Development and evaluation of virtual simulation games to increase the confidence and self-efficacy of healthcare learners in vaccine communication, advocacy, and promotion.

BACKGROUND: Although healthcare providers (HCPs) are the most trusted source of vaccine information, there is a paucity of easily accessible, multidisciplinary educational tools on vaccine communication for them. Virtual simulation games (VSGs) are innovative yet accessible and effective tools in healthcare education. The objectives of our study were to develop VSGs to increase HCP confidence and self-efficacy in vaccine communication, advocacy, and promotion, and evaluate the VSGs' effectiveness using a pre-post self-assessment pilot study. METHODS: A multidisciplinary team of experts in medicine, nursing, pharmacy, and simulation development created three VSGs for HCP learners focused on addressing conversations with vaccine hesitant individuals. We evaluated the VSGs with 24 nursing students, 30 pharmacy students, and 18 medical residents who completed surveys and 6-point Likert scale pre-post self-assessments to measure changes in their confidence and self-efficacy. RESULTS: There were no significant differences in baseline confidence and self-efficacy across the three HCP disciplines, despite varied levels of education. Post-VSG confidence and self-efficacy (median: 5) were significantly higher than pre-VSG (median: 4-5) for all three HCP disciplines (P ≤ 0.0005), highlighting the effectiveness of the VSGs. Medical residents reported significantly lower post-VSG confidence and self-efficacy than nursing and pharmacy learners despite completing the most significant amount of education. CONCLUSIONS: Following the completion of the VSGs, learners in medicine, nursing, and pharmacy showed significant improvement in their self-assessed confidence and self-efficacy in holding vaccine conversations. The VSGs as an educational tool, in combination with existing clinical immunization training, can be used to increase HCP confidence and engagement in vaccine discussions with patients, which may ultimately lead to increased vaccine confidence among patients.

What does "Timely" Mean to Residents? Challenging Feedback Assumptions in Postgraduate Education.

Introduction: Current orthodoxy states that feedback should be timely and face-to-face, yet the optimal timing and mode of delivery for feedback is unclear. We explored what "optimal timing" means from residents' points of view as feedback providers and receivers, to ultimately inform strategies to optimize feedback in training. Methods: As near-peers who have dual roles in both providing and receiving feedback, 16 subspecialty (PGY4 and 5) internal medicine residents were interviewed about their perceptions of the optimal timing and format of feedback. Using constructivist grounded theory, interviews were conducted and analyzed iteratively. Results: Drawing on their experiences as providers and recipients, residents described simultaneously considering and weighing multiple factors when deciding on when and how to provide feedback. These included their own readiness to engage in providing meaningful feedback, the perceived receptiveness of the learner and the apparent urgency of feedback delivery (e.g., if patient safety was at stake). Face-to-face verbal feedback was valued for encouraging dialogue but could be uncomfortable and limited by time constraints. Written feedback could be more honest and concise, and the possibility of asynchronous delivery had potential to overcome issues with timing and discomfort. Discussion: Participants' perceptions of the optimal timing of feedback challenge current assumptions about the benefits of "immediate" versus "delayed". The concept of "optimal timing" for feedback was found to be complex and context-dependent, defying a formulaic approach. There may be a role for asynchronous and/or written feedback, which has potential to address unique issues identified issues in near-peer relationships.

A mixed methods study to effectively utilize trigger tools in the ICU.

PURPOSE: This study aimed to create a trigger tool for our intensive care units (ICUs) to support our departmental quality improvement efforts. METHODS: We compiled an initial list of triggers used in an ICU setting through literature review. We used a modified Delphi method to develop a unique set of triggers. An expert panel was selected for multidisciplinary and multi-site representation from four adult medical-surgical ICUs of a Canadian city. Respondents ranked triggers on a Likert scale based on its likelihood of being associated with adverse event (sensitivity to harm), and likelihood of being associated with suboptimal ICU processes (specificity for internal recommendations). OUTCOMES: Our literature search yielded 10 articles and 59 triggers. Completion of the rating process resulted in 12 items that achieved consensus. Triggers included specific clinical, hospital-acquired infection, medication related, and procedural occurrences. One additional trigger (cardiopulmonary arrest) which consistently held high scores but did not achieve multidisciplinary consensus, was also included. CONCLUSIONS: We used the modified Delphi process to derive consensus-selected triggers to identify ICU specific adverse events with opportunity for improvement in local care. This methodology can be adopted by other centers looking to introduce trigger tools in a manner selective to their practice needs.

