Critical reflection in team-based practice: A narrative review.

INTRODUCTION: Research on critical reflection (a process of recognising and challenging assumptions that frame health care practice) has demonstrated strong potential for making health care more collaborative and equitable, yet its enactment within team-based health care remains underexplored. We conducted a narrative review to advance understanding of how critical reflection develops, occurs in and impacts team-based practice and care. METHODS: We searched three databases (Medline, CINAHL and Scopus) for articles related to the concepts of critical reflection and/or critically reflective practice in the context of team-based health care and examined how teams engage with those theoretical concepts, to inform ideas for a new approach to support critically reflective practice. FINDINGS: The search identified 974 citations of which nine articles showed elements of critical reflection in team-based practice. However, since only one of the nine included articles explicitly used the term 'critical reflection' in their research, critical reflection as a theoretical concept was found to be largely missing from the current team-based health care literature. Instead, aspects of critical reflection were evident in terms of challenging power hierarchies and questioning practice assumptions through dialogue, with a goal of collaborative practice. This sharing of knowledge and skills allowed teams to push boundaries and innovate together in practice. The included articles also emphasised the importance of creating a purposeful environment for open dialogue and practice change to occur. CONCLUSION: To support equitable care through collaborative practices, we suggest dialogue as and for critical reflection should be explicitly developed and researched within team-based health care.

Comparison of downsizing strategy (HANGZHOU Solution) and standard annulus sizing strategy in type 0 bicuspid aortic stenosis patients undergoing transcatheter aortic valve replacement: Rationale and design of a randomized clinical trial.

BACKGROUND: There has not been a consensus on the prothesis sizing strategy in type 0 bicuspid aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR). Modifications to standard annular sizing strategies might be required due to the distinct anatomical characteristics. We have devised a downsizing strategy for TAVR using a self-expanding valve specifically for patients with type 0 bicuspid AS. The primary aim of this study is to compare the safety and efficacy of downsizing strategy with the Standard Annulus Sizing Strategy in TAVR for patients with type 0 bicuspid AS. TRIAL DESIGN: It is a prospective, multi-center, superiority, single-blinded, randomized controlled trial comparing the Down Sizing and Standard Annulus Sizing Strategy in patients with type 0 bicuspid aortic stenosis undergoing transcatheter aortic valve replacement. Eligible participants will include patients with severe type 0 bicuspid AS, as defined by criteria such as mean gradient across aortic valve ≥40 mmHg, peak aortic jet velocity ≥4.0 m/s, aortic valve area (AVA) ≤1.0 cm², or AVA index ≤0.6 cm2/m2. These patients will be randomly assigned, in a 1:1 ratio, to either the Down Sizing Strategy group or the Standard Sizing Strategy group. In the Down Sizing Strategy group, a valve one size smaller will be implanted if the "waist sign" manifests along with less than mild regurgitation during balloon pre-dilatation. The primary end point of the study is a composite of VARC-3 defined device success, absence of both permanent pacemaker implantation due to high-degree atrioventricular block and new-onset complete left bundle branch block. CONCLUSION: This study will compare the safety and efficacy of Down Sizing Strategy with the Standard Annulus Sizing Strategy and provide valuable insights into the optimal approach for sizing in TAVR patients with type 0 bicuspid AS. We hypothesize that the Down Sizing Strategy will demonstrate superiority when compared to the Standard Annulus Sizing Strategy. (Down Sizing Strategy (HANGZHOU Solution) vs Standard Sizing Strategy TAVR in Bicuspid Aortic Stenosis (Type 0) (TAILOR-TAVR), NCT05511792).

Core outcomes for speech-language services in Ontario schools: a group concept mapping study and guiding framework.

