequency HL, the presence of effusion for 3 months in children with risk factors for HL warrants referral for audiometry. Children with effusion without risk factors or clinical concern for HL should be evaluated again at 3- to 6-month intervals for resolution or clinical change.Once a diagnosis of HL is made, federal guidelines require that referral to an early intervention program be initiated within 2 days of confirmation of HL for children younger than 3 years.In keeping with the AAP Periodicity Schedule, audiometry screens should take place in the medical home during childhood at ages 4, 5, 6, 8, and 10 years. Risk assessments should occur during the interim years. Standard HS typically includes low-frequency tones (<3,000 Hz) at these ages because the development of low-frequency HL is more common and often associated with a history of otitis media and effusion. Due to greater sensitivity in detecting high-frequency HL, adolescents should be screened with audiometry that includes high frequencies (6,000 and 8,000 Hz) once during early (11–14 years), middle (15–17 years), and late (18–21 years) adolescence. Approximately 1 in 6 adolescents in the United States has high-frequency HL. This is thought to be related to acoustic trauma, and physicians should counsel patients on the risks of HL associated with headphone/ear bud use and environmental exposures.Studies have been conducted to evaluate the effectiveness of the previously mentioned nationwide guidelines. Currently, more than 95% of infants in the United States are screened for congenital HL before hospital discharge. However, only approximately 50% of infants among those who fail initial HS ultimately receive the appropriate evaluation and services after discharge. Programs for children with HL should include speech-language pathology services, audiology, and access to educators of the deaf, and they may require referral to genetics or otolaryngology, among other subspecialties. Referrals for amplification devices/implants or reconstructive surgery may also be needed. Given the gap that exists between recognition and intervention, primary care providers must focus on ensuring adequate follow-up and coordination of care for all children with risk or concern for HL after HS. Developmental and academic outcomes ultimately hinge on early detection and coordination of care for the child with HL.Comments: HL can range from mild to profound and from unilateral to bilateral; be categorized as conduction, sensory, or neural HL; and be due to multiple etiologies. This is a major public health problem, and early intervention can maximize educational outcomes and social functioning for children who are affected. Dr C. Everett Koop, past US Surgeon General, encouraged identification and treatment of HL to be included in Healthy People 2000 goals for our nation. Federal agencies and national organizations, including the National Institutes of Health, the Centers for Disease Control and Prevention (CDC), the Maternal and Child Health Bureau, the AAP, the JCIH, and others, along with Congress have banded together to develop policy statements and road maps to address this important issue. Mandates have emphasized strategies for screening to provide early identification, followed by interventions such as sign language and other communication strategies, personal amplification, or cochlear implants that are individualized to each child. To accomplish these goals the screening needs to take place as outlined in this In Brief in conjunction with a finely tuned team approach with collaboration between information shared from the nursery or NICU discharge staff to primary care providers and timely referrals to audiologists to confirm the HL, otolaryngologists to identify the etiology of the HL and assist with interventions, and other subspecialists, including geneticists. Families of children and the children with HL have benefited from support groups with adult and child peers. It truly takes a village and a commitment among all involved to be successful in these programs and assist children with HL to obtain the services they need to reach their full potential.

