Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study.

INTRODUCTION: Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR). METHODS: We conducted a literature search on SBR practices using the terms "simulation," "remediation," and "simulation based remediation." We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM. RESULTS: Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved. CONCLUSION: Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

Tumor response after yttrium-90 radioembolization for hepatocellular carcinoma: comparison of diffusion-weighted functional MR imaging with anatomic MR imaging.

PURPOSE: Anatomic magnetic resonance (MR) imaging assessment of hepatocellular carcinoma (HCC) response to yttrium-90 ((90)Y) radioembolization may require 3 months before therapeutic effectiveness can be determined. The relationship between anatomic MR and diffusion-weighted imaging (DWI) changes after (90)Y therapy is unclear. The present study tested the hypothesis that apparent diffusion coefficient (ADC) values on DWI at 1 month precede anatomic tumor size change at 3 months after (90)Y radioembolization. MATERIALS AND METHODS: In this prospective study, 20 patients with HCC (16 men) enrolled between April 2005 and July 2006 underwent lobar (90)Y therapy with mean doses of 141 Gy (right lobe) and 98 Gy (left lobe). Anatomic 1.5-T MR imaging (gadolinium-enhanced T1-weighted gradient-recalled echo) and DWI (single-shot spin-echo echo-planar imaging; b value of 0, 500 sec/mm(2)) were performed at baseline (0-3 weeks before (90)Y therapy) and at 1 and 3 months after (90)Y therapy. Tumor size and ADC values were measured and compared, and the percentage change in ADC was compared to the change in tumor size (minimum >5% change in size), with use of a paired t test (alpha = .05). RESULTS: Yttrium-90 therapy was successfully delivered in all patients. The mean baseline ADC of 1.64 x 10(-3) mm(2)/sec +/- 0.30 significantly increased to 1.81 x 10(-3) mm(2)/sec +/- 0.37 at 1 month (P = .02), and to 1.82 x 10(-3) mm(2)/sec +/- 0.23 at 3 months (P = .02). The mean baseline tumor size of 83.0 cm(2) +/- 63.7 did not change statistically at 1 month (84.1 cm(2) +/- 62.1; P = .75) or 3 months (74.0 cm(2) +/- 57.0; P = .10). The overall mean ADC percentage change at 1 month of 10.5% +/- 23.1% preceded an overall mean tumor size percentage change at 3 months of -18.5% +/- 31.5% (P = .03). CONCLUSIONS: HCC tumor response assessed with DWI at 1 month preceded anatomic size changes at 3 months after (90)Y therapy. DWI may assist in early determination of the response or failure of (90)Y therapy for HCC.

Diffusion-weighted magnetic resonance imaging to predict response of hepatocellular carcinoma to chemoembolization.

AIM: To investigate whether intra-procedural diffusion-weighted magnetic resonance imaging can predict response of hepatocellular carcinoma (HCC) during transcatheter arterial chemoembolization (TACE). METHODS: Sixteen patients (15 male), aged 59 +/- 11 years (range: 42-81 years) underwent a total of 21 separate treatments for unresectable HCC in a hybrid magnetic resonance/interventional radiology suite. Anatomical imaging and diffusion-weighted imaging (b = 0, 500 s/mm(2)) were performed on a 1.5-T unit. Tumor enhancement and apparent diffusion coefficient (ADC, mm(2)/s) values were assessed immediately before and at 1 and 3 mo after TACE. We calculated the percent change (PC) in ADC values at all time points. We compared follow-up ADC values to baseline values using a paired t test (alpha = 0.05). RESULTS: The intra-procedural sensitivity, specificity, and positive and negative predictive values (%) for detecting a complete or partial 1-mo tumor response using ADC PC thresholds of +/-5%, +/-10%, and +/-15% were 77, 67, 91, and 40; 54, 67, 88, and 25; and 46, 100, 100, and 30, respectively. There was no clear predictive value for the 3-mo follow-up. Compared to baseline, the immediate post-procedure and 1-mo mean ADC values both increased; the latter obtaining statistical significance (1.48 +/- 0.29 mm(2)/s vs 1.65 +/- 0.35 x 10(-3) mm(2)/s, P < 0.014). CONCLUSION: Intra-procedural ADC changes of > 15% predicted 1-mo anatomical HCC response with the greatest accuracy, and can provide valuable feedback at the time of TACE.