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Innovation Concept: Ventilator management is an essential skill and a training objective for emergency medicine (EM) specialists in Canada. EM trainees obtain the majority of this training during off-service rotations. Previous attempts to strengthen ventilator knowledge include lectures and simulation – both of which are time and resource intensive. Given the unique features of ventilator management in the ED, we developed an ED-specific ventilator curriculum. The purpose of this study is to 1) identify resident needs regarding ventilator curricula and 2) assess resident response to this pilot curriculum. Methods: A needs-assessment survey administered to RCPSC- and CCFP-EM residents at The Ottawa Hospital (TOH) showed the majority of residents (87%, n = 31 respondents) believe there is a need for more ED-focused ventilator management training, and only 13% felt confident in ventilator management. Ten on-line modules were prepared by an EM-Critical Care attending, and distributed on-line to all EM trainees at TOH (n = 52). Mid- and post-implementation surveys are used to assess residents’ confidence in ventilator management, and perceived usefulness of the curriculum. User feedback from focus groups constitutes part of the curriculum evaluation. Curriculum, Tool or Material: Employing a flipped classroom approach, ten on-line modules were distributed to RCPSC- and CCFP-EM trainees at TOH. Each module requires less than ten minutes to complete and focuses on a single aspect of ventilation. The modules are available for residents to complete at their own pace and convenience. At curriculum completion, an EM-Critical Care attending physician facilitates an interactive session. Conclusion: Mid-implementation survey results demonstrate increased confidence in independently managing ventilated patients in the ED (13% pre- vs. 56% mid-implementation), and an increased perception of having sufficient ventilator training (26% pre- vs. 78% mid-implementation). All respondents felt the modules were of appropriate length, content was easy to follow, and that the modules should be part of the residency curriculum. Our ED-specific online ventilator modules area a viable tool to increase residents’ confidence in ventilator management. This novel curriculum could be adopted by other residency programs and continuing professional development initiatives. Future work will include post-implementation data-gathering, and formal curriculum evaluation.
Introduction: When a patient is incapable of making medical decisions for themselves, choices are made according to the patient's previously expressed, wishes, values, and beliefs by a substitute decision maker (SDM). While interventions to engage patients in their own advance care planning exist, little is known about public readiness to act as a SDM on behalf of a loved one. This mixed-methods survey aimed to describe attitudes, enablers and barriers to preparedness to act as a SDM, and support for a population-level curriculum on the role of an SDM in end-of-life and resuscitative care. Methods: From November 2017 to June 2018, a mixed-methods street intercept survey was conducted in Ottawa, Canada. Descriptive statistics and logistic regression analysis were used to assess predictors of preparedness to be a SDM and understand support for a high school curriculum. Responses to open-ended questions were analyzed using inductive thematic analysis. Results: The 430 respondents were mostly female (56.5%) with an average age of 33.9. Although 73.0% of respondents felt prepared to be a SDM, 41.0% of those who reported preparedness never had a meaningful conversation with loved ones about their wishes in critical illness. The only predictors of SDM preparedness were the belief that one would be a future SDM (OR 2.36 95% CI 1.34-4.17), and age 50-64 compared to age 16-17 (OR 7.46 95% CI 1.25-44.51). Thematic enablers of preparedness included an understanding of a patient's wishes, the role of the SDM and strong familial relationships. Barriers included cultural norms, family conflict, and a need for time for high stakes decisions. Most respondents (71.9%) believed that 16 year olds should learn about SDMs. They noted age appropriateness, potential developmental and societal benefit, and improved decision making, while cautioning the need for a nuanced approach respectful of different maturity levels, cultures and individual experiences. Conclusion: This study reveals a concerning gap between perceived preparedness and actions taken in preparation to be an SDM for loved ones suffering critical illness. The results also highlight the potential role for high school education to address this gap. Future studies should further explore the themes identified to inform development of resources and curricula for improved health literacy in resuscitation and end-of-life care.
Introduction: Competence committees (CCs) struggle with incorporating professionalism issues into resident progression decisions. This study examined how professionalism concerns influence individual faculty decisions about resident progression using simulated CC reviews. Methods: In 2017, the investigators conducted a survey of 25 program directors of Royal College emergency medicine residency training programs in Canada and those faculty members who are members of the CCs (or equivalent) at their home institution. The survey contained twelve resident portfolios, each containing formative and summative information available to a CC for making progression decisions. Six portfolios outlined residents progressing as expected and six were not progressing as expected. Further, a professionalism variable (PV) was added to six portfolios, evenly split between those residents progressing as expected and not. Participants were asked to make progression decisions based on each portfolio. Results: Raters were able to consistently identify a resident needing an educational intervention versus those who did not. When a PV was added, the consistency among raters decreased by 34.2% in those residents progressing as expected, versus increasing by 3.8% in those not progressing as expected (p = 0.01). Conclusion: When using an unstructured review of a simulated resident portfolio, individual reviewers can better discriminate between trainees progressing as expected when professionalism concerns are added. Considering this, educators using a competence committee in a CBME program must have a system to acquire and document professionalism issues to make appropriate progress decisions.
