Restriction of HIV-1 infection in sickle cell trait.

Patients with sickle cell disease (SCD) have a lower risk for HIV-1 infection. We reported restriction of ex vivo HIV-1 infection in SCD peripheral blood mononuclear cells (PBMCs) that was due, in part, to the upregulation of antiviral, inflammatory, and hemolytic factors, including heme oxygenase-1 (HO-1). Here, we investigated whether individuals with sickle cell trait (SCT), who develop mild hemolysis, also restrict HIV-1 infection. Ex vivo infection of SCT PBMCs exhibited an approximately twofold reduction of HIV-1 replication and lower levels of HIV-1 reverse transcription products, 2-long terminal repeat circle, HIV-1 integration, and gag RNA expression. SCT PBMCs had higher HO-1 messenger RNA (mRNA) and protein levels and reduced ribonucleotide reductase 2 (RNR2) protein levels. HO-1 inhibition by tin porphyrin eliminated ex vivo HIV-1 restriction. Among Howard University clinic recruits, higher levels of HO-1 and RNR2 mRNA and lower HIV-1 env mRNA levels were found in SCT individuals living with HIV-1. To determine the population-level effect of SCT on HIV-1 prevalence, we assessed SCT among women living with HIV (WLH) in the WIHS (Women Interagency HIV-1 Study). Among WIHS African-American participants, the prevalence of SCT was lower among women with HIV compared with uninfected women (8.7% vs 14.2%; odds ratio, 0.57; 95% confidence interval, 0.36-0.92; P = .020). WIHS WLH with SCT had higher levels of CD4+/CD8+ ratios over 20 years of follow-up (P = .003) than matched WLH without SCT. Together, our findings suggest that HIV-1 restriction factors, including HO-1 and RNR2, might restrict HIV-1 infection among individuals with SCT and limit the pathogenicity of HIV.

Impact of school closures and re-openings on COVID-19 transmission.

BACKGROUND: Globally, the education of students at primary and secondary schools has been severely disrupted by the implementation of school closures to reduce the spread of coronavirus disease 2019 (COVID-19). The effectiveness of school closures in reducing transmission of COVID-19 and the impact of re-opening schools are unclear. METHODS: Research criteria for this rapid review included empirical studies, published or pre-published worldwide before January 25, 2021, that assessed the effectiveness of school closures in reducing the spread of COVID-19 and the impact of school re-openings on COVID-19 transmission. RESULTS: Twenty-four studies on the impact of school closures and re-openings on COVID-19 transmission were identified through the seven databases that were searched. Overall the evidence from these studies was mixed and varied due to several factors such as the time of implementation of public health measures, research design of included studies and variability among the levels of schooling examined. CONCLUSION: Preliminary findings suggest that school closures have limited impact on reducing COVID-19 transmission, with other non-pharmaceutical interventions considered much more effective. However, due to the limitations of the studies, further research is needed to support the use of this public health measure in response to the COVID-19 pandemic.

Fostering trust, collaboration, and a culture of continuous quality improvement: A call for transparency in medical school accreditation.

Medical schools provide the foundation for a physician's growth and lifelong learning. They also require a large share of government resources. As such, they should seek opportunities to maintain trust from the public, their students, faculty, universities, regulatory colleges, and each other. The accreditation of medical schools attempts to assure stakeholders that the educational process conforms to appropriate standards and thus can be trusted. However, accreditation processes are poorly understood and the basis for accrediting authorities' decisions are often opaque. We propose that increasing transparency in accreditation could enhance trust in the institutions that produce society's physicians. While public reporting of accreditation results has been established in other jurisdictions, such as Australia and the United Kingdom, North American accrediting bodies have not yet embraced this more transparent approach. Public reporting can enhance public trust and engagement, hold medical schools accountable for continuous quality improvement, and can catalyze a culture of collaboration within the broader medical education ecosystem. Inviting patients and the public to peer into one of the most formative and fundamental parts of their physicians' professional training is a powerful tool for stakeholder and public engagement that the North American medical education community at large has yet to use.