BACKGROUND: Establishing the most important outcomes for school-based speech-language therapy is essential to guide future research and program evaluation for these services. Many health disciplines have developed core outcomes sets (COS) for this purpose. A COS encompasses the most important outcomes for particular health services as identified by appropriate interested parties. These interested parties usually represent health care providers and those with the health condition. In this paper, we report the development of a guiding framework for a COS for speech-language therapy services in schools in a Canadian context. METHODS: Using a group concept mapping method, we identified the outcomes for inclusion in the COS guiding framework through the elicited opinions of key interested parties: speech-language therapists, teachers, and family members of children with speech, language, and communication needs. We extracted 103 statements (potential outcomes) from a previous data set of interview transcripts. We then asked participants to sort the statements into conceptually similar groups, which were aggregated and transformed into a cluster map using multidimensional scaling followed by hierarchical cluster analysis. Participants also rated each statement on 5-point scales for importance and feasibility. We calculated mean ratings for individual statements and for all statements in a cluster, for all participants and for participant groups separately. RESULTS: We identified seven core outcomes for school-based speech-language services in Ontario, Canada. These included: classroom-based services, a holistic approach, support for teachers, care coordination, accessible services, family supports, and student success. All outcomes were rated highly for importance. Feasibility ratings were consistently below importance ratings. All participant groups concurred that a holistic approach was the most important outcome and accessible services was the least feasible outcome to achieve. CONCLUSIONS: The seven outcomes identified in this study are recommended to guide the development of a full COS to direct future research and program evaluation for school-based speech-language services. These outcomes have not been widely included in previous research and should be incorporated into future research alongside specific intervention outcomes. Data for some outcomes may be available from non-traditional sources such as administrative data sets. Consequently, their use for program evaluations should be accompanied by appropriate institutional support to allow speech-language therapists to make meaningful use of appropriate outcomes data.

Exploring the valued outcomes of school-based speech-language therapy services: a sequential iterative design.

Background: Achieving outcomes that community members value is essential to high-quality, family-centred care. These valued outcomes should inform the production and interpretation of research evidence. To date, outcomes included in studies of service delivery models for speech-language services in schools have been narrowly defined, and do not match the outcomes suggested as important by families, teachers, and children. The most important outcomes of school-based, speech-languages services have not been directly and systematically investigated. We aimed to address this gap by asking school community members what outcomes were most relevant to evaluating and improving the delivery of speech-language services in schools. Methods: A sequential, iterative mixed-method study was conducted using interviews with 14 family members, educators, and speech-language therapists that asked what outcomes or impacts of school-based services they considered most important or valuable. Summative content analysis was used to analyse the data. Structural topic modelling between rounds of qualitative analysis was used to describe both the quality and the quantity of the interview content. School community members' perspectives were compared through estimation of topic proportions within interviews from each member group and through qualitative comparison. Results: Structural topic modelling diagnostics and qualitative interpretation of topic output suggested a six-topic solution. This solution was estimated successfully and yielded the following topics: (1) meeting all needs appropriately, (2) teamwork and collaboration, (3) building capacities, (4) supporting individual student needs in context, (5) coordinating care, and finally (6) supporting core educational goals. Families focused on school-based services meeting all needs appropriately and coordinating care, while educators highlighted supporting individual student needs in context. By contrast, speech-language therapists emphasized building capacities and supporting core educational goals. All school community members agreed that current assessment tools and outcome measures were inadequate to capture the most important impacts of school-based services. Conclusions: Outcomes identified by school community members as important or valuable were broad, and included individual student outcomes, interpersonal outcomes, and systems-level outcomes. Although these outcomes were discussed by all member groups, each group focused on different outcomes in the interviews, suggesting differences in the prioritization of outcomes. We recommend building consensus regarding the most important outcomes for school-based speech-language services, as well as the prioritization of outcomes for measure development.

A critical interpretive synthesis of interprofessional education interventions.