Introduction: Over 150 Off Service Residents from 18 different programs rotate through our ED every academic year. We aim to determine the educational needs of these residents to we better design a curriculum for their ED rotation. Methods: We conducted a cross-sectional convenience sample survey of 133 Off-Service PGY-2 residents who had rotated through the ED of The Ottawa Hospital in their PGY-1 year. (from July 2016 to June 2017). The survey was emailed to residents from March to May 2018 and consisted of 19 questions. Questions were qualitative, selection from list and rank order. They focused on 3 main areas: EM rotation impact and areas for improvement, desired content, desired method of learning. Data was collected using Survey Monkey. Results: We received 70 responses (53%) from 13 different residency programs. 36 (51.4%) of respondents were from the Family Medicine program. Qualitative themes included that the ED provides great opportunity to develop the ability to workup undifferentiated patients and allows for teaching around cases. Allowing more involvement in acute care cases and having more SIM sessions could improve the rotation. The most useful topic was chest pain/cardiovascular conditions (73.3% of residents) with 16 additional ED topics listed as important for their practice. The most useful skill was suturing (51.6% of residents) with 16 other ED procedures listed as important for their practice. The preferred teaching method was SIM (48.3%) followed by small group teaching (33.3%). Conclusion: The emergency department provides an excellent learning environment for a large range of Off-Service residents early in their training. In addition to clinical shifts, a curriculum incorporating simulation and small group teaching and that covers a large scope of topics is necessary to meet the needs of these residents.
Many studies have identified changes in the brain associated with obsessive–compulsive disorder (OCD), but few have examined the relationship between genetic determinants of OCD and brain variation.
We present the first genome-wide investigation of overlapping genetic risk for OCD and genetic influences on subcortical brain structures.
Using single nucleotide polymorphism effect concordance analysis, we measured genetic overlap between the first genome-wide association study (GWAS) of OCD (1465 participants with OCD, 5557 controls) and recent GWASs of eight subcortical brain volumes (13 171 participants).
We found evidence of significant positive concordance between OCD risk variants and variants associated with greater nucleus accumbens and putamen volumes. When conditioning OCD risk variants on brain volume, variants influencing putamen, amygdala and thalamus volumes were associated with risk for OCD.
These results are consistent with current OCD neurocircuitry models. Further evidence will clarify the relationship between putamen volume and OCD risk, and the roles of the detected variants in this disorder.
Declaration of interest
The authors have declared that no competing interests exist.
Introduction: Maintaining and enhancing competence in the breadth of Emergency Medicine (EM) is an ongoing challenge for all clinicians. In particular, resuscitative care in EM involves high-stakes clinical encounters that demand strong procedural skills, effective leadership, and up-to-date knowledge. However, Canadian emergency physicians are not required to complete any specific ongoing training for these encounters beyond general CPD requirements of professional colleges. Simulation-based medical education (SBME) is an effective modality for enhancing technical (e.g. procedural) and non-technical (i.e. Crisis Resource Management) skills in crisis situations, and has been embedded in undergraduate and postgraduate medical curricula worldwide. We present a novel comprehensive curriculum of simulation-based CPD designed specifically for academic emergency physicians (AEPs) at our centre. Methods: The curriculum development involved a departmental needs assessment survey, focus groups with AEPs, data from safety metrics and critical incidents, and consultations with senior departmental leadership. Institutional support was provided in the form of a $25,000 grant to fund a physician Program Lead, monthly session instructors, and simulation centre operating costs. Based on the results of the needs assessment, a two-year curriculum was mapped out and tailored to the available resources. Results: CPD simulation commenced in January 2017 and occurs monthly for three hours, immediately following departmental Grand Rounds to provide convenient scheduling. Our needs assessment identified two key types of educational needs: (1) Crisis Resource Management skills and (2) frequent practice of high-stakes critical care procedures (e.g. central lines). The first six months of implementation was dedicated to low-fidelity skills labs to facilitate the transition to SBME. After this, the program transitioned to a hybrid model involving two high-fidelity simulated resuscitations and one skills lab per session. Conclusion: We have introduced a comprehensive curriculum of ongoing simulation-based CPD in our department based on the educational needs of our AEPs. Key to our successful implementation has been support from educational and administrative leadership within our department. Ongoing challenges include securing adequate protected time from clinical duties for program facilitators and participants. Future work will include establishing permanent funding, CPD accreditation, and a formal program evaluation.