Les facultés de médecine procurent les bases pour la croissance professionnelle et le développement professionnel continu. Elles absorbent également une grande part des ressources gouvernementales. Conséquemment, elles devraient chercher des occasions de maintenir la confiance du public, de leurs étudiants, du corps professoral, des universités, des organismes de réglementation et les unes des autres. L'accréditation des facultés de médecine vise à assurer les parties prenantes que le processus éducationnel est conforme aux normes appropriées et donc de confiance. Toutefois, les processus d'accréditation sont mal compris et les fondements des décisions d'accréditation des autorités sont souvent opaques.Nous proposons que l'accroissement de la transparence du processus d'agrément puisse rehausser la confiance dans les institutions qui forment les médecins de notre société. Bien que la diffusion publique des résultats de l'agrémentsoit établie dans d'autres juridictions, comme en Australie et au Royaume-Uni, les organismes d'agrément de l'Amérique du Nord n'ont pas encore adopté cette approche plus transparente. Les la diffusion publique peut améliorer la confiance et la participation du public, tenir les facultés responsables de l'amélioration continue de la qualité et catalyser une culture de collaboration au sein de l'écosystème élargi de la formation médicale. Inviter les patients et le public à scruter l'une des étapes les plus formative fondamentale de la formation professionnelle de leurs médecins est un puissant outil pour les parties prenantes ainsi que pour susciter la participation du public. Il reste à l'utiliser dans la communauté d'éducation médicale nord-américaine.

The current utility and future use of the medical student performance record: A survey of perceptions across Canada.

INTRODUCTION: The MSPR is a Canada wide tool that provides aggregate information on MD students' performance during training and used widely as part of PG admissions. This survey study elicits the perceptions of PG admissions stakeholders on the current use and future utility of the MSPR in Canada. METHODS: PG admissions stakeholders across the faculties of medicine were convenience sampled for a 15-question online survey in the fall of 2018. Participants were asked how and when the MSPR is incorporated into the admissions process and perceptions and recommendations for improvement. Data are summarized descriptively and thematically. RESULTS: Responses came from 164 participants across the 17 faculties of medicine. The MSPR was widely used (92%), most commonly in the file review process (52%) for professionalism issues. The majority of responses indicated that MSPRs were not fair for all MD students (60%) and required revision (74%) with greater emphasis required on transparency, professionalism, and narrative comments. DISCUSSION: The results indicate that though MSPRs are widely used in PG admissions their perceived value is limited to a few specific sources of information and to specific parts of the admissions process. There are significant concerns from PG stakeholders on the utility of MSPRs and future changes should align with the needs of these stakeholders while balancing the concerns of students and undergraduate programs.

INTRODUCTION: Le DREM est un outil pancanadien qui procure des renseignements regroupés sur le rendement des étudiants en médecine lors de la formation et il est largement utilisé dans le cadre des admissions post-doctorales. Cette étude par sondage révèle les perceptions des parties prenantes dans les admissions aux études médicales post-doctorales sur l'utilisation actuelle et l'utilité future du DREM au Canada. MÉTHODES: Les parties prenantes impliquées dans les admissions aux études médicales post-doctorales de l'ensemble des facultés de médecine ont été échantillonnés par convenance pour un sondage en ligne de 15 questions à l'automne 2018. Nous avons demandé aux participants comment et quand le DREM est intégré dans le processus d'admission et leurs perceptions et recommandations pour des améliorations. Les données sont résumées de manière descriptive par thèmes. RÉSULTATS: Les réponses proviennent de 164 participants provenant des 17 facultés de médecine. Le DREM a été largement utilisé (92 %) plus communément dans le processus d'examen du dossier (52 %) pour des questions de professionnalisme. La plupart des réponses indiquaient que les DREM n'étaient pas justes pour tous les étudiants en médecine (60 %) et nécessitaient une révision (74 %) avec une attention particulière sur la transparence, le professionnalisme et les commentaires narratifs. DISCUSSION: Les résultats indiquent que bien que les DREM soient largement utilisés dans l'admission aux études médicales post-doctorales, leur valeur perçue est limitée à quelques sources particulières de renseignements et à des parties précises du processus d'admission. Il existe des préoccupations importantes des parties prenantes aux études post-doctorales sur l'utilité des DREM et les changements futurs devraient correspondre aux besoins de ces parties prenantes, tout en équilibrant les préoccupations des étudiants et des programmes de premier cycle.

