Competence By Design: a transformational national model of time-variable competency-based postgraduate medical education.

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

Strategies to Enable Transformation in Medical Education: Faculty and Trainee Development in Competence By Design.

Transformative changes in health professions education need to incorporate effective faculty development, but few very large-scale faculty development designs have been described. The Royal College of Physicians and Surgeons of Canada's Competence by Design project was launched to transform the delivery of postgraduate medical education in Canada using a competency-based model. In this paper we outline the goals, principles, and rationale of the Royal College's national strategy for faculty and resident development initiatives to support the implementation of Competence by Design. We describe the activities and resources for both faculty and trainees that facilitated the redesign of training programs for each specialty and subspecialty at the national level, as well as supporting the implementation of the redesign at the local level. This undertaking was not without its challenges: we thus reflect on those challenges, enablers, and the lessons learned, and discuss a continuous quality improvement approach that was taken to iteratively inform the implementation process moving forward.

Impact of adding xylooligosaccharides encapsulated in butter: Microstructural, optical, rheological and sensory aspects.

This study investigated the microstructure, rheological properties, and sensory characteristics of butters produced with free and encapsulated xylooligosaccharides (XOS). Four formulations of butter were processed: BCONT: 0 % w/w XOS (control); BXOS: 20% w/w free XOS; BXOS-ALG: 20% w/w XOS microencapsulated with alginate (XOS-alginate ratio of 3:1 w/w); and BXOS-GEL: 20% w/w XOS microencapsulated with alginate-gelatin (XOS-alginate-gelatin ratio of 3:1:1.5 w/w). The microparticles showed a bimodal distribution, low size and low span values, demonstrating physical stability to be included in emulsions. The XOS-ALG presented surface weighted mean diameter (D3.2) of 90.24 µm, volume-weighted mean diameter (D4.3) of 131.8 µm, and Span of 2.14. In contrast, the XOS-GEL presented D3.2 of 82.80 µm, D4.3 of 141.0 µm, and a Span of 2.46. Products with XOS were characterized by higher creaminess, sweet taste, and lower salty taste than the control. However, the addition form significantly impacted the other evaluated parameters. The utilization of XOS in a free form (BXOS) resulted in smaller droplet sizes (1.26 µm) than encapsulated XOS and control (XOS-ALG = 1.32 µm / XOS-GEL = 1.58 µm, / BCONT = 1.59 µm), and changes in the rheological parameters (higher values of shear stress, viscosity, consistency index, rigidity (J0), and Newtonian viscosity (ηN) and lower elasticity (τ)). Furthermore, it changed the color parameters (more yellow and dark color, lower L* and higher b* values). On the other hand, the utilization of micropaticles of XOS (BXOS-ALG and BXOS-GEL) kept shear stress, viscosity, consistency index, rigidity (J0), and elasticity (τ) more similar to control. The products had a less intense yellow color (lower b* values) and was perceived with more consistency and butter taste. However, the presence of particles was perceived by consumers. The results suggest that consumers were more attentive to reporting flavor-related attributes than texture. In conclusion, adding microparticles of XOS could improve butter's rheological and sensory properties. In conclusion, adding microparticles of XOS could improve butter's rheological and sensory properties.

Frameworks for Integrating Learning Analytics With the Electronic Health Record.

ABSTRACT: The information systems designed to support clinical care have evolved separately from those that support health professions education. This has resulted in a considerable digital divide between patient care and education, one that poorly serves practitioners and organizations, even as learning becomes ever more important to both. In this perspective, we advocate for the enhancement of existing health information systems so that they intentionally facilitate learning. We describe three well-regarded frameworks for learning that can point toward how health care information systems can best evolve to support learning. The Master Adaptive Learner model suggests ways that the individual practitioner can best organize their activities to ensure continual self-improvement. The PDSA cycle similarly proposes actions for improvement but at a health care organization's workflow level. Senge's Five Disciplines of the Learning Organization, a more general framework from the business literature, serves to further inform how disparate information and knowledge flows can be managed for continual improvement. Our main thesis holds that these types of learning frameworks should inform the design and integration of information systems serving the health professions. An underutilized mediator of educational improvement is the ubiquitous electronic health record. The authors list learning analytic opportunities, including potential modifications of learning management systems and the electronic health record, that would enhance health professions education and support the shared goal of delivering high-quality evidence-based health care.