Interprofessional practice can look quite different depending on a number of dynamics. Interprofessional education interventions may or may not orient toward this range of practice possibilities. This literature review explores: (1) how interprofessional education interventions relate to different kinds of interprofessional practice and (2) the range of interprofessional practices assumed by interprofessional education interventions. Four databases were searched for articles published between 2011-2021 describing pre-licensure level interprofessional education interventions, resulting in a dataset of 110 articles. Our analysis involved (1) descriptive summaries of the articles, and (2) content analysis of the rationale and description of the intervention. Of the articles, 93% (102/110) of interprofessional education interventions were designed and/or evaluated using the concept of interprofessional education competencies. "Teamwork" was the most relied upon competency. Most articles were not explicit about the different kinds of interprofessional practices that these competencies might be oriented toward. Our study substantiates earlier claims that interprofessional education literature tends to focus on competencies and orient toward undifferentiated understandings of "teamwork." This analysis is particularly important as interprofessional teams are engaging in increasingly complex, fluid, and distributed forms of interprofessional practice that may not be captured in an undifferentiated approach to "teamwork."

From skillful to empathic: evaluating shifts in medical students' perceptions of surgeons through a combined patient as teacher and arts-based reflection program.

Introduction: The purpose of this study was to identify whether the incorporation of a combined Patient as teacher (PAT) and arts-based reflection (ABR) program during a surgical clerkship rotation could influence more humanistic perceptions of surgeons, using an innovative evaluation approach. Methods: A novel, single question evaluation tool was created. Third year medical-students were asked to "list the top 5 attributes of a surgeon, in order of perceived importance" both before and after their surgical clerkship rotations and participation in the PAT/ABR program. Attributes identified by students were coded as either "humanistic" or "non-humanistic," which were then analyzed using generalized linear regression models under a Bayesian framework. Results: After participation in the PAT/ABR program, the predicted probability of students ranking a humanistic characteristic as the most important attribute of a surgeon had increased by 17%, and the predicted probability of students ranking a humanistic characteristic amongst their top three attributes for a surgeon had increased by 21%. Conclusion: This innovative evaluative method suggested the success of a combined PAT/ABR program in encouraging a humanistic perspective of surgery and this approach could potentially be explored to evaluate other humanistic education initiatives.

Introduction: L'objectif de cette étude était de déterminer si l'introduction d'une nouvelle approche d'évaluation associant la participation de Patients comme enseignants (PCE) à une Réflexion basée sur les arts (RBA) dans un stage d'externat en chirurgie permettait de mieux percevoir les qualités humanistes chez les chirurgiens. Méthodes: Un nouvel outil d'évaluation à question unique a été créé. Des étudiants en troisième année de médecine ont été invités à ''énumérer les cinq principaux attributs d'un chirurgien, par ordre d'importance perçue'', avant et après leur stage d'externat en chirurgie et le programme PCE/RBA. Les attributs identifiés par les étudiants ont été codés comme « humanistes ¼ ou « non humanistes ¼, puis analysés à l'aide de modèles de régression linéaire généralisée dans un cadre bayésien. Résultats: Après leur participation au programme PCE/RBA, la probabilité prédite moyenne que les étudiants classent un trait humaniste comme l'attribut le plus important d'un chirurgien a augmenté de 17 %, et la probabilité prédite que les étudiants classent un trait humaniste parmi les trois premiers attributs d'un chirurgien a augmenté de 21 %. Conclusion: Cette méthode d'évaluation innovante porte à croire que le programme PCE/RBA réussit en effet à favoriser une vision humaniste de la chirurgie. Cette approche peut être explorée pour évaluer d'autres activités de formation axées sur l'humanisme.

Teaching critical reflection in health professions education with transformative-vygotskian praxis.

Reflective practice is a complex concept to adequately describe, communicate about and, ultimately, teach. Unrelieved tensions about the concept persist within the health professions education (HPE) literature owing to reflection's diverse theoretical history. Tensions extend from the most basic, e.g., what is reflection and what are its contents, to the complex, e.g., how is reflection performed and whether it should be evaluated. Nonetheless, reflection is generally seen as vital to HPE, because it imparts crucial strategies and awareness to learners in their professional practices. In this article, we explore both conceptual and pedagogical dimensions of teaching for reflection. We address the concept of reflection, its application to practice, and how to remain faithful to transformative, critical pedagogy when teaching for it. We present (a) an analysis of two theories of education in HPE: Transformative Learning and Vygotskian Cultural Historical Theory. We (b) outline a pedagogical approach that applies Piotr Gal'perin's SCOBA: schema for the complete orienting basis of an action. We then employ (a) and (b) to provide affordances for developing materials for educational interventions across HPE contexts.

