Analyzing the Administrative Burden of Competency Based Medical Education.

PURPOSE: Postgraduate residency programs in Canada are transitioning to a competency-based medical education (CBME) system. Within this system, resident performance is documented through frequent assessments that provide continual feedback and guidance for resident progression. An area of concern is the perception by faculty of added administrative burden imposed by the frequent evaluations. This study investigated the time spent in the documentation and submission of required assessment forms through analysis of quantitative data from the Queen's University Diagnostic Radiology program. METHODS AND MATERIALS: Data regarding time taken to complete Entrustable Professional Activities (EPA) assessments was collected from 24 full-time and part-time radiologists over a period of 18 months. This data was analyzed using SPSS to determine mean time of completion by individuals, departments, and by experience with the assessment process. RESULTS: The average time taken to complete an EPA assessment form was 3 minutes and 6 seconds. Assuming 3 completed EPA assessment forms per week for each resident (n = 12) and equal distribution among all staff, this averaged out to an additional 18 minutes of administrative burden per staff member over a 4 week block. CONCLUSIONS: This study investigated the perception by faculty of additional administrative burden for assessment in the CBME framework. The data provided quantitative evidence of administrative burden for the documentation and submission of assessments. The data indicated that the added administrative burden may be reasonable given mandate for CBME implementation and the advantages of adoption for postgraduate medical education.

Diagnostic Errors: Association with level of expertise, effect of time taken to reach the diagnosis and utilization of differential diagnosis checklists among postgraduate trainees.

Objectives: The objectives of this study were to evaluate: (1) The association between level of training (expertise) and rate of diagnostic errors. (2) The effect of time taken to reach a diagnosis on the frequency of diagnostic errors. (3) The effect of utilization of differential diagnosis checklists in reducing the frequency of diagnostic errors. Methods: The study was carried out from November 2020 till April 2021 in Peshawar. The participants included FCPS Part-II trainees of Maxillofacial Surgery undergoing training in five centres. Thirty written case scenarios were prepared and validated, ten scenarios for each of the three objectives. To evaluate the association between training level (expertise) and the rate of diagnostic errors, two groups of trainees (1st year group and 4th year group) were formed and given ten same case scenarios for diagnosis. To evaluate the effect of time taken to reach diagnosis on the frequency of diagnostic errors, two groups of 4th year trainees (fast group and slow group) were formed by random allocation of participants to groups and given ten similar case scenarios for diagnosis. Fast group was given 15-minutes whereas slow group was given 30-minutes to respond. To evaluate the effect of utilization of differential diagnosis checklists in reducing diagnostic errors, again two groups of 4th year trainees were formed by random allocation of participants to groups and given ten similar case scenarios for diagnosis. One group was given differential diagnosis checklists for the scenarios and the other none. Results: In this study, participants included were 1st year (n=36) and 4th year (n=36) trainees of Maxillofacial Surgery. The results showed that training level or expertise was significantly associated with the rate of diagnostic errors (p = 0.002). Time taken to reach diagnosis and differential diagnosis checklists have no significant effect on the frequency of diagnostic errors (p = 0.74 and 0.56 respectively). Conclusions: Training level (expertise) has significant effect on the frequency of diagnostic errors whereas no significant effect was recorded for time (time taken to reach diagnosis) and differential diagnosis checklists on the rate of diagnostic errors.

Comparative analysis on efficiency and accuracy of parallel confocal microscopy and three-dimensional in motion video with triangulation technology-based intraoral scanner under influence of moisture and mouth opening - A crossover clinical trial.