Effect of Bisphosphonates on Bone Health in Adult Renal Transplant Patients: Beyond the First Year Posttransplant-A Systematic Review and Meta-Analysis.

BACKGROUND: Bone mineral density (BMD) decreases postrenal transplantation. Evidence demonstrating the effects of bisphosphonates on BMD and fracture risk beyond 1-year posttransplant is sparse in existing literature, but remains essential to enhance clinical outcomes in this population. OBJECTIVE: Our study aimed to systematically review and meta-analyze the current literature on the use of any bisphosphonate in the adult renal transplant population beyond the first year of renal transplant to determine its effect on BMD and fracture incidence. DESIGN: We conducted a systematic review and meta-analysis of primary research literature that included full-text, English-language, original randomized clinical trials (RCTs) and observational studies. SETTING: Patient data were primarily captured in an outpatient setting across various studies. PATIENTS: Our population of interest was patients older than 18 years who received deceased/living donor kidney transplantation and any bisphosphonate with a follow-up greater than 12 months posttransplantation. MEASUREMENTS: The primary outcome was change in BMD from baseline. Secondary outcomes were the incidence of fractures and effects of other confounders on bone health. METHODS: We included RCTs and observational studies that satisfied our inclusion criteria. Each study was analyzed for risk of bias and data were extrapolated to analyze for overall statistical significance accounting for heterogeneity of studies. RESULTS: Sixteen studies (N = 1762) were analyzed. The follow-up ranged from 12 to 98 months. There was a nonsignificant improvement in BMD with bisphosphonate treatment persisting into the second and third years posttransplant at the lumbar spine. The calculated standardized mean BMD difference was -0.29 (-0.75 to 0.17), P = .22. Only 5 studies reported a total of 43 new fractures. Prednisone (P < .01), low body weight (P < .001), low body mass index (P < .01), and male gender (P < .05) correlated with reduced lumbar and femoral BMD. LIMITATIONS: Limitations of this review include the use of BMD as a surrogate outcome, the bias of the included studies, and the incomplete reporting data in numerous analyzed studies. CONCLUSIONS: We demonstrate no statistically significant benefit of bisphosphonate treatment on BMD beyond the first year postrenal transplantation. Despite heterogeneity of treatment, a differential nonsignificant improvement in lumbar spine BMD was consistent and may be clinically relevant. TRIAL REGISTRATION: PROSPERO CRD42019125593.

CONTEXTE: La densité minérale osseuse (DMO) décroit à la suite d'une greffe rénale. Les données probantes faisant état des effets des bisphosphonates sur la DMO et le risque de fracture au-delà d'un an post-greffe sont rares dans la littérature, mais demeurent essentielles pour améliorer les résultats cliniques pour cette population. OBJECTIF: L'étude actuelle visait à réaliser une revue systématique et une méta-analyse de la littérature faisant état de l'usage des bisphosphonates dans une population de greffés rénaux adultes, au-delà de la première année post-greffe, afin de connaître les effets de cette médication sur la DMO et sur l'incidence de fractures. TYPE D'ÉTUDE: Une revue systématique et une méta-analyse de la littérature ont été réalisées à partir d'articles rédigés en anglais, présentant les résultats d'essais cliniques et d'études observationnelles. CADRE: Dans les différentes études, les données provenaient principalement de patients suivis sur une base externe. SUJETS: Notre population d'intérêt était constituée de patients adultes ayant subi une greffe rénale provenant d'un donneur décédé ou vivant, ayant reçu un traitement par un bisphosphonate et ayant été suivis pendant plus de douze mois post-transplantation. MESURES: L'issue principale était une variation de la DMO par rapport à la valeur initiale. L'incidence de fractures et les effets des autres facteurs de confusion sur la santé osseuse constituaient les issues secondaires. MÉTHODOLOGIE: Ont été inclus les essais cliniques et les études observationnelles qui répondaient à nos critères d'inclusion. Chaque étude a fait l'objet d'une analyse des risques de biais et les données ont été extrapolées pour analyser la signification statistique de l'ensemble en tenant compte de l'hétérogénéité des études. RÉSULTATS: Seize études (n=1762) ont été analysées. La période de suivi variait de 12 à 98 mois. Une amélioration non significative de la DMO du rachis lombaire ayant persisté dans la deuxième et la troisième année post-greffe a été observée à la suite d'un traitement par un bisphosphonate. La moyenne normalisée calculée des variations de la DMO s'établissait à -0,29 (-0,75 à 0,17; p=0,22). Seules cinq études ont rapporté de nouvelles fractures, pour un total de 43 fractures. La prise de prednisone (p<0,01), un faible poids (p<0, 001), un faible IMC (p<0,01) et le fait d'être un homme (p<0,05) ont corrélé avec une DMO lombaire ou fémorale réduite. LIMITES: Le recours à la DMO comme issue intermédiaire, les biais contenus dans les études incluses et le fait que plusieurs des études analysées comportaient des données incomplètes constituent les limites de l'étude. CONCLUSION: Nous n'avons pu démontrer un avantage statistiquement significatif sur la DMO à poursuivre un traitement par les bisphosphonates au-delà de la première année suivant une greffe rénale. Malgré l'hétérogénéité du traitement, une amélioration non significative de la DMO lombaire a été observée et pourrait s'avérer pertinente sur le plan clinique.