Background A poor diet now outranks smoking as the leading cause of death globally. Much of the work to increase healthy food access is done by local non-profits. This creates a need for partnership between pediatricians and community advocates. Design/Methods The Food as Medicine curriculum (FAMC) was piloted as a 4-week elective September 2019. The FAMC comprised of (1) Exposure to food systems: Visits with various local organizations each addressing a different facet of the food system. Experiences included discussions with policy makers, gardening, participation at farmer's markets, and a tour at a food recovery center. (2) Self-directed learning time: multi-media resources addressing the basic tenets of nutrition. (3) Cooking sessions at teaching kitchens. (4) Interactive small group discussions with local experts about different facets of pediatric nutrition. Results 7 pediatric residents took the elective. The FAMC was evaluated using mixed methodology: pre/post-elective surveys and qualitative data via focus groups and open-ended survey questions. Wilcoxon Signed Rank Test revealed a significant increase in the knowledge of local community resources for nutrition and wellness (p=0.016). Focus group discussions were recorded. Curriculum leaders analyzed transcripts using constant comparative methodology until codes were agreed upon and organized into themes. The most common themes: 'Positive impact on resident-patient interactions,' and 'residents choosing and enjoying healthier food.' For example, below is a representative quote in response to if this elective will change future practice: "Yes! Loved hearing about the many community resources available in Denver that exist to improve access to healthy food for ourselves and for our patients. Will definitely be using them more [...] and also refer my patients." Conclusions The FAMC highlighted the need and feasibility of a formal nutrition curriculum for pediatric residents encompassing the food system as a whole. Resident engagement with local non-profits led to improved personal wellness and confidence in nutrition discussions with patients. A poor diet now outranks smoking as the leading cause of death globally. Much of the work to increase healthy food access is done by local non-profits. This creates a need for partnership between pediatricians and community advocates. The Food as Medicine curriculum (FAMC) was piloted as a 4-week elective September 2019. The FAMC comprised of (1) Exposure to food systems: Visits with various local organizations each addressing a different facet of the food system. Experiences included discussions with policy makers, gardening, participation at farmer's markets, and a tour at a food recovery center. (2) Self-directed learning time: multi-media resources addressing the basic tenets of nutrition. (3) Cooking sessions at teaching kitchens. (4) Interactive small group discussions with local experts about different facets of pediatric nutrition. 7 pediatric residents took the elective. The FAMC was evaluated using mixed methodology: pre/post-elective surveys and qualitative data via focus groups and open-ended survey questions. Wilcoxon Signed Rank Test revealed a significant increase in the knowledge of local community resources for nutrition and wellness (p=0.016). Focus group discussions were recorded. Curriculum leaders analyzed transcripts using constant comparative methodology until codes were agreed upon and organized into themes. The most common themes: 'Positive impact on resident-patient interactions,' and 'residents choosing and enjoying healthier food.' For example, below is a representative quote in response to if this elective will change future practice: "Yes! Loved hearing about the many community resources available in Denver that exist to improve access to healthy food for ourselves and for our patients. Will definitely be using them more [...] and also refer my patients." The FAMC highlighted the need and feasibility of a formal nutrition curriculum for pediatric residents encompassing the food system as a whole. Resident engagement with local non-profits led to improved personal wellness and confidence in nutrition discussions with patients.

This article was migrated. The article was marked as recommended. Background The skills needed to engage in scholarship in medical education are not part of the training that all physicians acquire. To build skills and promote scholarship, we developed a Center for Education Research and Scholarship (CERS) in the Department of Pediatrics at the University of Colorado. In this paper, we offer recommendations for others who seek to establish departmental-level efforts to support education. Approach and Lessons Learned CERS provides an "education home" for those interested in education scholarship, supplementing campus-wide efforts such as an Academy of Medical Educators. Mentorship from two experienced leaders in medical education provided a foundation for other faculty in the department and helped to build scholarship efforts more broadly. Through a weekly meeting and an annual departmental retreat, CERS provides opportunities for community among educators, faculty development in the skills needed to engage in education research, and a forum for generating ideas and planning projects.Essential resources for success include at least one leader with expertise in educational research, an administrative and/or research assistant, and some funding for faculty time and initiation of projects. Mentors with experience in education research and scholarship are also needed, although a group of mentors quickly grows as more individuals engage. Results Benefits to the department include peer-reviewed presentations and publications in medical education, with regional, national, and international recognition. Faculty members can focus on medical education as a key component of their careers, and the quality of education programs is enhanced. Conclusions While it takes time to fully develop a departmental center for education scholarship, it is possible to start small and grow. One or two leaders in education with vision can begin the effort and engage others, and the faculty will begin to experience the satisfaction of collaborative projects in education, successful innovation, and dissemination of scholarship.

