A Call to Action From the California Consortium for the Assessment of Clinical Competence: Making the Case for Regional Collaboration.

The discontinuation of the United States Medical Licensing Examination Step 2 Clinical Skills Examination emphasizes the need for other reliable standardized assessments of medical student clinical skills. For 30 years, the California Consortium for the Assessment of Clinical Competence (CCACC) has collaborated in the development of clinical skills assessments and has become a valuable resource for clinicians, standardized patient educators, psychometricians, and medical educators. There are many merits to strong multi-institutional partnerships, including the integration of data across multiple schools to provide feedback to both students and curricula, pooled test performance statistics for analysis and quality assurance, shared best practices and resources, individual professional development, and opportunities for research and scholarship. The infrastructure of the CCACC allows member schools to adapt to a changing medical landscape, from emerging trends in clinical medicine to the limitations imposed by a global pandemic. In the absence of a national examination, there is now a greater need for all medical schools to develop a comprehensive, dynamic, and psychometrically sound assessment that accurately evaluates clinical skills. Medical schools working together in regional consortia have the opportunity to create and implement innovative and robust assessments that evaluate a wide range of clinical skills, ensure that medical students have met an expected level of clinical competency before graduation, and provide a framework that contributes to ongoing efforts for the development of new national clinical skills standards.

Pediatric Heart Transplantation: Transitioning to Adult Care (TRANSIT): Feasibility of a Pilot Randomized Controlled Trial.

BACKGROUND: Young-adult heart transplant recipients transferring to adult care are at risk for poor health outcomes. We conducted a pilot randomized controlled trial to determine the feasibility of and to test a transition intervention for young adults who underwent heart transplantation as children and then transferred to adult care. METHODS: Participants were randomized to the transition intervention (4 months long, focused on heart-transplant knowledge, self-care, self-advocacy, and social support) or usual care. Self-report questionnaires and medical records data were collected at baseline and 3 and 6 months after the initial adult clinic visit. Longitudinal analyses comparing outcomes over time were performed using generalized estimating equations and linear mixed models. RESULTS: Transfer to adult care was successful and feasible (ie, excellent participation rates). The average patient standard deviation of mean tacrolimus levels was similar over time in both study arms and < 2.5, indicating adequate adherence. There were no between-group or within-group differences in percentage of tacrolimus bioassays within target range (> 50%). Average overall adherence to treatment was similarly good in both groups. Rates of appointment keeping through 6 months after transfer declined over time in both groups. CONCLUSIONS: The feasibility of the study was demonstrated. Our transition intervention did not improve outcomes.

Pediatric Heart Transplantation: Transitioning to Adult Care (TRANSIT): Baseline Findings.

Young adult solid organ transplant recipients who transfer from pediatric to adult care experience poor outcomes related to decreased adherence to the medical regimen. Our pilot trial for young adults who had heart transplant (HT) who transfer to adult care tests an intervention focused on increasing HT knowledge, self-management and self-advocacy skills, and enhancing support, as compared to usual care. We report baseline findings between groups regarding (1) patient-level outcomes and (2) components of the intervention. From 3/14 to 9/16, 88 subjects enrolled and randomized to intervention (n = 43) or usual care (n = 45) at six pediatric HT centers. Patient self-report questionnaires and medical records data were collected at baseline, and 3 and 6 months after transfer. For this report, baseline findings (at enrollment and prior to transfer to adult care) were analyzed using Chi-square and t-tests. Level of significance was p < 0.05. Baseline demographics were similar in the intervention and usual care arms: age 21.3 ± 3.2 vs 21.5 ± 3.3 years and female 44% vs 49%, respectively. At baseline, there were no differences between intervention and usual care for use of tacrolimus (70 vs 62%); tacrolimus level (mean ± SD = 6.5 ± 2.3 ng/ml vs 5.6 ± 2.3 ng/ml); average of the within patient standard deviation of the baseline mean tacrolimus levels (1.6 vs 1.3); and adherence to the medical regimen [3.6 ± 0.4 vs 3.5 ± 0.5 (1 = hardly ever to 4 = all of the time)], respectively. At baseline, both groups had a modest amount of HT knowledge, were learning self-management and self-advocacy, and perceived they were adequately supported. Baseline findings indicate that transitioning HT recipients lack essential knowledge about HT and have incomplete self-management and self-advocacy skills.

Healthcare students interprofessional critical event/disaster response course.

OBJECTIVE: Numerous disasters confirm the need for critical event training in healthcare professions. However, no single discipline works in isolation and interprofessional learning is recognized as a necessary component. An interprofessional faculty group designed a learning curriculum crossing professional schools. DESIGN: Faculty members from four healthcare schools within the university (nursing, pharmacy, allied health, and medicine) developed an interdisciplinary course merging both published cross-cutting competencies for critical event response and interprofessional education competencies. SETTING: Students completed a discipline-specific online didactic course. Interdisciplinary groups then participated in a 4-hour synchronous experience. This live course featured high-fidelity medical simulations focused on resuscitation, as well as hands-on modules on decontamination and a mass casualty triage incorporating moulaged standardized patients in an active shooter scenario. PARTICIPANTS: Participants were senior students from allied health, medicine, nursing, and pharmacy. MAIN OUTCOME MEASURES: Precourse and postcourse assessments were conducted online to assess course impact on learning performance, leadership and team development, and course satisfaction. RESULTS: Students participated were 402. Precourse and postcourse evaluations showed improvement in team participation values, critical event knowledge, and 94 percent of participants reported learning useful skills. Qualitative responses evidenced positive response; most frequent recurring comments concerned value of interprofessional experiences in team communication and desire to incorporate this kind of education earlier in their curriculum. Students demonstrated improvement in both knowledge and attitudes in a critical event response course that includes interprofessional instruction and collaboration. Further study is required to demonstrate sustained improvement as well as benefit to clinical outcomes.