Thermosonication as a pretreatment of raw milk for Minas frescal cheese production.

Minas frescal cheese is extremely popular in Brazil, with high perishability and acceptability. Among emerging technologies, ultrasound stands out for its satisfactory results regarding microbiological safety and technological and sensory aspects. The combined mild temperature application, called thermosonication, can generate even more promising results. In this study, a high-intensity ultrasound system combined with thermal heating (TS, thermosonication) was applied for the treatment of raw milk to produce Minas Frescal cheese. US energy was delivered to raw milk samples using a probe operating at a 20 kHz of frequency and nominal power of 160, 400, and 640 W. The TS system was compared with conventional pasteurization (HTST, high-temperature short-time pasteurization) at 72 to 75 °C and 15 s. Soft cheeses were prepared with different samples: (a) raw milk (control), b)conventionally pasteurized milk (HTST), and c) TS treat milk in different nominal power (TS160, TS400, and TS640). The produced cheeses were evaluated for microbiological behavior, rheology, color parameters, and bioactive compounds. TS treatment in milk resulted in higher microbial inactivation and stability during storage, improved color parameters (higher lightness (L*), and whiteness index (WI). TS treatment also showed a higher generation of bioactive compounds (higher antioxidant, and inhibitory activities of α-amylase, α-glucosidase, and angiotensin-converting enzymes) than HTST. The impact of TS on rheological properties was similar to HTST, resulting in more brittle and less firm products than the cheese produced with raw milk. The positive effects were more prominent using a nominal power of 400 W (TS400). Therefore, TS proved to be a promising process for processing milk for Minas Frescal cheese production.

Perceptions of patients and nurses regarding the use of wearables in inpatient settings: a mixed methods study.

Wearable devices for hospitalized patients could help improve care. The purpose of this study was to highlight key barriers and facilitators involved in adopting wearable technology in acute care settings using patient and clinician feedback. Hospitalized patients, 18 years or older, were recruited at the General Medicine inpatient units in Toronto, Ontario to wear the Fitbit® Charge 2 or Charge 3. Fifty General Medicine adult inpatients were recruited. Patients and nurses provided feedback on structured questionnaires. Key themes from open-ended questions were analyzed. Primary outcomes of interest included the exploring patient and nurse perceptions of their experiences with wearable devices as well as their feasibility in clinical settings. Overall, both patients (n = 39) and nurses (n = 28) valued the information provided by Fitbits and shared concerns about device functionality and wearable design. Specifically, patients were interested in using wearables to enhance their self-monitoring, while nurses questioned data validity, as well as ease of incorporating wearables into their workflow. We found that patients wanted improved device design and functionality and valued the opportunity to improve their self-efficacy and to work in partnership with the medical team using wearable technology. Nurses wanted more device functionality and validation and easier ways to incorporate them into their workflow. To achieve the potential benefits of using wearable devices for enhanced monitoring, this study identifies challenges that must first be addressed in order for this technology to be widely adopted in clinical settings.

The MedSafer Study-Electronic Decision Support for Deprescribing in Hospitalized Older Adults: A Cluster Randomized Clinical Trial.

