A Framework for Practice-Based Teaching in Public Health.

CONTEXT: To prepare master of public health graduates for successful application of public health competencies in their careers, accredited schools of public health must identify the knowledge, technical and professional skills needed for practice, and provide opportunities for application of these skills in public health settings. PROGRAM: Practice-based teaching (PBT) is a pedagogical approach where students learn through course instruction while working on a real problem and producing implementable deliverables for a public health agency. Currently, no framework exists for designing, implementing, and evaluating the pedagogy. This article defines PBT for public health and presents a novel 5-step framework, PBT STEPS, to guide faculty in development of a practice-based curriculum for public health education, including (1) securing partnerships, (2) training and technology, (3) engagement and implementation, (4) presenting deliverables, and (5) sizing up the results. IMPLEMENTATION: PBT has been implemented using PBT STEPS in both domestic and global courses, teaching a variety of technical competencies. Collaborating agencies for PBT courses have ranged from small community-based organizations to large departments of public health, to international nongovernmental organizations and to private hospitals. Each step is described and illustrated through a practical example from a past PBT course. EVALUATION: The practical example was evaluated through a mixed-methods approach to assess outcomes for students and collaborating agencies. All students (n = 12) reported significant increases in ability with the technical and professional competencies addressed in the course, and all agencies (n = 3 representing 5 distinct projects) reported utility of the final deliverables to the agency and populations served. DISCUSSION: Evidence-informed, feasible, and innovative solutions created through PBT collaboration provide significant benefits to the agency and the communities they serve while successfully training students for the public health workforce. Utilizing the PBT STEPS framework allows for successful and productive academic and community collaborations.

The Effectiveness and Flexibility of Practice-Based Teaching: A Long-term, Cross-disciplinary Evaluation.

OBJECTIVES: Schools of public health (SPHs) must train students through real-world situations. Practice-based teaching (PBT) uses immediate application for skill development through multiple modes of delivery including virtual collaborations. PBT provides short-term benefits but is less understood long term. We sought to understand the longer-term impacts of PBT on students, public health agencies, faculty, and SPH administration and determine if the reported benefits of PBT outweigh the challenges. METHODS: We used a mixed-methods pre-post-test evaluation to assess short-term outcomes in spring 2015 and long-term outcomes 3 years later using quantitative and qualitative assessments. The evaluation included 4 PBT courses spanning disciplines in 1 SPH. Participants included students (n = 56), collaborating agencies (n = 9), teaching faculty (n = 7), and SPH administrators (n = 8). RESULTS: Students reported acquisition of competencies, application at follow-up, and being workforce ready (91.0%) with greater appreciation 3 years post-semester (78.6%). Collaborating agencies reported successful implementation of deliverables (77.8%) and enhanced networks (88.7%) with cost savings and better outcomes for the communities served. Faculty recognized beneficial outcomes to students including workforce preparation (71.4%), and administration recognized the benefits and worth of PBT to the school for teaching (100%) and research opportunities (87.5%). CONCLUSIONS: Given the shifting higher education landscape as a result of the pandemic, public health courses are being redesigned to provide opportunities for skill development, regardless of delivery mode, and enhanced connections to the field are essential. PBT is a flexible pedagogy that results in lasting and innovative resources to agencies and prepares public health students with technical skills and professional competencies to be workforce ready.

Examining health care champions: a mixed-methods study exploring self and peer perspectives of champions.

Background: Champions are widely recognized as playing a key role in the successful implementation of evidence-based interventions within the health care sector; however, little is known about which characteristics and skills enable them to play that role. Furthermore, previous studies have measured only individual champions' responses to personal attributes without incorporating input from other observers. A mixed-methods study was conducted to identify, analyze, and group the behaviors and characteristics of champions who have successfully promoted the adoption of new initiatives within the health care delivery system, taking into consideration self and peer perspectives. Methods: Using a mixed-methods, cross-sectional triangulation design with a convergence model, quantitative data were collected and analyzed from health care champions (n = 30) and their colleagues (n = 58) from 11 countries using a survey. Every champion and a subset of colleagues (n = 14) also participated in in-depth interviews. Descriptive statistics were used to explore the relationship between champion and colleague responses to survey items; chi-squared tests and Kruskal-Wallis tests were used to compare the differences. Thematic content analysis of qualitative data was used to explore champion-like behaviors and features. Characteristics of champions were categorized using the Transformational Leadership Theory framework. Results: Champions exhibited characteristics that facilitated trust and encouraged motivation among their colleagues to adopt innovations, such as being intrinsically motivated, persistent, enthusiastic, and highly effective communicators. Champions were described by their colleagues as empathetic, curious, physically present, approachable, and often soliciting feedback from others. Although there was a high degree of agreement between champion and colleague survey responses, champions were more likely to underrate their skills and abilities to instigate change compared to their colleagues. Conclusion: Both champions and colleagues described key champion-like characteristics, but champions often downplayed the characteristics and behaviors that make champions uniquely effective at facilitating the adoption of evidence-based interventions. Plan language abstract: Health care champions are people who promote the adoption of new initiatives to improve the quality of patient care among their colleagues within health care settings. Champions are often viewed by organizational leaders and researchers as critical for the successful implementation of new ideas; however, little is known about what specific skills or characteristics make them effective at promoting the adoption of new ideas among their colleagues. Most studies on champions' behaviors have only included the perspectives of champions, and not perspectives from others within the organization. The goal of our study was to not only explore champions' perspectives of themselves, but also the views of champions' colleagues to understand why and how champions motivated and influenced their colleagues to try new things. Findings from this study could lead to more accurate identification of health care champions, which in turn could lead to more efficient and effective adoption of new initiatives to improve the quality of patient care.

