A graduate medical education (GME) quality improvement curriculum leads to improved knowledge and participation in high quality improvement projects by trainees.

BACKGROUND: There is increased awareness about the need for quality improvement (QI) education for trainees within clinical training programs. However, formal integration of a QI curriculum into graduate medical education (GME) remains a work-in-progress. We describe the creation and implementation of a novel, virtual QI curriculum complemented by virtual-based workshops. OBJECTIVE: To determine the impact of a GME QI curriculum on 1) trainee QI knowledge; 2) Quality of QI projects. METHODS: The GME Quality Improvement curriculum was transitioned to an optional formal curriculum in 2020. It is led by three faculty with expertise in QI training and education. The team developed four, web-based learning modules that focused on fundamental QI concepts. These modules are completed monthly and are paired with virtual workshops that facilitate applying learned QI concepts to project development. We evaluated the effectiveness of the curriculum by assessing participants' performance on knowledge-based quizzes before and after each online module. We used IBM SPSS (version 28), to conduct a two-sided paired samples t-test, comparing each post-session test scores with their corresponding pre-session scores. The alpha, or statistical threshold significance threshold, was 0.05. Additionally, two independent judges with expertise in QI evaluated the quality of the projects presented at the annual QI showcase using a standardized scoring rubric. The poster evaluation forms included 8 questions, rated on a scale from 1 to 5. Projects were graded into 4 quartiles (poor, fair, good, excellent). RESULTS: In the knowledge assessment quiz, the difference between the mean pre- and post-session quiz scores was statistically significant (p < 0.01). The average score of the quality of the projects presented at the annual showcase was 31, in the fourth quartile which was graded as "excellent" quality. CONCLUSION: A GME-led QI curriculum was effective in improving knowledge of QI concepts and producing high-quality scholarly projects.

Left Ventricular Non-compaction Cardiomyopathy: The Key to Its Diagnosis and Implications for Management.

Left ventricular non-compaction (LVNC) cardiomyopathy is a condition with increasing prevalence as cardiac imaging technology improves, although there is currently no diagnostic gold standard. Characterized by the presence of a bilayered myocardium with prominent trabeculations, LVNC cardiomyopathy has a wide range of presentations, from asymptomatic to severe heart failure, thromboembolism, and sudden cardiac death. We present the case of a 62-year-old male who was admitted for a heart failure exacerbation with a worsening ejection fraction and signs of increased trabeculations of the left ventricle on an echocardiogram. We highlight the rarity of this condition, especially when diagnosed via echocardiogram, and the importance of considering anticoagulation as part of the treatment plan.

Burnout: exploring the differences between U.S. and international medical graduates.

BACKGROUND: International medical graduates (IMGs) have less burnout than U. S. medical school graduates (USMGs) during residency training. This study evaluates possible correlates of differences in burnout rates between USMGs and IMGs. METHODS: We surveyed 375 first-year residents at orientation in June/July 2017. We assessed burnout using the Copenhagen Burnout Inventory (CBI) and used validated scales to measure stress, quality of life (QoL), mastery, and spirituality. We collected data on gender, place of graduation, language fluency, and specialty. We compared CBI scores between USMGs and IMGs, performed a multivariate linear regression analysis of relationships between covariates and CBI subscales, and logistic regression analysis for our categorical definition of burnout. RESULTS: Two hundred twenty-two residents responded for a response rate of 59%. Personal, work or patient- related burnout was common among residents, particularly among USMGs. The most common form of burnout was work-related. Forty nine percent of USMGs have work burnout compared to 26% of IMGs (p < 0.01). In multivariate analysis, being an IMG reduced odds of work-related and of total burnout by 50% (OR 0.5 C.I 0.25-0.99). Perceived mastery was associated with reductions in all subscales of burnout (p < 0.05). Stress and low QoL related to personal and work burnout scores (p < 0.01). CONCLUSION: Work-related burnout is more common among USMGs than in IMGs. Although mastery, QoL and stress were correlates of burnout among all residents, these factors did not explain the difference. Future studies should evaluate the role of medical school structure and curriculum on differences in burnout rates between the two groups.