Krabbe disease is a progressive neurologic disorder caused by deficiency of the lysosomal enzyme galactocerebrosidase. The disease commonly has an early-infantile onset, but can have late-infantile, juvenile, or adult-onset phenotypes. Classic computed tomography (CT) and magnetic resonance imaging (MRI) findings in Krabbe have been well described. We report a patient, ultimately diagnosed with juvenile-onset Krabbe, who presented with atypical CT imaging and rapid disease progression. Our patient was a previously healthy and developmentally appropriate female who presented at 3 years 4 months of age with ataxia and motor regression that had progressed over the course of 6 weeks without an identifiable catalyst. CT, performed in the emergency setting, demonstrated extensive white matter hyperdensity. Subsequent MRI showed T2 hyperintensity of the white matter corresponding to the areas of hyperdensity on the CT, as well as enhancement of multiple cranial nerves bilaterally, suggestive of Krabbe disease. Enzymatic testing demonstrated low galactocerebrosidase activity and molecular testing of GALC revealed compound heterozygosity for 2 known pathogenic mutations, consistent with a diagnosis of Krabbe Disease. This included the common 30-kb deletion and a known pathogenic mutation associated with juvenile/adult-onset disease. Our patient's diffuse hyperdensity on CT offers a new radiographic finding to include in the repertoire of Krabbe imaging, and thus aide in the diagnostic evaluation. The rapidity of progression our patient demonstrated is additionally unique and should be considered in the identification of juvenile Krabbe as well as the complicated decision-making process regarding potential treatments.

BackgroundPrimary care forms a critical part of pediatricians' practices, yet the most effective ways to teach primary care during residency are not known.ObjectiveWe established a new primary care curriculum based on Malcolm Knowles' theory of andragogy, with brief clinical content that is easily accessible and available in different formats.MethodsWe used Kern's model to create a curriculum. In 2013, we implemented weekly e-mails with links to materials on our learning management system, including moderators' curricular content, resident-developed quizzes, and podcasts. After 3 years, we evaluated the curriculum with resident focus groups, retrospective pre-/post-resident surveys, faculty feedback, a review of materials accessed, and resident attendance.ResultsFrom content analysis of focus groups we learned that residents found the curriculum beneficial, but it was not always possible to do the pre-work. The resident survey, with a response rate of 87% (71 of 82), showed that residents perceived improvement in 37 primary care clinical skills, with differences from 0.64 to 1.46 for scales 1-5 (P < .001 for all). Faculty feedback was positive regarding curriculum organization and structure, but patient care often precluded devoting time to discussing the curriculum. In other ways, our results were disappointing: 51% of residents did not access the curriculum materials, 51% did not open their e-mails, only 37% completed any of the quizzes, and they attended a weekly conference 46% of the time.ConclusionsAlthough residents accessed the curriculum less than expected, their self-assessments reflect perceptions of improvement in their clinical skills after implementation.

Underuse and overuse of medical interventions, failure to use interventions known to be effective, and provision of tests or interventions in which benefits do not exceed harms are types of low-value care. The Lown Institute's Right Care Alliance Children's Health Council identified five "do" recommendations that highlight underuse and five "don't" recommendations that highlight overuse in children's health care. The five "do" recommendations include: do provide access to long-acting reversible contraception for adolescents, do use nonpharmacologic interventions first for treatment of attention-deficit/hyperactivity disorder, do discuss quality of life for children with complex medical conditions using a shared decision-making model and access resources such as palliative care subspecialists, do promote childhood literacy development by providing free, age-appropriate books in clinical settings, and do screen for socioeconomic status of the patient and family and provide access to community health and wellness resources. The five "don't" recommendations include: don't routinely prescribe antibiotics in children two to 12 years of age with a middle ear infection, don't perform computed tomography of the head for children with minor head trauma, don't use albuterol in children with bronchiolitis, don't routinely screen for hyperlipidemia in children and adolescents, and don't routinely perform preparticipation sports evaluations. These 10 examples of underuse and overuse were identified with the intent of improving health care value and promoting "Right Care."