Public health, medicine, and dentistry as partners in community health: a pioneering initiative in interprofessional, practice-based education.

CONTEXT: As public health challenges grow more complex, the call for professional education to be interprofessional, collaborative, and grounded in real world practice has intensified. OBJECTIVE: In this article, we describe the development, implementation, and results of one pioneering course at Boston University that aims to prepare public health, medical, and dental students for their combined roles in community health settings. SETTING AND PARTICIPANTS: The Schools of Public Health, Medicine, and Dental Medicine jointly offered the course in partnership with 3 community organizations. Participants include MPH, MD, and DMD candidates. INTERVENTION: The course design integrates the use of "The Challenge Model" (created by Management Sciences for Health) with training in public health consultation techniques (eg, community-based participatory research, logic models, monitoring and evaluation). Teams of 6 to 8 medical and public health students collaborate with managers and staff of a community health center to address 1 organizational challenge and recommend a sustainability plan. RESULTS: Postcourse evaluations revealed that a cross-disciplinary, practice-based education model is feasible and can meet students' learning objectives and exceed expectations of community partners. We overcame formidable obstacles related to the "silo'ed" nature of academic institutions and the competing priorities within overburdened community organizations. We found that sustained project implementation was attained at some but not all sites, yet all sites highly valued the perspective and contribution of student teams. CONCLUSION: Dynamic and replicable, this practice-based education model is adaptable to professional schools whose work intersects in the real world and calls for collaborative leadership.

The accuracy of magnetic resonance imaging in the assessment of glenohumeral articular degenerative disease.

Degenerative joint disease is a major source of disability in the world with over 43 million individuals suffering from the affliction in the United States alone. It is the most common cause of activity limitation in individuals over 65 years of age. While much of the focus in recent years has been on osteoarthritis of the hips and knees, shoulder degenerative disease is becoming a more commonly recognized source of morbidity with a wide range of associated lifestyle-limiting disabilities. At the same time therapeutic options for treatment of degenerative joint disease are rapidly increasing, both medically and surgically. This combination of factors makes it necessary to determine a reliable, noninvasive means by which to accurately diagnose the early changes of shoulder degenerative disease. The clinical diagnosis of shoulder osteoarthritis is extremely challenging. There are numerous existing mimickers such as rotator cuff injuries, bursitis, and impingement syndrome. While the conventional radiographic findings are well recognized, they are generally late developments in the course of the disease when therapeutic options are more limited and less effective. Additionally, plain film evaluation has poor sensitivity for the detection of many of the alternative diagnoses that may underlie chronic shoulder pain. Though correlative findings are seen in MR imaging, its role in evaluating glenohumeral degenerative changes has been limited, with much of the focus being on the identification of tendinous and ligamentous disease or osseous tumors. A retrospective analysis is presented which demonstrates the efficacy of MR imaging in assessing GHJ OA, as well as shows that dedicated evaluation for specific degenerative findings results in improved detection rates of GHJ degenerative disease. It is believed that with improved detection and reporting, improved clinical care for this prevalent disorder may be achieved.

Mobile Health Apps in OB-GYN-Embedded Psychiatric Care: Commentary.

This paper explores the potential benefits of the use of mobile health (mHealth) apps in obstetrician-gynecologist (OB-GYN)-embedded psychiatric clinics in the United States. First, we highlight the increasing trend of integrating mental health care within the OB-GYN context. Second, we provide examples of successful uses of mHealth in the global health context and highlight the dearth of available research in the United States. Finally, we provide a summary of the shortcomings of currently available apps and describe the upcoming trial of a novel app currently underway at the Mother-Child Wellness Clinical and Research Center at Boston Medical Center.

Pharmacogenetics and irinotecan therapy.

PURPOSE: Irinotecan metabolism, irinotecan pharmacogenetic research, and the role of genetic testing before administration of the drug are reviewed. SUMMARY: Irinotecan is approved worldwide for the treatment of metastatic colorectal cancer but causes dose-limiting neutropenia and diarrhea. When severe, these can lead to dehydration, infection, patient discomfort, additional medication requirements, hospitalization, and death. The identification of predictive markers in irinotecan therapy has been a significant goal of pharmacogenetic research. The labeling of irinotecan was recently changed and now includes a warning of greater neutropenia risk in patients with reduced activity in the drug-metabolizing enzyme uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1). A known marker of reduced UGT1A1 activity is the genetic variant UGT1A1*28. Numerous studies have demonstrated the effects of genetic factors, especially UGT1A1*28, that contribute to interpatient variability in irinotecan pharmacokinetics and toxicity. Irinotecan's new labeling recommends that clinicians consider reducing the dosage of irinotecan in patients homozygous for UGT1A1*28. CONCLUSION: At least part of the interpatient variability of irinotecan toxicity can be explained by the UGT1A1*28 polymorphism. Patients who are homozygous for the UGT1A1*28 allele have an increased risk of developing severe neutropenia when receiving irinotecan, especially the 300-350- mg/m2 regimen. A molecular assay is now available to identify the at-risk subgroup and should be used by health care professionals to help guide irinotecan-treatment decisions.