"Disadvantaged patient populations": A theory-informed education needs assessment in an urban teaching hospital.

BACKGROUND: Recent calls in medical education and health care emphasize equitable care for disadvantaged patient populations (DPP), with education highlighted as a key mechanism toward this goal. As a first step in understanding potential education needs we wanted to better understand the DPP concept. METHODS: Framed as a critical needs assessment, we used a critical discourse analysis approach to explore the meanings and effects of DPP. We analyzed transcripts from 15 focus groups with trainees, staff and patients. RESULTS: We identified three main assumptions about DPP: 1) disadvantaged patients require care above what is normal; 2) the system is to blame for failures in serving disadvantaged patients; and 3) labeling patients is problematic and stigmatizing. Patients appreciated that the DPP concept opened up better access to care, but also felt 'othered' by the concept. As a result, patients felt they were not accessing the same level of care in terms of compassion and respect. CONCLUSION: We must define access beyond ability to receive services; access must also engender a sense of common humanity and respect. With this aim, we suggest three, theory-informed educational approaches to help improve care for DPP: 1) sharing authentic and varied stories; 2) fostering dialogue; 3) aligning assessment and educational approaches.

CONTEXTE: Des préoccupations récentes en éducation médicale et ensanté mettent l'accent sur les soins équitables dispensés auprès des Patients issus de Populations Défavorisés (PPD). Dans ce contexte, l'éducation est mise de l'avant comme un mécanisme clé dans l'atteinte de cet objectif. Comme première étape dans la compréhension des besoins potentiels en éducation, nous voulions mieux comprendre ce que recouvre le concept de PPD. MÉTHODES: Présentée comme une évaluation critique des besoins, nous avons utilisé une approche d'analyse du discours critique pour explorer les significations et les effets des PPD. Nous avons analysé les transcriptions de quinze groupes de discussion avec des stagiaires, du personnel et des patients. RÉSULTATS: Nous avons repéré trois suppositions principales au sujet des PPD : 1) les patients défavorisés nécessitent davantage de soins que la normale; 2) le système est à l'origine des défaillances à servir les patients défavorisés; et 3) l'étiquetage des patients est problématique et stigmatisant. Les patients ont aimé que le concept des PPD procure un meilleur accès aux soins, mais ils se sont sentis également « exclus ¼ par les paramètres du concept. En conséquence, les patients estimaient qu'ils ne recevaient pas le même niveau de soins en matière de compassion et de respect. CONCLUSIONS: Nous devons définir l'accès au-delà de la capacité de recevoir des services; l'accès doit également engendrer un sens d'humanité commune et de respect. Dans ce but, nous suggérons trois démarches pédagogiques éclairées par la théorie pour aider à améliorer les soins aux PPD : 1) partager des histoires authentiques et variées; 2) promouvoir le dialogue; 3) aligner les démarches d'évaluation et d'enseignement.

Thirty-Five Years Later: HIV Stigma in Washington, DC Health Care Workers.

Stigma has negatively influenced the lives of people living with HIV since the beginning of the epidemic. It affects every facet of their lives and can cause mental health problems, loss of human rights, and barriers to care. Studies in developing countries have shown a high prevalence of HIV stigma among health care workers. Few studies have been conducted in the United States. We used a validated instrument to survey 330 health care workers in Washington, DC, a high HIV prevalence area. The goal was to obtain data to assess the severity of the problem. We found that stigmatizing beliefs and attitudes were prevalent as reflected in responses from 66% of the participants. Of clinicians surveyed, 31% reported using double gloves. Participants with stigma training had lower stigma levels, whereas older individuals and support staff were more stigmatizing. Negative attitudes affect access to care and have major public health implications.

The alignment imperative in curriculum renewal.