Ventriculostomy supply cart decreases time-to-external ventricular drain placement in the emergency department.

BACKGROUND: Minimizing time-to-external ventricular drain (EVD) placement in the emergency department (ED) is critical. We sought to understand factors affecting time-to-EVD placement through a quality improvement initiative. METHODS: The use of process mapping, root cause analyses, and interviews with staff revealed decentralized supply storage as a major contributor to delays in EVD placement. We developed an EVD "crash cart" as a potential solution to this problem. Time-to-EVD placement was tracked prospectively using time stamps in the electronic medical record (EMR); precart control patients were reviewed retrospectively. RESULTS: The final cohorts consisted of 33 precart and 18 postcart cases. The mean time-to-EVD in the precart group was 99.09 min compared to 71.88 min in the postcart group (two-tailed t-test, P = 0.023). Median time-to-EVD was 92 min in the precart group compared to 64 min in the postcart group (rank sum test, P = 0.0165). Postcart patients trended toward improved outcomes with lower modified Rankin score scores at 1 year, but this did not reach statistical significance (two-tailed t-test, P = 0.177). CONCLUSION: An EVD "crash cart" is a simple intervention that can significantly reduce time-to-EVD placement and may improve outcomes in patients requiring an EVD.

A Versatile and Highly Selective Colorimetric Sensor for the Detection of Amines.

The utility of Meldrum's activated furan (MAF) for the colorimetric detection of sub ppm levels of amines in solution, on solid supports, and as vapors is reported. MAF is synthesized in one step from inexpensive and commercially available starting materials and exhibits high selectivity for primary and secondary amines in the presence of competing nucleophiles. The reaction between activated furans and amines results in a distinct color change, discernable by the naked eye. UV/Vis absorption spectroscopy was utilized to monitor reactions in solution and determine detection limits. Additionally, solutions of MAF were useful as stains for thin layer chromatography and for monitoring solid-phase synthesis of peptides and peptidomimetics. Finally, MAF was used to detect volatile amines released from fish samples, demonstrating potential for food spoilage applications.

Tunable Visible and Near Infrared Photoswitches.

A class of tunable visible and near-infrared donor-acceptor Stenhouse adduct (DASA) photoswitches were efficiently synthesized in two to four steps from commercially available starting materials with minimal purification. Using either Meldrum's or barbituric acid "acceptors" in combination with aniline-based "donors", an absorption range spanning from 450 to 750 nm is obtained. Additionally, photoisomerization results in complete decoloration for all adducts, yielding fully transparent, colorless solutions and films. Detailed investigations using density functional theory, nuclear magnetic resonance, and visible absorption spectroscopies provide valuable insight into the unique structure-property relationships for this novel class of photoswitches. As a final demonstration, selective photochromism is accomplished in a variety of solvents and polymer matrices, a significant advantage for applications of this new generation of DASAs.

Comparison of Two Methods of Estradiol Replacement: their Physiological and Behavioral Outcomes.

Fluctuating sex steroids during the estrous or menstrual cycle of mammalian females make it difficult to determine their role on behaviors and physiology. To avoid this, many investigators ovariectomize their animals and administer progesterone, estradiol or a combination of both. Several different strategies are used to administer estradiol, which confounds interpretation of results. This study compared two methods of estradiol replacement implants: Silastic tubes filled with crystalline estradiol benzoate (E2) and commercially available estradiol benzoate pellets. Implants were placed subcutaneously in adult ovariectomized (OVX) rats and blood samples obtained weekly. Control OVX rats received empty Silastic tubes or placebo pellets. Our data shows that E2 plasma levels from rats with Silastic implants peaked after one week and decreased slowly thereafter. In contrast, plasma E2 from commercial pellets peaked after two weeks, increasing and decreasing over time. To validate hormone release, body weight was monitored. All E2 treated animals maintained a similar body weight over the four weeks period whereas an increase in body weight over time was observed in the OVX group that received empty implants, confirming E2 release and supporting the role of E2 in the regulation of body weight. Furthermore, the effects of E2 on basal locomotor activity were assessed using animal activity cages. Results showed no difference between E2 and control group in several locomotor activities. These results indicate that Silastic implants achieve more stable plasma estradiol levels than pellets and thus are a better alternative for studies of estradiol on brain function and behavior.