IMPORTANCE: Scalable deprescribing interventions may reduce polypharmacy and the use of potentially inappropriate medications (PIMs); however, few studies have been large enough to evaluate the impact that deprescribing may have on adverse drug events (ADEs). OBJECTIVE: To evaluate the effect of an electronic deprescribing decision support tool on ADEs after hospital discharge among older adults with polypharmacy. DESIGN, SETTING, AND PARTICIPANTS: This was a cluster randomized clinical trial of older (≥65 years) hospitalized patients with an expected survival of more than 3 months who were admitted to 1 of 11 acute care hospitals in Canada from August 22, 2017, to January 13, 2020. At admission, participants were taking 5 or more medications per day. Data analyses were performed from January 3, 2021, to September 23, 2021. INTERVENTIONS: Personalized reports of deprescribing opportunities generated by MedSafer software to address usual home medications and measures of prognosis and frailty. Deprescribing reports provided to the treating team were compared with usual care (medication reconciliation). MAIN OUTCOMES AND MEASURES: The primary outcome was a reduction of ADEs within the first 30 days postdischarge (including adverse drug withdrawal events) captured through structured telephone surveys and adjudicated blinded to intervention status. Secondary outcomes were the proportion of patients with 1 or more PIMs deprescribed at discharge and the proportion of patients with an adverse drug withdrawal event (ADWE). RESULTS: A total of 5698 participants (median [range] age, 78 [72-85] years; 2858 [50.2%] women; race and ethnicity data were not collected) were enrolled in 3 clusters and were adjudicated for the primary outcome (control, 3204; intervention, 2494). Despite cluster randomization, there were group imbalances, eg, the participants in the intervention arm were older and had more PIMS prescribed at baseline. After hospital discharge, 4989 (87.6%) participants completed an ADE interview. There was no significant difference in ADEs within 30 days of discharge (138 [5.0%] of 2742 control vs 111 [4.9%] of 2247 intervention participants; adjusted risk difference [aRD] -0.8%; 95% CI, -2.9% to 1.3%). Deprescribing increased from 795 (29.8%) of 2667 control to 1249 (55.4%) of 2256 intervention participants [aRD, 22.2%; 95% CI, 16.9% to 27.4%]. There was no difference in ADWEs between groups. Several post hoc sensitivity analyses, including the use of a nonparametric test to address the low cluster number, group imbalances, and potential biases, did not alter study conclusions. CONCLUSIONS AND RELEVANCE: This cluster randomized clinical trial showed that providing deprescribing clinical decision support during acute hospitalization had no demonstrable impact on ADEs, although the intervention was safe and led to improvements in deprescribing. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03272607.

Electronic Health Records That Support Health Professional Reflective Practice: a Missed Opportunity in Digital Health.

A foundational component of digital health involves collecting and leveraging electronic health data to improve health and wellbeing. One of the central technologies for collecting these data are electronic health records (EHRs). In this commentary, the authors explore intersection between digital health and data-driven reflective practice that is described, including an overview of the role of EHRs underpinning technology innovation in healthcare. Subsequently, they argue that EHRs are a rich but under-utilised source of information on the performance of health professionals and healthcare teams that could be harnessed to support reflective practice and behaviour change. EHRs currently act as systems of data collection, not systems of data engagement and reflection by end users such as health professionals and healthcare organisations. Further consideration should be given to supporting reflective practice by health professionals in the design of EHRs and other clinical information systems.

Becoming a deliberately developmental organization: Using competency based assessment data for organizational development.

Medical education is situated within health care and educational organizations that frequently lag in their use of data to learn, develop, and improve performance. How might we leverage competency-based medical education (CBME) assessment data at the individual, program, and system levels, with the goal of redefining CBME from an initiative that supports the development of physicians to one that also fosters the development of the faculty, administrators, and programs within our organizations? In this paper we review the Deliberately Developmental Organization (DDO) framework proposed by Robert Kegan and Lisa Lahey, a theoretical framework that explains how organizations can foster the development of their people. We then describe the DDO's conceptual alignment with CBME and outline how CBME assessment data could be used to spur the transformation of health care and educational organizations into digitally integrated DDOs. A DDO-oriented use of CBME assessment data will require intentional investment into both the digitalization of assessment data and the development of the people within our organizations. By reframing CBME in this light, we hope that educational and health care leaders will see their investments in CBME as an opportunity to spur the evolution of a developmental culture.

Effects of microwave heating on the chemical composition and bioactivity of orange juice-milk beverages.

The effect of microwave heating (MH, 65 and 75 °C for 15, 30, and 60 s) on the bioactive compounds, fatty acid profile, and volatile compounds of orange juice-milk beverage (OJMB) was evaluated during 28 days of refrigerated (4 °C) storage. Conventionally pasteurized (75 °C/15 s) and untreated beverages were used as controls. MH-OJMB presented a lower browning index and higher levels of ascorbic acid, total phenolics, and carotenoids, higher antioxidant activity, and greater α-amylase, α-glucosidase, and ACE inhibitory activity than the pasteurized product, similar to the untreated beverage. No significant differences were observed in the volatile organic compounds and fatty acids levels. Lower temperatures (65 °C) and longer process times (60 s) resulted in higher retention of bioactive compounds. MH can be an alternative to conventional pasteurization for OJMB processing.

