Assessing Nephrology Fellows' Skills in Communicating About Kidney Replacement Therapy and Kidney Biopsy: A Multicenter Clinical Simulation Study on Breaking Bad News.

RATIONALE & OBJECTIVE: Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy. STUDY DESIGN: Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy. SETTING & PARTICIPANTS: 58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and 2018. PREDICTORS: Fellowship training year and clinical scenario. OUTCOME: Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score < 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score < 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed). ANALYTICAL APPROACH: Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario. RESULTS: Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P = 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored < 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored < 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions. LIMITATIONS: Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS. CONCLUSIONS: The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

Echocardiography vs cardiac magnetic resonance imaging assessment of the systemic right ventricle for patients with d-transposition of the great arteries status post atrial switch.

OBJECTIVE: Patients with Dextro-transposition of the great arteries status post atrial switch (dTGA s/p atrial switch) are "at-risk" for systemic right ventricular (RV) dysfunction. Due to complex RV geometry, echocardiography (Echo) does not allow accurate determination of ejection fraction (EF), but cardiac magnetic resonance imaging (CMR) allows quantitative right ventricular assessment. Measures of ventricular deformation may be precursors to global ventricular dysfunction. The primary aim of this study was to characterize imaging and clinical findings for adult patients with dTGA s/p atrial switch. DESIGN: This was a retrospective cohort study of patients with dTGA s/p atrial switch operation (February 1966 to August 1988) with CMR performed at Children's Hospital of Wisconsin (from September 2005 to May 2015). Eligible patients had clinic visit, Echo, and exercise stress test within 1 year of CMR. RESULTS: This study enrolled twenty-seven patients (16 males, 11 females) with dTGA s/p atrial switch (18 with Mustard operation and 9 with Senning operation; median age 30 years; 74% New York Heart Association class 1 and 26% class 2). Seventy-four percentage had normal RV systolic function (RV EF >45% by CMR). No correlation was observed between Echo strain data and clinical status (EF, exercise endurance, VO2 max, or New York Heart Association class). Cardiac magnetic resonance imaging RV global circumferential strain GCS and RV EF had moderate negative correlation (r = -0.65, P < .001). Global circumferential strain was significantly different for those with RV EF above and below 45%, while global peak longitudinal strain (GLS) was not. Patients had reduced CMR myocardial strain values compared with healthy controls. CONCLUSIONS: Reduced RV CMR GCS (for those with RV EF <45%) suggests that CMR evaluation may enhance early detection of detrimental changes in the systemic RV myocardium.

Quantitative Assessment of Right Ventricular Volumes and Ejection Fraction in Patients with Left Ventricular Systolic Dysfunction by Real Time Three-Dimensional Echocardiography versus Cardiac Magnetic Resonance Imaging.

AIMS: The aim of this study was to assess the accuracy and reproducibility of real time three-dimensional echocardiographic (RT3DE) for the determination of right ventricular (RV) volumes and function in patients with left ventricular (LV) systolic dysfunction. METHODS AND RESULTS: Dedicated RT3DE was prospectively performed to assess RV volumes and EF in patients with LV systolic function identified on routine clinical cardiac magnetic resonance (CMR) imaging. RV end-diastolic volume (RV EDV), RV end-systolic volume (RV ESV), and RV EF were obtained using an offline analysis software (TomTec) by two observers blinded to CMR results. In this population of 27 patients with LV systolic dysfunction with a mean LV EF of 36 ± 12%, RV RT3DE dataset could be assessed in 27 of 30 patients (90%). High correlation was noted between RT3DE and CMR for RV EDV, ESV, and EF (r = 0.90, 0.89, and 0.77, respectively). RV EDV was lower by RT3DE as compared to CMR (129 ± 52 vs. 142 ± 53 mL, P = 0.005) while there was no significant difference in RV ESV and RV EF (71 ± 37 vs. 77 ± 45 mL, P = 0.146; 45 ± 11 vs. 48 ± 13%, P = 0.134, respectively). The intraclass correlation coefficient ranged from 0.94 to 0.94 between measurements and from 0.84 to 0.96 between observers. CONCLUSION: Overall, RV volumes and EF assessed by RT3DE correlate well with CMR measurements in patients with LV dysfunction. RT3DE may be used as a more widely available and versatile alternative to CMR for the quantitative assessment of RV size and function in patients with LV dysfunction.

Echocardiographic indices of diastolic function relate to functional capacity and quality of life in ambulatory men with atrial fibrillation.

OBJECTIVE: We sought to explore the reliability of echocardiographic parameters of diastolic function and determine their relationship with functional capacity (New York Heart Association [NYHA] class and 6-minute walk test [6MWT]) and the domains of a health-related quality of life (HR-QOL) questionnaire (Veterans RAND 36-Item Health Survey) in a cohort of ambulatory patients with atrial fibrillation (AF). METHODS: Forty-eight male veterans with persistent or permanent AF underwent clinical examination, echocardiography, and 6MWT, and filled out a Veterans RAND 36-Item Health Survey questionnaire at two visits 1 week apart. Pairwise correlation was performed to evaluate the reliability of echocardiographic parameters and multiple regression analyses to assess the association of these parameters with functional capacity and HR-QOL. RESULTS: E/e' average had the highest correlation between the two visits (coefficient: 0.87) and had a significant relationship with NYHA, 6MWT, and physical functioning domain of HR-QOL even after adjusting for confounding variables (odds of NYHA >1: OR 1.5, 95% CI, 1.2-1.9; 6MWT coefficient: -31 ± 9 ft; physical functioning score coefficient: -1.7 ± 0.7). CONCLUSION: Average E/e' is a reliable diastolic function parameter that also independently relates with functional capacity and HR-QOL in ambulatory patients with atrial fibrillation.

Quality of life in patients with end-stage renal disease treated with hemodialysis: survival is not enough!

The quality of life (QoL) of end stage renal disease (ESRD) patients is a frequently overlooked yet critical consideration when evaluating the overall medical care of patients. There are a variety of measures used to assess the QoL of ESRD patients. Some of the more frequently used tools include the single-question QoL questionnaire, the 36 Item Short Form Health Survey (SF-36), and the Kidney Disease Quality of Life (KDQoL) questionnaire. The best intervention to improve the QoL of ESRD patients is renal transplantation. The role of erythropoietin and intensification of dialysis dose in improving patients' QoL is undergoing review. We have previously shown relationships between patients' perception of quality of life and depressive affect, perception of burden of illness (IEQ), social support (MSP), pain and sleep disturbances. Further studies should focus on interventions that modify patients' perceptions of these psychosocial parameters with the goal of improving their QoL. Treatment of depression, pain and sleep disorders holds particular promise in this regard.