Interventions to improve hospice and palliative care referral: a systematic review.

BACKGROUND: Hospice and palliative care are underutilized among patients at the end of their lives despite evidence that they improve patient satisfaction and reduce costs. OBJECTIVE: To synthesize evidence regarding interventions to increase hospice referral/enrollment. DESIGN AND MEASUREMENTS: We conducted a systematic review of the literature and selected studies that evaluated interventions aimed at increasing hospice use. We performed a MEDLINE search (1979 to April 2013) supplemented by manual searches of bibliographies of key articles. Study design, quality criteria, population, interventions, and outcomes for each study were extracted. The main outcome evaluated was hospice referral/enrollment. RESULTS: Our search strategy yielded 419 studies, of which only 6 met our eligibility criteria. Three studies included nursing home populations; 1 included home care patients, 1 targeted care managers, and 1 reported on heart failure patients. Three studies had a cohort design, 2 were pre-post, and only 1 was randomized. Two studies evaluated a process to identify eligible subjects. Two evaluated the impact of advance care planning programs and 2 only provided education. Interventions that only provided education showed a median increase in referral of 5% (2.8%-17%) while interventions that identified hospice candidates showed a median increase in hospice referral of 19.5 % (19%-20%). CONCLUSIONS: Interventions of different levels of complexity can improve the use of hospice services among subjects with high mortality risk. An approach that allows the medical team to assess patients' treatment goals and that engages the treating physician seems to be the most successful one.

Estrogen receptors mediate estradiol's effect on sensitization and CPP to cocaine in female rats: role of contextual cues.

Preclinical studies show that estradiol enhances sensitization to cocaine in females by mechanisms not fully understood. These studies consistently show that ovariectomized (OVX) rats exhibit little or no sensitization to cocaine compared to OVX rats administered estradiol. In this study we varied the dose of cocaine (10, 15, and 30mg/kg), the length of cocaine treatment (from 5 to 10days) and the context of cocaine injections to determine if these factors play a role on estradiol's effects on cocaine sensitization. Because OVX rats are hormonally compromised, they are not representative of the natural state of the animal, and thus the physiological context of these studies remains unclear. To address this issue, we blocked ERs in gonadally intact females by icv administration of the antiestrogen ICI-182,780. Varying the dose or length of exposure to cocaine does not alter estradiol's effect on cocaine sensitization. In contrast, a highly context-dependent sensitization protocol results in robust sensitization even in OVX rats. Interestingly, using this protocol, sensitization in OVX rats diminished with time, suggesting that estradiol is necessary for the maintenance of cocaine sensitization. Blocking brain ERs with ICI completely abolishes the development and expression of cocaine sensitization in gonadally intact female rats, even when tested in a highly context-dependent sensitization protocol. Given these findings, we propose that activation of brain ERs is required for the development and maintenance of sensitization and CPP.

Incompletely condensed fluoroalkyl silsesquioxanes and derivatives: precursors for low surface energy materials.