Internal medicine trainee perspectives on back-up call systems and relationships to burnout.

INTRODUCTION: As burnout within medicine escalates, residency programmes should strive to understand how training structures may contribute. Back-up call systems that address gaps in overnight resident call coverage are one possible contributing structure. However, the intersection between back-up call policies and burnout remains unclear. The authors explored residents' decision-making process when deciding whether or not to activate a back-up resident for call coverage, perspectives surrounding the legitimacy of call activations and the impact of back-up call systems on education and experienced burnout. METHODS: Internal medicine residents at the University of Toronto were recruited through email. Eighteen semi-structured one-on-one interviews were conducted with residents from September 2019 to February 2020. Interviews explored participants' experiences and perceptions with back-up call and call activations. A constructivist grounded theory approach was used to develop a conceptual understanding of the back-up system as it relates to residents' decisions underlying activations, downstream impacts and relationships to burnout. RESULTS: Residents described a complex thought process when deciding whether to activate back-up. Decisions were coloured by inner conflicts including sense of collegiality, need to maintain an image and time of year balanced against self-reported burnout. Residents described how back-up calls can lead to burnout, usually in the form of exhaustion, lowering their threshold to trigger future back-up activations. Impacts included anxiety of not knowing whether an activation would occur, decreased educational productivity and the 'domino effect' of increased workload for colleagues. DISCUSSION: Residents weigh inner tensions when deciding to activate back-up. Their collective experience suggests that burnout is both a trigger and consequence of back-up calls, creating a cyclical relationship. Escalating rates of call activations may signal that burnout amongst residents is high, warranting educational leads to assess for resident wellness and to critically evaluate the structure of such systems with respect to unintended consequences.

Outcomes management practices in tiered school-based speech-language therapy: A Canadian example.

BACKGROUND: Measuring, assessing and managing outcomes in school practice environments is difficult due to the complex nature of school communities as well as the recent shift in service-delivery models towards tiered approaches. In tiered approaches, multiple levels of service are offered to better match students' needs. Each level of service may require different outcomes and management techniques. Research to date on outcomes has focused on measuring outcomes in medical settings, leaving a substantive gap in the literature regarding practice in schools. AIMS: The first aim was to explore how school-based speech-language therapists approached outcomes management as their clinical programmes transitioned to tiered service-delivery models The second aim was to describe the successes and challenges in outcomes management reported by clinicians in this context. METHODS & PROCEDURES: A secondary deductive-inductive content analysis was performed using qualitative interviews with 24 clinical managers and senior therapists from schools across Ontario, Canada. Using a framework of outcomes measurement, assessment and management in schools based on previous research studies, data were grouped into broad categories deductively, and then the content of each category was further explored using inductive coding. Iterative peer debriefing and reflexive journaling were key strategies to increase the trustworthiness of the results. FINDINGS & RESULTS: Participants reported measuring and qualitatively assessing seven key outcomes for school-based practice. These included: (1) student progress and achievement, (2) student participation and inclusion in the school community, (3) stakeholder perspectives, (4) 'buy-in', (5) expanded capacities, (6) responsiveness to needs and (7) accountability to systems. Participants reported more challenges than successes in outcomes management during this transition to tiered services. Challenges were attributed to idiosyncratic organizational barriers, the transition to tiered models and the philosophy of working within the educational system. CONCLUSIONS & IMPLICATIONS: School-based speech-language therapists measure, assess and manage multiple outcomes relevant to school-based practice in tiered service-delivery models. Many challenges remain. Solutions to support meaningful, systematic and proactive outcomes management in schools should address the broader set of outcomes relevant to tiered service-delivery models and the unique practice context of the educational system, while remaining responsive to idiosyncratic organizational factors. Sustained clinical-research collaboration and knowledge exchange is recommended. WHAT THIS PAPER ADDS: What is already known on the subject Systematic, proactive collection and interpretation of outcomes has long been encouraged within speech-language therapy. However, implementing outcomes management in clinical practice remains a substantial challenge. Additionally, research on outcomes to date has focused on medical practice environments, to the exclusion of school-based practice. What are the potential or actual clinical implications of this work? Outcomes management is valued in school practice environments; however, the current repertoire of techniques for outcomes management are a poor match for school-based practice. Clinicians in schools would benefit from the development of contextually relevant, meaningful and feasible outcomes management tools.