Acute care needs in an Indian emergency department: A retrospective analysis.

BACKGROUND: Emergencies such as road traffic accidents (RTAs), acute myocardial infarction (AMI) and cerebrovascular accident (CVA) are the most common causes of death and disability in India. Robust emergency medicine (EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department (ED) is needed. METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences (KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed. RESULTS: A total of 1 196 ED patient charts were analyzed. Of these patients, 55.35% (n=662) were male and 44.7% (n=534) were female. The majority (67.14%, n=803) were adults, while only 3.85% (n=46) were infants. The most common chief complaints were fever (21.5%, n=257), renal colic (7.3%, n=87), and dyspnea (6.9%, n=82). The most common ED diagnoses were gastrointestinal (15.5%, n=185), pulmonary (12.3%, n=147), tropical (11.1%, n=133), infectious disease and sepsis (9.9%, n=118), and trauma (8.4%, n=101). CONCLUSION: The patient demographics, diagnoses, and distribution of resources identified by this study can help guide and shape Indian EM training programs and faculty development to more accurately reflect the burden of acute disease in India.

Interobserver variation in cervical cancer tumor delineation for image-based radiotherapy planning among and within different specialties.

Radiation therapy for cervical cancer involves a team of specialists, including diagnostic radiologists (DRs), radiation oncologists (ROs), and medical physicists (MPs), to optimize imaging-based radiation therapy planning. The purpose of the study was to investigate the interobserver variations in tumor delineation on MR images of cervical cancer within the same and among different specialties. Twenty MRI cervical cancer studies were independently reviewed by two DRs, two ROs, and two MPs. For every study, each specialist contoured the tumor regions of interest (ROIs) on T2-weighted Turbo Spin Echo sagittal images on all slices containing tumor, and the total tumor volume was computed for statistical analysis. Analysis of variance (ANOVA) was used to compare the differences in tumor volume delineation among the observers. A graph of all tumor-delineated volumes was generated, and differences between the maximum and minimum volumes over all the readers for each patient dataset were computed. Challenges during the evaluation process for tumor delineation were recorded for each specialist. Interobserver variations of delineated tumor volumes were significant (p < 0.01) among all observers based on a repeated measures ANOVA, which produced an F(5,95) = 3.55. The median difference between the maximum delineated volume and minimum delineated volume was 33.5 cm3 (which can be approximated by a sphere of 4.0 cm diameter) across all 20 patients. Challenges noted for tumor delineation included the following: (1) partial voluming by parametrial fat at the periphery of the uterus; (2) extension of the tumor into parametrial space; (3) similar signal intensity of structures proximal to the tumor such as ovaries, muscles, bladder wall, bowel loops, and pubic symphysis; (4) postradiation changes such as heterogeneity and necrosis; (5) susceptibility artifacts from bowels and vaginal tampons; (6) presence of other pathologies such as atypical myoma; (7) factors that affect pelvic anatomy, including the degree of bladder distension, bowel interposition, uterine malposition, retroversion, and descensus. Our limited study indicates significant interobserver variation in tumor delineation. Despite rapid progress in technology, which has improved the resolution and precision of image acquisition and the delivery of radiotherapy to the millimeter level, such "human" variations (at the centimeter level) may overshadow the gain from technical advancement and impact treatment planning. Strategies of standardization and training in tumor delineation need to be developed.

Cystic masses of the knee: magnetic resonance imaging findings.

Cystic masses of the knee comprise a diverse group of pathologic entities ranging from simple cysts to complications of underlying disease to tumors. Although their presentations may be similar, the appropriate treatment and patient management can differ greatly. In this article, we review radiographic and magnetic resonance imaging characteristics of both common and uncommon cystic masses of the knee.

Mucoid degeneration of the anterior cruciate ligament: a case report.

Mucoid degeneration of the ACL is an unusual entity that has only been recently described. The imaging features of this entity have been described to a sufficient degree to provide diagnostic criteria, and its appearance can be characteristic. It is important to recognize this entity as a chronic process as its presentation and appearance can mimic a tear of the ACL. The etiology of mucoid degeneration of the ACL is unclear, but it may represent part of a continuum between early degeneration of the collagen fibrils of the ACL and frank formation of a ganglion cyst. The mucoid degeneration usually produces symptoms similar to those of an intra-articular mass, but pain may also be associated with this process. Treatment may require partial or complete resection of the ACL, but percutaneous aspiration of the fluid components of the affected ACL may also be effective at alleviating the associated symptoms.