Primary care is the backbone of today’s medical infrastructure and has many proven benefits including improved health, reduced healthcare disparities and lowered healthcare costs [1]. Despite this, there is a growing lack of interest in primary care among graduating residents. Although there are many deterrents to a career in primary care, the most significant is the failure of residency programmes to provide adequate education in this field. The majority of primary care training in residency occurs in the continuity clinic but this model is flawed. Residents see high volumes of patients but may not be able to participate in other aspects of patient care, such as following up on laboratory results or telephone calls. Residents also may not have continuity with patients, as there may be months where the resident is not available due to other responsibilities. Resident clinics are often the medical home for medically and/or socially complex patients, and the lack of continuity can make caring for these patients frustrating. Because of this, residents do not feel like the patient’s Primary Care Provider (PCP) and do not receive an experience reflective of a career in primary care. In fact, in an internal medicine programme, continuity clinic was found to have an overall negative influence on residents’ attitudes towards a career in general medicine [2]. More troubling still, there is a prevalent feeling that primary care is for those who are not smart enough to match into a subspecialty fellowship. Residents may receive criticism from mentors for their desire to enter into a career in primary care. These sentiments are subtly echoed on a system level, as primary care topics are rarely discussed during educational sessions, and paediatricians may be criticised by inpatient teams for ‘missing’ the diagnosis. Thus, it is critical that residency programmes prioritise changing the primary care experience. Within the literature, there have been multiple interventions piloted to improve primary care education, yet many programmes have not taken note. We propose programmes focus on a few key areas that could dramatically improve the resident experience. First, priority must be given to improving patient continuity. This could be achieved by implementing the empanelment model, which has been adopted successfully in some programmes. Similarly, granting residents the ability to self-schedule patients onto their own panel for subsequent appointments (rather than relying on schedulers) has improved continuity for residents in our clinic. Additionally, residents should be provided with the infrastructure and time to be more involved in office responsibilities like care coordination and lab followup. Improving communication systems through the electronic medical system or email could help residents stay connected with all involved providers. Programmes should also introduce residents to different practice types to give a better representation of a career in primary care. A primary care elective could be created, where residents would rotate through local private and hospital practices to experience the breadth of opportunities available. Or, allowing residents to customise more traditional elective time may serve as an easy way to improve education. To change the systemic perception that primary care is less prestigious, programme directors and mentors simply need to be supportive, which has been shown to improve perceptions about primary care [3]. Programmes can emphasise the importance of primary care by including relevant topics in educational sessions and minimising critiques of outpatient colleagues. In the face of an ever-growing shortage of residents entering a career in primary care, it is critical that residency programmes strive to better primary care education. By improving continuity, expanding opportunities to a range of practice settings and improving mentorship within primary care, programmes can foster interest in this important aspect of medicine.

Introduction:Pediatric residents encounter issues related to school health (SH) throughout their training, particularly in their continuity clinics, and often serve as liaisons between a patient's medical home and school environment. However, there is currently a paucity of formal education on SH for pediatric residents to prepare them for this role.Methods:We created a 3-hour interactive learning conference that was delivered to four groups of six to eight pediatric residents during their intern year by a multidisciplinary team. Our curriculum focused on understanding the differences between individualized educational plans (IEPs), individualized health plans (IHPs), and 504 plans; the IEP process; and communication with schools. Residents were given pre- and postdidactic surveys, completed reflective writings, and participated in feedback sessions.Results:Twenty-seven pediatric interns completed the curriculum; 85% and 74% had improved knowledge of IEP/504/IHP and SH personnel, respectively. Eighty-five percent reported feeling comfortable with family conversations about accommodations postcurriculum versus 0% precurriculum. The majority of interns found the curriculum to be valuable to their clinic performance.Discussion:Our curriculum offers a unique multidisciplinary approach to teaching and can be easily integrated into other residency programs, even with limited protected didactic time.

School health (SH) refers to the physical, cognitive and emotional needs of a child that impact classroom performance. A needs assessment showed that our residents frequently serve as liaisons between patients and schools but feel poorly prepared for this role and desire formal SH training.

