A Mastery Learning Capstone Course to Teach and Assess Components of Three Entrustable Professional Activities to Graduating Medical Students.

PROBLEM: Thirteen measurable Entrustable Professional Activities (EPAs) have been proposed by the Association of American Medical Colleges as a means to operationalize medical school graduates' patient care qualifications. Mastery learning is an effective method for boosting clinical skills, but its applicability to the EPAs remains to be studied. The authors designed this study to evaluate a mastery learning intervention to teach and assess components of 3 of the 13 EPAs in a 4th-year capstone course. INTERVENTION: The course featured mastery learning principles and addressed three EPA-based skills: (a) obtain informed consent, (b) develop a differential diagnosis and write admission orders, and (c) write discharge prescriptions. All students underwent a baseline skills assessment, received feedback, engaged in deliberate practice with actionable feedback, and completed a similar skills-based posttest assessment. Students continued with practice and testing until the minimum passing standards (MPSs) were reached for each posttest. CONTEXT: All medical students at a single medical school (Northwestern University, Feinberg School of Medicine) who matriculated in 2012 and graduated with the class of 2016 participated in a required transition to residency course immediately prior to graduation. OUTCOME: There were 134 students eligible to participate, and 130 (97.0%) completed all curricular requirements and assessments. All 130 medical students who completed the course met or exceeded the MPS for each of the three EPA-based clinical skills. Reliability coefficients for outcome data were uniformly high. Measures for each of the three clinical skills showed statistically significant improvement. LESSONS LEARNED: The capstone course was an effective approach to teach and assess components of three EPA-based clinical skills to mastery learning standards in a 4th-year capstone course. We learned that this approach for implementation is feasible and results in significant improvement in components of EPA skill performance. Next steps will include developing assessments incorporating the mastery model into components of additional EPAs, identifying the best location within the curriculum to insert this content, and expanding the number of assessments as part of a larger assessment system.

Enhanced acetylcholine-induced dilation in afferent arterioles in simvastatin-fed rats.

OBJECTIVE: 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been shown to increase renal blood flow and glomerular filtration rate independent of their lipid lowering effects. The purpose of this study was to determine the effect of simvastatin on acetylcholine-induced vasodilation in the renal microcirculation. The hypothesis of the study was that simvastatin would increase acetylcholine-induced vasodilation in the renal microcirculation. METHODS: The hydronephrotic kidney preparation was used. On the day of the experiment the kidney was prepared for videomicroscopy and dose-response curves were done with acetylcholine and sodium nitroprusside (10(-10) M to 10(-5) M) in simvastatin-fed rats ??(n=8) and control rats (n=13). The vasodilator responses of afferent and efferent arterioles were directly quantitated using videomicroscopy. L-NAME; (N(omega)-nitro-L-arginine methyl ester) was also given in a group of simvastatin-fed rats (10(-5) M) to determine if it would block the acetylcholine (Ach)-induced vasodilation. RESULTS: Simvastatin enhanced Ach-induced vasodilation in the afferent arteriole compared to control rat responses to Ach. At 10(-7) M, ACH caused a 31.6+/-7.2% increase from baseline diameter in the afferent arteriole in the simvastatin-fed rats compared to a 23+/-8.1% vasodilation in the control rats (p<0.05). There were no differences in the response to ACH in the efferent arteriole between the two groups. L-NAME completely abolished the ACH response in the simvastatin-fed rats. CONCLUSIONS: The increase in renal blood flow and glomerular filtration rate observed with simvastatin may be due to its preglomerular vasodilator effects. This may be due to an increase in nitric oxide production.

Ethyl pyruvate enhances intra-resuscitation hemodynamics in prolonged ventricular fibrillation arrest.

AIMS: As the duration of untreated cardiac arrest increases, the effectiveness of standard therapies declines, and may be more harmful than helpful. We investigated the hemodynamic, metabolic and anti-inflammatory effects of Ringer's ethyl pyruvate solution (REPS) versus Ringer's solution (RS) in the acute model of prolonged porcine arrest. METHODS: Seventeen mixed-breed swine were induced into ventricular fibrillation (VF) and left untreated for 8min. CPR was begun using a mechanical chest compression device at a rate of 100 per minute. At the onset of CPR, animals were randomly assigned to treatment with either 25mL/kg of RS or 25mL/kg of REPS containing 40mg/kg of ethyl pyruvate, infused over 5min in blinded fashion. CPR continued with administration of a drug cocktail at 2min and the first rescue shock was delivered at minute 13 of VF. Animals having ROSC were supported with standardized care for 2h. RESULTS: Both groups had 100% ROSC and 100% 2-h survival. The REPS group exhibited higher median CPP (27.3mmHg) than the control group (16.5mmHg) by 3min of CPR, which continued throughout the duration of CPR (p=0.02). The median time to hypotension following ROSC was 9.64min in the REPS group and 7.25min in controls (p=0.04) and there was a non-significant trend of decreased use of vasopressors for the duration of resuscitation. There was no difference in systemic or cerebral metabolism between groups. There were non-significant trends of decreased IL-6, increased Il-10 and decreased mesenteric bacterial colony growth in those treated with REPS when compared to RS. CONCLUSIONS: The administration of REPS with CPR significantly improved intra- and post-resuscitation hemodynamics in this swine model of prolonged cardiac arrest, but did not definitely change the metabolic or inflammatory profile during the acute resuscitation period.