Curricular needs for training telemedicine physicians: A scoping review.

PURPOSE: The use of telemedicine, a part of 'Virtual Care', is rapidly entering mainstream clinical practice. The ideal curriculum for educating physicians to practice in this emerging field has not been established. We examined the literature to evaluate published curricula for quality and comprehensiveness through the lens of Competency-Based Medical Education (CBME). METHODS: We performed a scoping review using CanMEDS as a framework. Peer-reviewed articles describing telemedicine training curricula were identified. Trainee population, curricular points, stage of implementation, evaluation depth, country, and citations (a marker of quality) were examined. RESULTS: Forty-three curricula from 11 countries were identified, addressing all training levels and covering multiple specialties. Instructional methods included lectures (60.5%), hands-on experiences (76%), directed reading (24%), online modules (21%), reflection (13%), simulation (34%), and group discussions (16%). Hands-on curricula covered all CanMEDS roles more often. Twenty-nine of the implemented curricula were evaluated; 83% were rated positively. CONCLUSIONS: Our scoping review helps inform more comprehensive and efficacious curricula for teaching telemedicine. We suggest centering curricula on a competency-based, outcomes-oriented framework such as CanMEDS with multiple teaching modalities complementing hands-on experiences. This will facilitate rigorous telemedicine training to deliver on the promise of high-quality patient care.

Melatonin Increasingly Used in Hospitalized Patients.

The frequency of melatonin use for insomnia in hospitalized patients is unknown. This study assessed temporal trends of melatonin use in the hospital and compared them with those of use of zopiclone and lorazepam. We performed a retrospective observational study over 6 years from January 2013 to December 2018 at two academic urban hospitals in Toronto, Canada. We abstracted pharmacy dispensing data and standardized rates of medication use by inpatient days. Melatonin use increased from almost none to more than 70 doses per 1,000 inpatient days during 2013-2018, while zopiclone use decreased by 20 doses per 1,000 inpatient days. Melatonin use was twice as high at one hospital and was higher on internal medicine and critical care. Overall use of the three medications increased by 25.7%, which mainly reflects a marked increase in melatonin use. Melatonin is likely being used in a proportion of patients who would not otherwise have received a sleep medication.

Next Steps in the Implementation of Learning Analytics in Medical Education: Consensus From an International Cohort of Medical Educators.

BACKGROUND: With the implementation of competency-based assessment systems, education programs are collecting increasing amounts of data about medical learners. However, learning analytics are rarely employed to use this data to improve medical education. OBJECTIVE: We identified outstanding issues that are limiting the effective adoption of learning analytics in medical education. METHODS: Participants at an international summit on learning analytics in medical education generated key questions that need to be addressed to move the field forward. Small groups formulated questions related to data stewardship, learner perspectives, and program perspectives. Three investigators conducted an inductive qualitative content analysis on the participant questions, coding the data by consensus and organizing it into themes. One investigator used the themes to formulate representative questions that were refined by the other investigators. RESULTS: Sixty-seven participants from 6 countries submitted 195 questions. From them, we identified 3 major themes: implementation challenges (related to changing current practices to collect data and utilize learning analytics); data (related to data collection, security, governance, access, and analysis); and outcomes (related to the use of learning analytics for assessing learners and faculty as well as evaluating programs and systems). We present the representative questions and their implications. CONCLUSIONS: Our analysis highlights themes regarding implementation, data management, and outcomes related to the use of learning analytics in medical education. These results can be used as a framework to guide stakeholder education, research, and policy development that delineates the benefits and challenges of using learning analytics in medical education.

Derivation and Validation of a Novel Risk Score to Predict Overcorrection of Severe Hyponatremia: The Severe Hyponatremia Overcorrection Risk (SHOR) Score.