Effects of ultrasound implementation on physical examination learning and teaching during the first year of medical education.

OBJECTIVES: Increasing emphasis has been placed on point-of-care ultrasound in medical school. The overall effects of ultrasound curriculum implementation on the traditional physical examination skills of medical students are still unknown. We studied the effects on the Objective Standardized Clinical Examination (OSCE) scores of year 1 medical students before and after ultrasound curriculum implementation. METHODS: An ultrasound curriculum was incorporated into the physical diagnosis course for year 1 medical students in the 2012-2013 academic year. We performed a prospective observational study comparing traditional OSCE scores of year 1 medical students exposed to the ultrasound curriculum (post-ultrasound) versus historic year 1 medical student controls (pre-ultrasound) with no ultrasound exposure. Questionnaire data were also obtained from year 1 medical students and physical diagnosis faculty to assess attitudes toward ultrasound implementation. RESULTS: The final overall OSCE scores were graded with a 5-point Likert-type scale from unsatisfactory to outstanding. There was a significant increase in outstanding scores in the post-ultrasound compared to the pre-ultrasound group (27.0% versus 10.9%; P< .001). The post-ultrasound group had significantly (P< .05) increased first-time pass rates on blood pressure measurements, the abdominal examination, and professionalism. Student and physical diagnosis faculty questionnaire data showed an overall positive response, with most agreeing or strongly agreeing that ultrasound should be included in the future year 1 medical student curriculum. CONCLUSIONS: Ultrasound implementation into a physical diagnosis curriculum for year 1 medical students is feasible and may improve their overall traditional physical examination skills.

Calcineurin inhibitor minimization using sirolimus leads to improved renal function in pediatric heart transplant recipients.

The introduction of cyclosporine revolutionized the practice of immunosuppression for solid organ transplant recipients, and has resulted in a significant increase in survival. While CNI use has been the mainstay of immunosuppressive therapy in pediatric heart transplantation, CNIs have been associated with an increased risk of nephropathy leading to significant morbidity and mortality. We evaluated the effect on renal function of a CNI minimization protocol using SRL in pediatric heart transplant patients with CNI induced renal insufficiency. An IRB approved retrospective chart review and case control study was performed. There were 20 patients identified with renal insufficiency who had been converted to SRL (target 5-8 ng/mL) and cyclosporine (target 50-75 vs. 125-150 ng/mL). Renal insufficiency was defined as isotopic (Indium 111 DTPA) GFR <60 mL/min per 1.73 m(2) or sCr >1 mg/dL. Outcome variables evaluated were GFR and sCr at time of conversion and at two yr post conversion. Comparison was made with case control subjects matched for age at Tx, time from Tx to conversion, and initial GFR. The median age at Tx = 81 days (S.D. ±26), median time of conversion after Tx = 10 yrs (s.d. ±0.65). Self-limited/treatable side effects included hypercholesterolemia (10), neutropenia (6), aphthous ulcer (3), edema (2), anemia (2), and tremor (1). One patient rejected in the two yr prior to conversion, and one patient had two rejection episodes following conversion. GFR at conversion for study group was 51 ± 14 vs. 60 ± 2 at two yr, p = 0.018. GFR at inclusion for control group was 56 ± 20 vs. 53 ± 21, p = 0.253. This report demonstrates that minimizing CNI exposure by addition of SRL to the immunosuppressant regimen in pediatric heart transplant recipients result in improved renal function in comparison to historically managed patients. Furthermore, immunotherapy with SRL and lower-dose CNI can effectively prevent rejection with an acceptable side-effect profile.

Developmental outcomes after pediatric heart transplantation.

BACKGROUND: Pediatric heart transplantation has now been successfully performed for more than 20 years. As survival rates have improved, more attention is now focused on long-term outcomes. METHODS: This report reviews the literature on developmental outcomes after pediatric heart transplantation. RESULTS: Pediatric patients undergoing heart transplantation generally can be expected to have developmental outcomes in the low-normal range, consistent with outcomes seen in other children with complex congenital heart disease requiring surgical intervention. When these children reach school age, or return to school, most can be expected to function reasonably well in mainstream school settings. A significant minority will require additional educational assistance. Approximately 10% will have significant neurologic impairment. In school, particular attention should be paid to evaluating the child for deficits in arithmetic and verbal skills. Performance may be better than predicted from IQ testing. Behavioral issues are common, with depression, concerns about social competence, and attention difficulties most frequently endorsed. This may pre-date transplantation in those who undergo transplantation during childhood and may improve with time. Parents more often report problem behaviors than teachers. Family resources and family coping skills are also strongly correlated with the child's emotions and coping skills. CONCLUSION: The pediatric heart transplant recipient's ability to transition from childhood into a happy and productive adult life can be significantly affected by his or her cognitive abilities, learning experiences, sense of self, and emotions. Attention to these factors is an important part of caring for these children.

Cardiac re-transplantation in pediatrics: a multi-institutional study.

BACKGROUND: Cardiac re-transplantation (re-Tx) among pediatric recipients remains controversial. The purpose of this study is to use the Pediatric Heart Transplant Study (PHTS) database to investigate the incidence of re-Tx and analyze the risk factors and outcomes after transplantation among children. METHODS: The PHTS database was reviewed for all subjects or=1 year after their PTx, especially those with graft coronary artery disease.