Introduction: Direct observation is essential to assess medical trainees and provide them with feedback to support their progression from novice to competent physicians. However, learners consistently report infrequent observations, and calls to increase direct observation in medical training abound. In this study, a theory-driven approach using the Theoretical Domains Framework (TDF) was applied to systematically investigate factors that serve as barriers and enablers to direct observation in residency training. Methods: Semi-structured interviews of faculty and residents from various specialties at two large tertiary-care teaching hospitals were conducted. An interview guide based on the TDF was used to capture 14 theoretical domains that may influence direct observation. Interview transcripts were independently coded using direct content analysis by two researchers, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on the frequencies of beliefs reported, presence of conflicting beliefs, and perceived influence on direct observation practices. Results: Data saturation was achieved after 12 resident and 13 faculty interviews, with a total of 10 different specialties represented. Median postgraduate year among residents was 4 (range 1-6), and mean years of independent practice among faculty was 10.3 (SD=8.6). Ten TDF domains were identified as influencing direct observation: knowledge, skills, beliefs about consequences, social professional role and identity, intention, goals, memory/attention/decision-making, environmental context and resources, social influences, and behavioural regulation. Discord between faculty and resident intentions to engage in direct observation, coupled with the social expectation that residents should be responsible for ensuring observations occur, was identified as a key barrier. Additionally, competing demands identified across multiple TDF domains emerged as an important and pervasive theme. Conclusion: This study identified key barriers and enablers to direct observation. The influencing factors identified in this study provide a basis for the development of potential strategies aimed at embedding direct observation as a routine pedagogical practice in residency training.
Multiple human immunodeficiency virus (HIV)-1 genotypes in China were first discovered in Yunnan Province before disseminating throughout the country. As the HIV-1 epidemic continues to expand in Yunnan, genetic characteristics and transmitted drug resistance (TDR) should be further investigated among the recently infected population. Among 2828 HIV-positive samples newly reported in the first quarter of 2014, 347 were identified as recent infections with BED-captured enzyme immunoassay (CEIA). Of them, 291 were successfully genotyped and identified as circulating recombinant form (CRF)08_BC (47.4%), unique recombinant forms (URFs) (18.2%), CRF01_AE (15.8%), CRF07_BC (14.4%), subtype C (2.7%), CRF55_01B (0.7%), subtype B (0.3%) and CRF64_BC (0.3%). CRF08_BC and CRF01_AE were the predominant genotypes among heterosexual and homosexual infections, respectively. CRF08_BC, URFs, CRF01_AE and CRF07_BC expanded with higher prevalence in central and eastern Yunnan. The recent common ancestor of CRF01_AE, CRF07_BC and CRF08_BC dated back to 1983.1, 1992.1 and 1989.5, respectively. The effective population sizes (EPS) for CRF01_AE and CRF07_BC increased exponentially during 1991–1999 and 1994–1999, respectively. The EPS for CRF08_BC underwent two exponential growth phases in 1994–1998 and 2001–2002. Lastly, TDR-associated mutations were identified in 1.8% of individuals. These findings not only enhance our understanding of HIV-1 evolution in Yunnan but also have implications for vaccine design and patient management strategies.
To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data.
Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires.
Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5).
This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.
Since mid-2007 we have carried out a dedicated long-term monitoring programme at 15 GHz using the Owens Valley Radio Observatory 40 meter telescope (OVRO 40m). One of the main goals of this programme is to study the relation between the radio and gamma-ray emission in blazars and to use it as a tool to locate the site of high energy emission. Using this large sample of objects we are able to characterize the radio variability, and study the significance of correlations between the radio and gamma-ray bands. We find that the radio variability of many sources can be described using a simple power law power spectral density, and that when taking into account the red-noise characteristics of the light curves, cases with significant correlation are rare. We note that while significant correlations are found in few individual objects, radio variations are most often delayed with respect to the gamma-ray variations. This suggests that the gamma-ray emission originates upstream of the radio emission. Because strong flares in most known gamma-ray-loud blazars are infrequent, longer light curves are required to settle the issue of the strength of radio-gamma cross-correlations and establish confidently possible delays between the two. For this reason continuous multiwavelength monitoring over a longer time period is essential for statistical tests of jet emission models.