RATIONALE: There are perennial calls for MD curricula to reform in order to meet the changing needs of students, patients, and society. And yet, efforts at renewal have also been suggested to have minimal impact on the pedagogy and outcomes of medical education. One reason may be misalignment between the components of the curriculum during design and implementation. The University of Toronto MD program recently renewed its undergraduate preclinical Foundations curriculum. Mindful of the pitfalls of misalignment, the renewal process focused deliberately on alignment between the various components of the curriculum: instructional methods, student assessment, faculty development, and the larger purpose of serving students and society. INNOVATION: Educational evidence was used to drive the alignment process which resulted in three major changes. First, we created a spiral curriculum centered on 72 virtual patient cases designed to integrate content and prepare students for clinical learning. Second, we introduced a novel medical psychiatry component to address a core societal need in mental health. This exposed students early to experiences of complexity, ambiguity, and integrated patient care. Lastly, a shift to assessment for learning and programmatic assessment was designed and implemented concurrently to reinforce the pedagogy of the curriculum. Synchronous faculty development was developed for the new roles required of faculty. CONCLUSIONS: Early program evaluation shows alignment of these curricular components requires ongoing attention and resources in order to be successful. The potential benefits of this alignment are well prepared students who can meet the needs of their patients and society in an increasingly complex health system.

Simulation as a toolkit-understanding the perils of blood transfusion in a complex health care environment.

BACKGROUND: Administration of blood is a complex process requiring vigilance and effective teamwork. Despite strict policies and training on blood administration, errors still occur and can lead to mistransfusion with adverse patient outcomes. We used an in situ simulated scenario within an operating room (OR) to identify weaknesses in the current process and hazards that could contribute to mistransfusion. METHODS: A process checklist of critical steps of safe transfusion was developed based on a large academic centre's internal hospital policy and practice. Ten standardized operating room scenarios were conducted involving management of postoperative bleeding. Scenarios lasted 20 min or until blood transfusion was started. Debriefing followed immediately. Video recordings were reviewed, scored, and evaluated for team performance. Latent safety threats were identified. Focus groups further helped to identify rationale for decisions made. Participants completed questionnaires to evaluate the exercise. RESULTS: Forty-three experienced OR professionals participated. Of the 19 steps identified as essential for the safe administration of blood components, the median number of steps correctly completed per team was 11. The largest number of errors occurred when different team members interacted and during the immediate pre-transfusion check. We report that this type of learning immediately increased participants' self-reported ability to perform in a team (90%) and to improve clinical care (88%). CONCLUSIONS: In situ simulation is valuable in identifying common susceptibilities in blood administration error in a complex healthcare organization. Administrators and clinicians may wish to use simulation as an opportunity for system improvement in the delivery of quality care.

Hydroxyurea and growth in young children with sickle cell disease.

BACKGROUND: Growth impairment is a known complication of sickle cell disease. Effects of hydroxyurea (HU) on growth in very young children are not known. METHODS: Height, weight, BMI, and head circumference (HC) were compared with World Health Organization (WHO) standards in BABY HUG, a multicenter, randomized, double-blinded, placebo-controlled 2-year clinical trial of HU in 193 children 9 to 18 months of age. Anthropometric data were closely monitored and converted to z scores by using WHO standardized algorithms for descriptive analyses. The treatment and placebo groups were compared longitudinally by using a mixed model analysis. RESULTS: At entry, the z scores of BABY HUG children were higher than WHO norms. After 2 years of HU or placebo treatment, there were no significant differences between the groups, except for the mean HC z scores at study exit (HU: +0.8 versus placebo: +1.0, P = .05). Baseline z scores were the best predictors of z scores at study exit. The absolute neutrophil count, absolute reticulocyte count, and total white blood cell count had significant negative correlations with growth measures. CONCLUSIONS: Both groups had normal or near normal anthropometric measures during the study. The HC z scores at study entry and exit were slightly greater than WHO norms. Higher baseline white blood cell count, absolute reticulocyte count, and absolute neutrophil count were associated with poorer growth. The significance of the slightly lower HC in the treatment group at study exit is not clear. Trends toward normalization of weight and height and effects on HC will be monitored in ongoing BABY HUG follow-up studies.