Aim: The intraoral scanners are digital devices used to digitise the oral tissues. The accuracy of the intraoral scanners has been studied under different environmental conditions, but there might be differences that occur in the actual oral environment, which is still in question. The aim of the study was to evaluate the accuracy and efficiency of Parallel Confocal Microscopy and 3D in motion video with triangulation technology-based intraoral scanners under the influence of moisture and mouth opening. Settings and Design: This was an Cross over clinical controlled study. Materials and Methods: The controlled in vivo study included healthy subjects who were in need of CBCT for the purpose of locating the position of unerupted third molars before going abroad for a job. The subjects were exposed to scans in the upper and lower jaws with two intraoral scanners based on 3D motion video technology with triangulation (Medit) and parallel confocal microscopy (Trios) under the influence of two oral conditions, which were moisture (presence and absence of moisture) and mouth opening (30 mm and 50 mm, respectively). A total of 96 scans were obtained and superimposed individually over the reference CBCT scans to find the deviations in the Geomagic Rapidform (version 2020, USA) software. The efficiency of the scanners was calculated by recording the time taken and the number of images obtained after each scan. Statistical Analysis Used: The significance was calculated by using the independent and paired sample t test in SPSS software (IBM, version 23). Results: Based on the surface analysis, the trueness of the intra-oral scanners had statistically significant differences when compared between 3D in motion video technology with Triangulation and Parallel Confocal Microscopy (P < 0.05) whereas no statistical significance was observed in precision. There was a significant difference observed in the efficiency of the intra-oral scanners (P < 0.05). Conclusion: There is a significant difference in the accuracy and efficiency of the intraoral scanners under the influence of oral conditions, such as different moisture levels and mouth opening conditions. 3D in motion video technology with Triangulation showed better results with the least deviation than Parallel Confocal Microscopy.

Doffing Corridor: Establishing Expedited High-Volume Doffing With Exposure Reduction to Contaminated Personal Protective Equipment (PPE) in a COVID-19 Hospital in India.

Background Considering the virulent nature of the COVID-19, the safety of healthcare workers (HCW) became a challenge for hospital administrators. Wearing a personal protective equipment (PPE) kit, called donning, which can be easily done by the help of another staff. But correctly removing the infectious PPE kit (doffing) was a challenge. The increased number of HCWs for COVID-19 patient care raised the opportunity to develop an innovative method for the smooth doffing of PPEs. Objective We aimed to design and establish an innovative PPE doffing corridor in a tertiary care COVID-19 hospital during the pandemic in India with a heavy doffing rate and minimize the COVID-19 virus spread among healthcare workers. Methodology A prospective, observational cohort study at the COVID-19 hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, was conducted from July 19, 2020, to March 30, 2021. The time taken for PPE doffing process of HCWs was observed and compared between the doffing room and doffing corridor. The data was collected by a public health nursing officer using Epicollect5 mobile software and Google forms. The following parameters, like grade of satisfaction, time and volume of doffing, the errors in the steps of doffing, rate of infection, were compared between the doffing corridor and the doffing room. The statistical analysis was done by the use of SPSS software. Result 'Doffing corridor' decreased the overall doffing time by 50% compared to the initial doffing room. The doffing corridor solved the purpose of accommodating more HCWs for PPE doffing and an overall saving of 50% time. Fifty-one percent of HCWs rated the satisfaction rate as Good in the grading scale. The errors in the steps of doffing that occurred in the doffing process were comparatively lesser in the doffing corridor. The HCWs who doffed in the doffing corridor were three times less likely to get self-infection than the conventional doffing room. Conclusion Since COVID-19 was a new pandemic, the healthcare organizations focused on innovations to combat the spread of virus. One of these was an innovative doffing corridor to expedite the doffing process and decrease the exposure time to the contaminated items. The doffing corridor process can be considered at a high-interest rate to any hospital dealing with infectious disease, with high working satisfaction, less exposure to the contagion, and less risk of infection.

Is It Feasible to Conduct Post-Tuberculosis Assessments at the End of Tuberculosis Treatment under Routine Programmatic Conditions in China?