What's NewAfter creating single-photo digital stories about overuse, misuse, and underuse in medicine, medical students, and pediatric residents increase their awareness and experience emotions that empower them to change future behavior. Reflection is integral to professional development and a key element of Kolb's experiential learning cycle. 1 Kolb D. Experiential Learning: Experience as the Source of Learning and Development. Prentice Hall, Englewood Cliffs, NJ1984 Google Scholar The Department of Pediatrics at the University of Colorado encourages reflection, a deliberate process used to develop an understanding or make sense of a situation so that future actions can be informed 2 Sandars S. The use of reflection in medical education: AMEE Guide No. 44. Med Teach. 2009; 31: 685-695 Crossref PubMed Scopus (533) Google Scholar —and uses digital storytelling 3 Treitz M, Lane J, Hanson J. Structuring reflective practices for pediatric residents. Platform presentation at: Association of American Medical Colleges Education Conference; November 7, 2014; Chicago, Ill. Google Scholar —creation of a short video with a personal narrative, images, and music—as a tool for reflection. The concept of RightCare, the vision of the Lown Institute for strong clinician-patient relationships in which no patient receives unnecessary care or lacks necessary care, 4 The Lown Institute. Available at: http://lowninstitute.org. Accessed September 14, 2016. Google Scholar is also incorporated into our pediatric education programs. Although there are different perspectives about what constitutes overuse, misuse, or underuse in medicine, we believe that RightCare, and its tenets of high-value care 5 Owens D.K. Qaseem A. Chou R. Shekelle P. Clinical Guidelines Committee of the American College of PhysiciansHigh-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011; 154: 174-180 Crossref PubMed Scopus (242) Google Scholar is a vision worth striving for. After creating single-photo digital stories about overuse, misuse, and underuse in medicine, medical students, and pediatric residents increase their awareness and experience emotions that empower them to change future behavior.

INTRODUCTION:Studies have shown that clinicians do a poor job of diagnosing middle ear infections, and an inaccurate diagnosis may result in inappropriate treatment, such as overuse of antibiotics. Antibiotic overuse is known to lead to increased bacterial resistance and puts patients at risk of deleterious side effects, including allergic reactions, vomiting, diarrhea, and rash. In this curriculum, we teach three important topics for achieving a successful middle ear exam and diagnosis of pathology. METHODS:The topics covered during the session are middle ear examination techniques, diagnosis of middle ear pathology and criteria for diagnosing acute otitis media, and treatment of acute otitis media. Each topic has a 30-minute lesson plan with broad goals, specific and measurable learning objectives, interactive learning activities, and assessment measures. Teaching activities include a mix of knowledge, skill, and attitude activities. Assessment measures aim at the highest level of Miller's pyramid of assessment when possible. Also included is a scholarship map that relates how this learning activity can fit into the assessment of learners at the program level by linking learning objectives with pediatric developmental milestones. RESULTS:The interactive nature of these lessons has been very well received by learners, and pediatric residents have had a self-perceived increase in skills. DISCUSSION:This curriculum provides a standardized approach to teaching the middle ear exam structured by educational rubrics and allows for accurate assessment of learners.

INTRODUCTION:Demands on residents' time during training make it difficult for them to engage consistently with a primary care curriculum. In response to this, the emergency medicine and critical care fields have successfully utilized podcasting to the point where a recent study showed US emergency medicine residents ranked podcasts as the best use of their time for extracurricular education.METHODS:We produced a 30-minute podcast on urinary tract infections from a primary care perspective, based on descriptors from Entrustable Professional Activity 4, "Manage acute common illnesses in the ambulatory setting." A moderator, a primary care pediatrician, and a pediatric nephrologist used a loose script of salient points, allowing for a natural evolution of the dialogue. The podcast was distributed to residents via email, along with a 7-question survey.RESULTS:The survey was completed by 50 out of 84 residents. Ninety-two percent listened to all or part of the podcast, 98% found it educational, 93% enjoyed listening, and 74% felt more confident identifying and managing patients with possible urinary tract infections after listening. Ninety-six percent felt podcasts were a good alternative method for delivering this curriculum. One comment read, "This was great! It makes the information more accessible so that I can listen while working out or driving or just laying on the couch."DISCUSSION:Based on this success, we are producing additional podcasts and will strive to keep them under 20 minutes, provide key summary points at the end, and improve ease of access by utilizing an RSS (rich site summary) feed.