Combining adaptive expertise and (critically) reflective practice to support the development of knowledge, skill, and society.

Adaptive expertise (AE) and reflective practice (RP), two influential and resonant theories of professional expertise and practice in their own right, may further benefit health professions education if carefully combined. The current societal and systemic context is primed for both AE and RP. Both bodies of work position practitioners as agentive, learning continually and thoughtfully throughout their careers, particularly in order to manage unprecedented situations well. Similar on the surface, the roots and practices of AE and RP diverge at key junctures and we will focus on RP's movement toward critically reflective practice. The roots of AE and RP, and how they relate to or diverge from present-day applications matter because in health professions education, as in all education, paradigmatic mixing should be undertaken purposefully. This paper will explore the need for AE and RP, their shared commitments, distinctive histories, pedagogical possibilities both individually and combined, and next steps for maximizing their potential to positively impact the field. We argue that this exploration is urgently needed because both AE and RP hold much promise for improving health care and yet employing them optimally-whether alone or together-requires understanding and intent. We build an interprofessional education case situated in long-term care, throughout the paper, to demonstrate the potential that AE and RP might offer to health professions education individually and combined. This exploration comes just in time. Within the realities of uncertain practice emphasized by the pandemic, practitioners were also called to act in response to complex and urgent social movements. A combined AE and RP approach, with focus on critically reflective practice in particular, would potentially prepare professionals to respond effectively, compassionately, and equitably to future health and social crises and challenges.

Examining the Impact of Dialogic Learning on Critically Reflective Practice.

PURPOSE: While research is beginning to reveal the potential of dialogue in sparking critical reflection (critically reflective ways of seeing), additional research is needed to guide the teaching of critical reflection toward enabling critically reflective practice (critically reflective ways of seeing and doing). An experimental study was conducted to investigate the impact of dialogic learning on critically reflective practice, compared to discussion-based learning. The dialogic intervention integrated the theory of Mikhail Bakhtin with the theory of critical reflection and critical disability studies. METHOD: In interprofessional groups of 4, medical, occupational therapy, and speech-language pathology students were randomly assigned to a learning condition that used a reflective discussion or critically reflective dialogue about a pediatric patient case. All participants were then randomly assigned a clinical report for a novel pediatric patient and asked to write a hypothetical clinical letter to the child's school. Hierarchical logistic regression models were constructed to estimate the probabilities of sentences and letters being critically reflective. RESULTS: The probability of sentences being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.2, 0.33]), compared to the discussion condition (0.11, 95% CI [0.07, 0.15]). Likewise, the probability of letters being critically reflective was significantly higher for the dialogue condition (0.26, 95% CI [0.15, 0.4]), compared to the discussion condition (0.04, 95% CI [0.01, 0.16]). In both conditions, the probability of a letter being critically reflective was positively associated with the proportion of critically reflective sentences. CONCLUSIONS: The results demonstrate dialogic learning prepared students to enact critically reflective practice when writing mock clinical letters. Students who participated in a dialogue engaged in a collaborative process of critical reflection and subsequently applied that way of seeing in the individual act of writing a letter. This study highlights how Bakhtin's theory of dialogue can advance critical pedagogy.