Generating level-dependent models of cervical and thoracic spinal cord injury: Exploring the interplay of neuroanatomy, physiology, and function.

The majority of spinal cord injuries (SCI) occur at the cervical level, which results in significant impairment. Neurologic level and severity of injury are primary endpoints in clinical trials; however, how level-specific damages relate to behavioural performance in cervical injury is incompletely understood. We hypothesized that ascending level of injury leads to worsening forelimb performance, and correlates with loss of neural tissue and muscle-specific neuron pools. A direct comparison of multiple models was made with injury realized at the C5, C6, C7 and T7 vertebral levels using clip compression with sham-operated controls. Animals were assessed for 10weeks post-injury with numerous (40) outcome measures, including: classic behavioural tests, CatWalk, non-invasive MRI, electrophysiology, histologic lesion morphometry, neuron counts, and motor compartment quantification, and multivariate statistics on the total dataset. Histologic staining and T1-weighted MR imaging revealed similar structural changes and distinct tissue loss with cystic cavitation across all injuries. Forelimb tests, including grip strength, F-WARP motor scale, Inclined Plane, and forelimb ladder walk, exhibited stratification between all groups and marked impairment with C5 and C6 injuries. Classic hindlimb tests including BBB, hindlimb ladder walk, bladder recovery, and mortality were not different between cervical and thoracic injuries. CatWalk multivariate gait analysis showed reciprocal and progressive changes forelimb and hindlimb function with ascending level of injury. Electrophysiology revealed poor forelimb axonal conduction in cervical C5 and C6 groups alone. The cervical enlargement (C5-T2) showed progressive ventral horn atrophy and loss of specific motor neuron populations with ascending injury. Multivariate statistics revealed a robust dataset, rank-order contribution of outcomes, and allowed prediction of injury level with single-level discrimination using forelimb performance and neuron counts. Level-dependent models were generated using clip-compression SCI, with marked and reliable differences in forelimb performance and specific neuron pool loss.

Bilateral contusion-compression model of incomplete traumatic cervical spinal cord injury.

Despite the increasing incidence and prevalence of cervical spinal cord injury (cSCI), we lack clinically relevant animal models that can be used to study the pathomechanisms of this injury and test new therapies. Here, we characterize a moderate cervical contusion-compression model in rats that is similar to incomplete traumatic cSCI in humans. We characterized the effects of 18-g clip-compression injury at cervical level C6 over an 8-week recovery period. Using Luxol fast blue/hematoxylin-eosin staining in combination with quantitative stereology, we determined that 18-g injury results in loss of gray matter (GM), white matter (WM), as well as in cavity formation. Magnetization transfer and T2-weighted magnetic resonance imaging were used to analyze lesion dynamics in vivo. This analysis demonstrated that both techniques are able to differentiate between the injury epicenter, subpial rim, and WM distal to the injury. Neurobehavioral assessment of locomotor function using Basso, Beattie, and Bresnahan (BBB) scoring and CatWalk revealed limited recovery from clip-compression injury at C6. Testing of forelimb function using grip strength demonstrated significant forelimb dysfunction, similar to the loss of upper-limb motor function observed in human cSCI. Sensory-evoked potentials recorded from the forelimb and Hoffman reflex recorded from the hindlimb confirmed the fore- and hindlimb deficits observed in our neurobehavioral analysis. Here, we have characterized a clip-compression model of incomplete cSCI that closely models this condition in humans. This work directly addresses the current lack of clinically relevant models of cSCI and will thus contribute to improved success in the translation of putative therapies into the clinic.