Abstract Digital macroview otoscopy allows learners to practice visualization of the tympanic membrane and middle ear, allows faculty to ascertain that the learner has obtained an adequate view of the tympanic membrane and middle ear, and allows both learners and faculty together to describe and interpret the findings. A digital macroview otoscope shows real-time images of the middle ear during examination. This instructor's guide and the related resources equip faculty to introduce the digital otoscope to faculty and learners, which will make possible the study and evaluation of teaching with this promising technology. Learners may use this form for self-reflection, highlighting areas of the otoscopic exam that they believe need further assistance. This otoscopy tool offers a different method of teaching the ear exam that has not yet been used in medical education, and builds on previous work that shows that completion of online curricula with pictures and videos increases proficiency in identification of middle ear pathology. This project will contribute to master educator development and support efforts to improve the quality of care in the pediatric outpatient setting. The module is intended to be the first part of a series of publications highlighting the successful introduction and meaningful use of digital otoscopy in medical education. Once the curriculum has been fully developed, implemented, and evaluated, we will expand to other learners such as family medicine residents, medical students, and physician assistant students who rotate through the outpatient pediatric clinic.

Abstract Introduction While refugee health conditions are often amenable to primary care intervention and community support, asylum seekers and refugees are less likely to utilize health care and social services than other immigrant groups. Resettlement challenges, language barriers, stigma, and lack of knowledge of the health care system are just a few of the barriers to healthcare that refugees face. This clinical elective is geared toward fourth-year medical students interested in working with underserved populations and patients whose health is greatly affected by their unique cultures, personal histories, social circumstances, and legal circumstances. Methods At our home institution, this resource follows the Refugee Health Elective, which can also be found on MedEdPORTAL. This Refugee Health II Elective is designed to meet the curricular requirements of the ACGME with alignment between broad goals, specific learning objectives, educational activities, and evaluation. As learners experience this resource, they complete required reading assignments, community experiences at a refugee clinic where they are observed by a clinician, home visits, and a reflection paper. Results The Refugee Health II Elective has been well received at our home institution. Students have stated that: “The rotation and the opportunity to work with one of the most underprivileged populations in the Denver area very invaluable and fulfilling,” and “I can't tell you how valuable it is to see the refugees outside of clinic and start to get a better sense of all of their challenges.” Discussion Successful students have learned how to effectively use a translator, how to culturally negotiate clinical encounters, and how to incorporate the patient's unique life circumstance into their clinical encounters. They will be able to use these skills as they move forward in their medical careers.

The transforming growth factor-β (TGF-β) signal transduction pathway controls many cellular processes, including differentiation, proliferation and apoptosis. It plays a fundamental role during development and it is dysregulated in many diseases. The factors that control the dynamics of the pathway, however, are not fully elucidated yet and so far computational approaches have been very limited in capturing the distinct types of behaviour observed under different cellular backgrounds and conditions into a single-model description. Here, we develop a detailed computational model for TGF-β signalling that incorporates elements of previous models together with crosstalking between Smad1/5/8 and Smad2/3 channels through a negative feedback loop dependent on Smad7. The resulting model accurately reproduces the diverse behaviour of experimental datasets for human keratinocytes, bovine aortic endothelial cells and mouse mesenchymal cells, capturing the dynamics of activation and nucleocytoplasmic shuttling of both R-Smad channels. The analysis of the model dynamics and its system properties revealed Smad7-mediated crosstalking between Smad1/5/8 and Smad2/3 channels as a major determinant in shaping the distinct responses to single and multiple ligand stimulation for different cell types.