Elevated N-terminal pro C-type natriuretic peptide is associated with mortality in patients undergoing transcatheter aortic valve replacement.

BACKGROUND: Unlike N-terminal pro-B-type natriuretic peptide (NT-proBNP), which have been extensively studied, little is known about the role of N-terminal pro-C-type natriuretic peptide (NT-proCNP) for predicting survival post transcatheter aortic valve replacement (TAVR). METHODS: A total of 309 patients were included in the analysis. Patients were grouped into quartiles (Q1-4) according to the baseline NT-proCNP value. Blood for NT-proCNP analysis was obtained prior to TAVR procedure. The primary endpoint was mortality after a median follow-up of 32 months. Multivariable Cox proportional hazards regression models analyzed prognostic factors. The predictive capability was compared between NT-proBNP and NT-proCNP using receiver operator curve (ROC) analysis. RESULTS: A total of 309 subjects with the mean age of 76.8 ± 6.3 years, among whom 58.6% were male, were included in the analysis. A total of 58 (18.8%) patients died during follow-up. Cox multivariable analyses indicated society of thoracic surgeons (STS)-score was a strong independent predictor for mortality (hazard ratio (HR) 1.08, 95% confidential interval (CI) 1.05-1.12, P < 0.001). Elevated NT-proCNP was associated with a higher risk of cardiovascular mortality (HR 1.02, 95% CI 1.00-1.03, P = 0.025) and All-cause mortality (HR 1.01, 95% CI 1.00-1.03, P = 0.027), whereas NT-proBNP showed a small effect size on mortality. ROC analysis indicated that NT-proCNP was superior to NT-proBNP for TAVR risk evaluation in patients with left ventricular ejection fraction (LVEF) < 50% [(Area under the curve (AUC)-values of 0.79 (0.69; 0.87) vs. 0.59 (0.48; 0.69), P = 0.0453]. CONCLUSIONS: NT-proCNP and STS-Score were the independent prognostic factors of mortality among TAVR patients. Furthermore, NT-proCNP was superior to NT-proBNP for TAVR risk evaluation in patients with LVEF < 50%. Trial registration NCT02803294, 16/06/2016.

Validation of a novel staging classification system based on the extent of cardiac damage among Chinese patients after transcatheter aortic valve replacement: A single-center retrospective study.

OBJECTIVES: We aimed to validate a novel staging system for aortic stenosis (AS) in a Chinese patient cohort undergoing transcatheter aortic valve replacement (TAVR), and to compare this classification system to the traditional Society of Thoracic Surgeons (STS) score for TAVR risk stratification. BACKGROUND: A novel staging system for AS based on the extent of cardiac damage upon echocardiography was recently proposed. METHODS: Patients were prospectively enrolled into the Transcatheter Aortic Valve Replacement Single Center Registry in Chinese Population and analyzed retrospectively following additional exclusion criteria. On the basis of echocardiographic findings of cardiac damage, patients were classified into five stages (0-4). RESULTS: A total of 427 patients were included in the current analysis. Forty-eight deaths occurred during a median follow-up of 730 days following TAVR. The staging system showed a statistically significant association between cardiac damage and all-cause mortality; advanced stages were associated with higher mortality. In a multivariate-adjusted Cox proportional hazards regression model, stage and STS scores served as risk factors for 2-year mortality. Each increment in the staging class was associated with an increased risk of mortality (hazard ratio, 1.275; 95% confidence interval [CI], 1.052-1.545). Receiver operating characteristic (ROC) curves were plotted for stage (area under the curve, 0.644; 95% CI, 0.562-0.725) and STS score (0.661; 0.573-0.749), and with no statistically significant differences between ROC curves (p = 0.920). CONCLUSIONS: We validated a novel staging system as a key risk factor for 2-year mortality in a Chinese TAVR patient cohort. Efficacy for risk stratification was comparable to the STS score.