From theory to pamphlet: the 3Ws and an H process for the development of meaningful patient education resources.

There is growing recognition of the importance of patient education given the prevalence and consequences of low health literacy in Canada and the USA. Research has shown that in addition to plain language, the use of theories of learning can contribute to the effectiveness of patient education resources, and as such, various guidelines and toolkits have been put together to help healthcare providers utilize these theories. Despite these efforts, this knowledge is not consistently applied in practice. To address this gap, we describe a new theory-based protocol, the "3Ws and an H," that is designed to guide healthcare providers in the production of effective patient education resources. Adult learning theory underpins each step of the process, and by using the "3Ws and an H," relevant theories are applied as the steps of the protocol are followed. To facilitate the adoption of this process, we describe it using a resource development project for survivors of endometrial cancer as an example.

Obtaining vascular access in the obese patient population.

Obese patients are a highly specialized population to manage within the health care system. Excess weight contributes to changes in patients' anatomy and physiology. Specialized equipment, including vascular access devices, is required to accommodate their needs. Research has shown that traditional methods of obtaining vascular access can prove unfruitful in the obese patient population. Choosing the most appropriate device in conjunction with practicing the most effective technique will improve vascular access outcomes for obese patients.

Chest compressions performed by ED staff: a randomized cross-over simulation study on the floor and on a stretcher.

BACKGROUND: Multiple factors may contribute to the observed survival variability following in-hospital cardiopulmonary resuscitation (CPR). While in-hospital CPR is most often performed on patients lying on a bed or stretcher, CPR training uses primarily manikins placed on the floor. We analyzed the quality of external chest compressions (ECC) in simulated cardiac arrest scenarios occurring both on a stretcher and on the floor. METHODS: Prospective cross-over simulation study enrolling ED nurses and nurse's aides as part of an annual evaluation. Simulated CPR was performed in the 2 rescuer-mode for 2 min, both kneeling on the floor, and standing beside a knee high stretcher. The order of position was randomized. ECC parameters were compared. RESULTS: ED nurses (n=48) and nurse's aides (n=26) performed 128 scenarios. Mean ECC depth was 32 ± 13 mm on the floor and 27 ± 11 mm on a stretcher (∆: 5 mm, 95%CI [3-7], P<.001). Participants last trained within a year (n=17) developed deeper ECCs than their colleagues (n=47) in both positions (floor: 39 ± 12 mm vs stretcher: 34 ± 11 mm (p=0.016) for those trained within the year, and floor: 29 ± 12 mm vs stretcher: 24 ± 10 mm (P<.001) for those trained over a year ago). CONCLUSIONS: The quality of chest compressions performed by ED staff was below 2005 guideline standards, with decreased ECC depth during CPR on a stretcher. Annual refresher courses should be implemented in the ED, with a focus on obtaining required ECC depth while standing next to a stretcher.

Guideline for the management of postoperative nausea and vomiting.

OBJECTIVE: To provide recommendations for the management of postoperative nausea and vomiting (PONV), which may affect as many as 30% of patients. METHODS AND EVIDENCE: Medline, PubMed, and the Cochrane Database were searched for articles published in English from 1995 to 2007. Recognizing that we must work as a team to optimize the care of our patients perioperatively, this guideline was written in partnership with anaesthesiologists. OPTIONS: The areas of clinical practice considered in formulating this guideline are prevention and prophylaxis, treatment, both medical and alternative, and patient education. OUTCOMES: Implementation of this guideline should optimize the prevention of and prophylaxis against PONV and the prompt treatment of women who suffer from PONV following gynaecologic surgery. Increased awareness of options for management should help minimize the effects of PONV. BENEFITS, HARMS, AND COSTS: PONV results not only in increased patient discomfort and dissatisfaction but also in increased costs related to length of hospital stay. Cost of medications to prevent and treat PONV must be weighed against improved surgical experience for the patient and decreased costs to the system. VALUES: Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.