We present results from deep Chandra X-ray observations of the galaxy group NGC 5813. This system shows three pairs of collinear cavities, with each pair associated with an elliptical AGN outburst shock. Due to the relatively regular morphology of this system, and the unique unambiguous detection of three distinct AGN outburst shocks, it is particularly well-suited for the study of AGN feedback and the AGN outburst history. We find that the mean kinetic power is roughly the same for each outburst, and that the total energy associated with the youngest outburst is significantly lower than that of the previous outbursts. This implies that the mean AGN jet power has remained stable for at least 50 Myr, and that the youngest outburst is ongoing. We find that the mean shock heating rate balances the local radiative cooling rate at each shock front, suggesting that AGN outburst shock heating alone is sufficient to offset cooling and establish AGN/ICM feedback within at least the central 30 kpc. Finally, we find non-zero shock front widths that are too large to be explained by particle diffusion, but are instead consistent with arising from broadening of the shock fronts due to propagation through a turbulent ICM with a mean turbulent speed of ~ 70 km s−1.
In this talk, we will show the beaming effect for Fermi/LAT blazars, then we discuss the correlations between γ-ray luminosity and other parameters, such as radio Doppler factors, superluminal motions, and core-dominance parameters. We also compare the Doppler factors determined from the γ-ray luminosity, X-ray emissions, and the short-term time scales with those from other methods. Our discussions suggest that γ-ray emissions may be strongly beamed.
In this work, we reported the optical photometry monitoring results for two brightest nearby quasars, PHL 1811 and 3C 273 using the ST-6 camera at Abastumani Observatory, Georgia. For PHL 1811, we found 3 microvariability events with time scale of ΔT = 6.0 min. For 3C273, we found that the largest variations are ΔV = 0.369 ± 0.028 mag, ΔR = 0.495 ± 0.076 mag, and ΔI = 0.355 ± 0.009 mag. When periodicity analysis methods are adopted to the available data, a period of p = 5.80 ± 1.12 years is obtained for PHL 1811, and p = 21.10 ± 0.14, 10.00 ± 0.14, 7.30 ± 0.09, 13.20 ± 0.09, 2.10 ± 0.06, and 0.68 ± 0.05 years are obtained for 3C 273.
Variability is one of the extreme observational properties of BL Lacertae objects. AO 0235+164 is a well studied BL Lac through the whole electro-magnetic wavebands, it is violently variable in the optical bands. In the present work, we show its optical R band photometric observations carried out during the period of Nov. 2006 to Dec. 2012 using the Ap6E CCD camera attached to the primary focus of the 70 cm meniscus telescope at Abastumani Observatory, Georgia. It shows a large variation of ΔR = 4.88 mag (14.20 - 19.08 mag) during our monitoring period. When periodicity analysis methods are adopted to its R observations from our Abastumani monitoring programme and those in the literature, the signs of some periods, P1 = 8.26 yr, P2 = 0.55 yr, P3 = 0.85 yr, P4 = 1.99 yr are found.
Cygnus A, the nearest truly powerful radio galaxy, resides at the centre of a massive galaxy cluster. Chandra X-ray observations reveal its cocoon shocks, radio lobe cavities and an X-ray jet, which are discussed here. It is argued that X-ray emission from the outer regions of the cocoon shocks is nonthermal. The X-ray jets are best interpreted as synchrotron emission, suggesting that they, rather than the radio jets, are the path of energy flow from the nucleus to the hotspots. In that case, a model shows that the jet flow is non-relativistic and carries in excess of one solar mass per year.
To examine the opinions of stakeholders on strategies to improve dietary quality of Supplemental Nutrition Assistance Program (SNAP) participants.
Participants answered a thirty-eight-item web-based survey assessing opinions and perceptions of SNAP and programme policy changes.
Survey of 522 individuals with stakeholder interest in SNAP, conducted in October through December 2011.
The top three barriers to improving dietary quality identified were: (i) unhealthy foods marketed in low-income communities; (ii) the high cost of healthy foods; and (iii) lifestyle challenges faced by low-income individuals. Many respondents (70 %) also disagreed that current SNAP benefit levels were adequate to maintain a healthy diet. Stakeholders believed that vouchers, coupons or monetary incentives for purchasing healthful foods might have the greatest potential for improving the diets of SNAP participants. Many respondents (78 %) agreed that sodas should not be eligible for purchases with SNAP benefits. More than half (55 %) believed retailers could easily implement such restrictions. A majority of respondents (58 %) agreed that stores should stock a minimum quantity of healthful foods in order to be certified as a SNAP retailer, and most respondents (83 %) believed that the US Department of Agriculture should collect data on the foods purchased with SNAP benefits.
Results suggest that there is broad stakeholder support for policies that align SNAP purchase eligibility with national public health goals of reducing food insecurity, improving nutrition and preventing obesity.