Three-year outcomes of transcatheter aortic valve implantation for bicuspid versus tricuspid aortic stenosis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) might be a feasible treatment option for more patients with bicuspid aortic valve (BAV) stenosis. However, long-term follow-up data in this population are scarce. AIMS: The aim of this study was to evaluate three-year outcomes after TAVI in patients with BAV. METHODS: A total of 246 consecutive patients who underwent TAVI at a single centre in China between March 2013 and February 2018 were enrolled in this study. Clinical outcomes, health status and echocardiography were followed and recorded for three years. RESULTS: Among 109 (44.3%) BAV patients, 61.5% were Type 0 and 36.7% were Type 1 BAV patients. BAV patients were younger (75 vs 77 years, p=0.041) and had a lower Society of Thoracic Surgeons (STS) score (5.09 vs 6.00, p=0.026) compared to tricuspid aortic valve (TAV) patients. There were no differences in three-year survival rates between bicuspid and tricuspid patients (87.1% vs 79.5%, log-rank p=0.126). Multivariate Cox regression analysis adjusting for confounding factors revealed a similar risk of all-cause mortality in the BAV population (hazard ratio [HR] 0.86, 95% confidence interval [CI]: 0.44-1.70, p=0.666). Except for the rate of permanent pacemaker implantation that was lower in BAV patients (11.9% vs 21.9%, p=0.041), the incidence of other clinical adverse events was comparable between the two groups. Both BAV and TAV patients showed an obvious improvement in valve haemodynamics, which was sustained for three years. In addition, similar left ventricular reverse remodelling was found during follow-up. CONCLUSIONS: BAV patients showed similar satisfactory three-year clinical outcomes, persistent valve haemodynamics improvement, and obvious cardiac reverse remodelling after TAVI compared to TAV patients.

Anemia and risk of periprocedural cerebral injury detected by diffusion-weighted magnetic resonance imaging in patients undergoing transcatheter aortic valve replacement.

BACKGROUND: Anemia is prevalent in patients undergoing transcatheter aortic valve replacement (TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new ischemic lesions post TAVR. METHODS: We prospectively enrolled 158 patients who received TAVR in our center. Anemia was defined according to the World Health Organization criteria as hemoglobin <12 g/dL in women and <13 g/dL in men. All patients underwent diffusion-weighted magnetic resonance imaging (DW-MRI) procedure before and within 4-7 days after TAVR. RESULTS: Anemia was present in 85 (53.8%) patients who underwent TAVR, and 126 (79.7%) patients had 718 new DW-MRI positive lesions with a mean of 4.54±5.26 lesions per patient. The incidence of new ischemic lesions was 81.2% in patients with anemia versus 78.1% in patients without anemia (P=0.629). Moreover, anemic patients had bigger total volume/lesions in the anterior cerebral artery/middle cerebral artery (ACA/MCA) and MCA regions compared to the non-anemic patients (31.89±55.78 mm3 vs. 17.08±37.39 mm3, P=0.049; and 54.54±74.72 mm3 vs. 33.75±46.03 mm3, P=0.034). Anemia was independently associated with the volume/lesion in the ACA/MCA (ß=16.796, 95% confidence interval [95% CI] 2.001 to 31.591, P=0.026) and in the MCA zone (ß=0.020, 95% CI 0.001 to 0.040, P=0.041). CONCLUSIONS: Patients with pre-procedural anemia may have bigger total volume/lesions in the ACA/MCA and MCA regions compared to the non-anemic patients. Whether the consequences of bigger total volume/lesions impact neurological and cognitive outcomes remains to be investigated.

Toward 'seeing' critically: a Bayesian analysis of the impacts of a critical pedagogy.