BACKGROUND AND OBJECTIVES: Osmotic demyelination syndrome is the most concerning complication of severe hyponatremia, occurring with an overly rapid rate of serum sodium correction. There are limited clinical tools to aid in identifying individuals at high risk of overcorrection with severe hyponatremia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We identified all patients who presented to a tertiary-care hospital emergency department in Ottawa, Canada (catchment area 1.2 million) between January 1, 2003 and December 31, 2015, with serum sodium (corrected for glucose levels) <116 mmol/L. Overcorrection was determined using 14 published criteria. Latent class analysis measured the independent association of baseline factors with a consensus overcorrection status on the basis of the 14 criteria, and was summarized as a risk score, which was validated in two cohorts. RESULTS: A total of 623 patients presented with severe hyponatremia (mean initial value 112 mmol/L; SD 3.2). The prevalence of no, unlikely, possible, and definite overcorrection was 72%, 4%, 10%, and 14%, respectively. Overcorrection was independently associated with decreased level of consciousness (2 points), vomiting (2 points), severe hypokalemia (1 point), hypotonic urine (4 points), volume overload (-5 points), chest tumor (-5 points), patient age (-1 point per decade, over 50 years), and initial sodium level (<110 mmol/L: 4 points; 110-111 mmol/L: 2 points; 112-113 mmol/L: 1 point). These points were summed to create the Severe Hyponatremic Overcorrection Risk (SHOR) score, which was significantly associated with overcorrection status (Spearman correlation 0.45; 95% confidence interval, 0.36 to 0.49) and was discriminating (average dichotomized c-statistic 0.77; 95% confidence interval, 0.73 to 0.81). The internal (n=119) and external (n=95) validation cohorts had significantly greater use of desmopressin, which was significantly associated with the SHOR score. The SHOR score was significantly associated with overcorrection status in the internal (P<0.001) but not external (P=0.39) validation cohort. CONCLUSIONS: In patients presenting with severe hyponatremia, overcorrection was common and predictable using baseline information. Further external validation of the SHOR is required before generalized use.

Microwave Processing: Current Background and Effects on the Physicochemical and Microbiological Aspects of Dairy Products.

Overheating is still a major problem in the use of conventional heating for milk and various dairy products, because it leads to the lowering of quality and sensory and nutritional values. Microwave (MW) heating has been credited with providing superior-quality dairy-based products with extended shelf-life, representing a good alternative to conventional heat treatment. The main drawback of MW heating refers to nonuniform temperature distribution, resulting in hot and cold spots mainly in solid and semisolid products; however, MW heating has been shown to be suitable for liquid foods, especially in a continuous fluid system. This review aims to describe the main factors and parameters necessary for the application of MW heating technology for dairy processing, considering the theoretical fundamentals and its effects on quality and safety aspects of milk and dairy products. MW heating has demonstrated great ability for the destruction of pathogenic/spoilage microorganisms and their spores, and also inactivation of enzymes, thereby preserving fresh characteristics of dairy products.

Guarana (Paullinia cupana) Extract Protects Caenorhabditis elegans Models for Alzheimer Disease and Huntington Disease through Activation of Antioxidant and Protein Degradation Pathways.

Guarana (Paullinia cupana) is largely consumed in Brazil in high energy drinks and dietary supplements because of its stimulant activity on the central nervous system. Although previous studies have indicated that guarana has some protective effects in Parkinson's (PD), Alzheimer's (AD), and Huntington's (HD) disease models, the underlying mechanisms are unknown. Here, we investigated the protective effects of guarana hydroalcoholic extract (GHE) in Caenorhabditis elegans models of HD and AD. GHE reduced polyglutamine (polyQ) protein aggregation in the muscle and also reduced polyQ-mediated neuronal death in ASH sensory neurons and delayed ß-amyloid-induced paralysis in a caffeine-independent manner. Moreover, GHE's protective effects were not mediated by caloric restriction, antimicrobial effects, or development and reproduction impairment. Inactivation of the transcription factors SKN-1 and DAF-16 by RNAi partially blocked the protective effects of GHE treatment in the AD model. We show that the protective effect of GHE is associated with antioxidant activity and modulation of proteostasis, since it increased the lifespan and proteasome activity, reduced intracellular ROS and the accumulation of autophagosomes, and increased the expression of SOD-3 and HSP-16.2. Our findings suggest that GHE has therapeutic potential in combating age-related diseases associated with protein misfolding and accumulation.