A novel synthetic method was developed for the controlled functionalization of fluorinated polyhedral oligomeric silsesquioxanes (F-POSS), which are useful as low surface energy materials for superhydrophobic and superoleophobic materials. Utilizing triflic acid, open-cage compounds were created and then reacted with a variety of dichlorosilanes to produce functional F-POSS structures possessing alkyl-, aryl-, and acrylate-based moieties. The crystal structure for an endo,endo-disilanol F-POSS compound was determined by single-crystal X-ray diffraction. The chemical structures were confirmed using multinuclear NMR spectroscopy ((1)H, (13)C, (19)F, and (29)Si), FT-IR, and combustion analysis. Dynamic contact angle measurements of these compounds were taken with water and hexadecane. These novel structures were found to possess excellent wetting-resistant behavior, similar to that of the parent F-POSS compound. They are the first well-defined fluorinated nano-building blocks with a controlled level of reactive functionality for the development of new superhydrophobic and superoleophobic materials.

Estradiol: a key biological substrate mediating the response to cocaine in female rats.

A consistent finding in drug abuse research is that males and females show differences in their response to drugs of abuse. In women, increased plasma estradiol is associated with increased vulnerability to the psychostimulant and reinforcing effects of drugs of abuse. Our laboratory has focused on the role of estradiol in modulating the response to cocaine. We have seen that ovariectomy increases the locomotor response to a single cocaine injection, whereas estradiol exacerbates the locomotor response to repeated cocaine administration. Cocaine-induced sensitization of brain activity, as measured by fMRI, is also dependent on plasma estradiol. Moreover, we observed that although all ovariectomized rats show conditioned place preference to cocaine, it is more robust in ovariectomized rats with estradiol. Opioid receptors are enriched in brain regions associated with pleasure and reward. We find that in females, the effectiveness of kappa opioid agonists in decreasing the locomotor response to repeated cocaine varies with plasma estradiol. We also find that estradiol regulates the density of mu opioid receptors in brains areas associated with reward. These data hint that in females, estradiol modulates the behavioral effects of cocaine by regulating mu and kappa opioid signaling in mesocorticolimbic brain structures. Identifying the mechanisms that mediate differences in vulnerability to drugs of abuse may lead to effective therapeutic strategies for the treatment and prevention of addiction and relapse. We encourage health practitioners treating persons addicted to drugs to consider gender differences in response to particular pharmacotherapies, as well the sex steroid milieu of the patient.

Evaluation of a novel assessment form for observing medical residents: a randomised, controlled trial.

CONTEXT: Teaching faculty cannot reliably distinguish between satisfactory and unsatisfactory resident performances and give non-specific feedback. OBJECTIVES: This study aimed to test whether a novel rating form can improve faculty accuracy in detecting unsatisfactory performances, generate more rater observations and improve feedback quality. METHODS: Participants included two groups of 40 internal medicine residency faculty staff. Both groups received 1-hour training on how to rate trainees in the mini-clinical evaluation exercise (mini-CEX) format. The intervention group was given a new rating form structured with prompts, space for free-text comments, behavioural anchors and fewer scoring levels, whereas the control group used the current American Board of Internal Medicine Mini-CEX form. Participants watched and scored six scripted videotapes of resident performances 2-3 weeks after the training session. RESULTS: Intervention group participants were more accurate in discriminating satisfactory from unsatisfactory performances (85% versus 73% correct; odds ratio [OR] 2.13, 95% confidence interval [CI] 1.16-3.14, P = 0.02) and yielded more correctly identified unsatisfactory performances (96% versus 52% correct; OR 25.35, 95% CI 9.12-70.46), but were less accurate in identifying satisfactory performances (73% versus 95% correct; OR 0.15, 95% CI 0.05-0.39). Intervention group participants averaged one fewer declared intended feedback item (4.7 versus 5.7) and showed no difference in the amount of feedback that was above minimal in quality. Intervention group participants generated more written evaluative observations (10.8 versus 5.7). Inter-rater agreement improved with the new form (Fleiss' kappa, 0.52 versus 0.30). CONCLUSIONS: Modifying the currently used direct observations process may produce more recorded observations, increase inter-rater agreement and improve overall rater accuracy, but it may also increase severity error.