Critical reflection supports enactment of the social roles of care, like collaboration and advocacy. We require evidence that links critical teaching approaches to future critically reflective practice. We thus asked: does a theory-informed approach to teaching critical reflection influence what learners talk about (i.e. topics of discussion) and how they talk (i.e. whether they talk in critically reflective ways) during subsequent learning experiences? Pre-clinical students (n = 75) were randomized into control and intervention conditions (8 groups each, of up to 5 interprofessional students). Participants completed an online Social Determinants of Health (SDoH) module, followed by either: a SDoH discussion (control) or critically reflective dialogue (intervention). Participants then experienced a common learning session (homecare curriculum and debrief) as outcome assessment, and another similar session one-week later. Blinded coders coded transcripts for what (topics) was said and how (critically reflective or not). We constructed Bayesian regression models for the probability of meaning units (unique utterances) being coded as particular what codes and as critically reflective or not (how). Groups exposed to the intervention were more likely, in a subsequent learning experience, to talk in a critically reflective manner (how) (0.096 [0.04, 0.15]) about similar content (no meaningful differences in what was said). This difference waned at one-week follow up. We showed experimentally that a particular critical pedagogical approach can make learners' subsequent talk, ways of seeing, more critically reflective even when talking about similar topics. This study offers the field important new options for studying historically challenging-to-evaluate impacts and supports theoretical assertions about the potential of critical pedagogies.

Rapid Knowledge Mobilization and Continuing Professional Development: Educational Responses to COVID-19.

INTRODUCTION: The field of Continuing Professional Development (CPD) has a role to play in supporting health care professionals as they respond to the COVID-19 pandemic. However, the evolving science of COVID-19, the need for quick action, and the disruption of conventional knowledge networks pose challenges to existing CPD practices. To meet these emergent and rapidly evolving needs, what is required is an approach to CPD that draws insights from the domain of knowledge mobilization (KMb). METHODS: This short report describes a research protocol for exploring rapid KMb responses to COVID-19 at one Canadian academic teaching hospital. The proposed research will proceed as a case study using a mixed methods design collecting quantitative (surveys and Web site use metrics) and qualitative data (interviews) from individuals involved in developing, using, and supporting the KMb resources. Analysis will proceed in two phases: descriptive analysis of data to share insights and integrative analysis of data to build theory. RESULTS: Results from this study will inform the immediate KMb and CPD contribution to the COVID-19 response. DISCUSSION: Findings from this study will also make a broader contribution to the field of CPD, theoretically informing intersections between KMb and CPD and therefore contributing to an integrated science of CPD.

Getting everyone to the table: exploring everyday and everynight work to consider 'latent social threats' through interprofessional tabletop simulation.

In this methodological intersection article, we describe how we developed a new variation of the established tabletop simulation modality, inspired by institutional ethnography (IE)-informed principles. We aimed to design and conduct pilot implementations of this innovative tabletop simulation modality, which focused uniquely on everyday and everynight work, along with the factors that govern that work. In so doing, we aimed to develop a modality and preliminary findings that researchers and educators can use to simulate healthcare practices across longer episodes of care (i.e., time scales of hours or an entire day) and to detect the 'latent social threats' that can emerge during interprofessional clinical care.An interprofessional team designed tabletop simulation scenarios of interprofessional challenges during transfers of care on a labour and delivery (L&D) unit. Within each scenario, participants provided real-time explanations for their work and associated drivers, both independently and as a team. Thus, we combined 'think-aloud' and simulation principles to design tabletop simulation scenarios to elicit healthcare professionals' descriptions of how they collaborate in their work on the L&D unit. We completed a total of five tabletop simulations with eight participants (obstetricians, N = 2; midwives, N = 2; nurses, N = 5).The conversations stimulated by the tabletop simulation scenarios and debriefs allowed us to generate a preliminary understanding of the texts that govern and organize clinicians' everyday work processes. We generated data about longitudinal, multi-hour work processes in a condensed timeline, with opportunities to pause and probe, and with reduced focus on individual practitioner's competence.We believe our innovative tabletop simulation approach allowed us to examine clinical work in ways no other simulation permits. Participants described how the scenarios opened a productive dialogue between professional groups and suggested this simulation-based approach might contribute to enhanced interprofessional understanding and cultural change. We suggest that others can adapt our low-resource approach to understand clinicians' everyday work and to map how this work is governed by documents, like policies, with the end goal of facilitating system change and managing latent social threats.