There is growing evidence that a substantial proportion of people who complete anti-tuberculosis treatment experience significant morbidity and mortality which can negatively affect their quality of life. It is suggested that national tuberculosis programs conduct end-of-treatment assessments, but whether this is feasible is currently not known. We therefore assessed whether tuberculosis program staff could assess functional and general health status of patients at the end of treatment in five TB clinics in four provinces in China. There were 115 patients, aged 14-82 years, who completed anti-tuberculosis treatment and a post-TB assessment. There were 54 (47%) patients who continued to have symptoms, the commonest being cough, dyspnea and fatigue. Symptom continuation was significantly more common in the 22 patients with diabetes (p = 0.027) and the 12 patients previously treated for TB (p = 0.008). There were 12 (10%) current smokers, an abnormal chest X-ray was found in 106 (92%) patients and distance walked in the 6-min walking test (6MWT) ranged from 30-750 m (mean 452 ± 120); 24 (21%) patients walked less than 400 m. Time taken to perform the post-TB assessment, including the 6MWT, ranged from 8-45 min (mean 21 ± 8 min). In 98% of the completed questionnaires, health workers stated that conducting post-TB assessments was feasible and useful. This study shows that post-TB assessments can be conducted under routine programmatic conditions and that there is significant morbidity that needs to be addressed.

Parathyroid Frozen Section Interpretation via Desktop Telepathology Systems: A Validation Study.

BACKGROUND: Telepathology can potentially be utilized as an alternative to having on-site pathology services for rural and regional hospitals. The goal of the study was to validate two small-footprint desktop telepathology systems for remote parathyroid frozen sections. SUBJECTS AND METHODS: Three pathologists retrospectively diagnosed 76 parathyroidectomy frozen sections of 52 patients from three pathology services in Australia using the "live-view mode" of MikroScan D2 and Aperio LV1 and in-house direct microscopy. The final paraffin section diagnosis served as the "gold standard" for accuracy evaluation. Concordance rates of the telepathology systems with direct microscopy, inter-pathologist and intra-pathologist agreement, and the time taken to report each slide were analyzed. RESULTS: Both telepathology systems showed high diagnostic accuracy (>99%) and high concordance (>99%) with direct microscopy. High inter-pathologist agreement for telepathology systems was demonstrated by overall kappa values of 0.92 for Aperio LV1 and 0.85 for MikroScan D2. High kappa values (from 0.85 to 1) for intra-pathologist agreement within the three systems were also observed. The time taken per slide by Aperio LV1 and MicroScan D2 within three pathologists was about 3.0 times (P < 0.001, 95% confidence interval [CI]: 2.8-3.2) and 7.7 times (P < 0.001, 95% CI: 7.1-8.3) as long as direct microscopy, respectively, while MikroScan D2 took about 2.6 times as long as Aperio LV1 (P < 0.001, 95% CI: 2.4-2.7). All pathologists evaluated Aperio LV1 as being more user-friendly. CONCLUSIONS: Telepathology diagnosis of parathyroidectomy frozen sections through small-footprint desktop systems is accurate, reliable, and comparable with in-house direct microscopy. Telepathology systems take longer than direct microscopy; however, the time taken is within clinically acceptable limits. Aperio LV1 takes shorter time than MikroScan D2 and is more user-friendly.

Preclinical efficacy and safety of rVIII-SingleChain (CSL627), a novel recombinant single-chain factor VIII.

INTRODUCTION: The preclinical efficacy and safety of rVIII-SingleChain (CSL627), a novel recombinant single-chain factor VIII, was assessed in a series of animal studies. MATERIALS AND METHODS: In the tail-clip bleeding model, hemophilia A mice were injected with escalating doses (1-150 IU/kg) of rVIII-SingleChain, B-domain deleted (BDD) rFVIII (ReFacto AF(®)), or full-length rFVIII products (Advate(®), Helixate(®)). Total blood loss and the percentage of animals in which hemostasis occurred were assessed in this observer-blinded, randomized study. In a second non-randomized study in hemophilia A mice, thromboelastographic analysis, thrombin generation, and activated partial thromboplastin time assays were performed. General safety and toxicity were assessed in three animal species, including determination of the prothrombotic potential of rVIII-SingleChain in a rabbit venous thrombosis model. RESULTS: Under acute bleeding conditions, the effect of rVIII-SingleChain on total blood loss and hemostasis was indistinguishable from BDD and full-length rFVIII. rVIII-SingleChain and full-length rFVIII (both 20 IU/kg) corrected thromboelastographic parameters, activated partial thromboplastin time, and thrombin generation to a similar degree in hemophilia A mice. In a thrombosis model, the effect of rVIII-SingleChain on thrombus incidence was non-significant and comparable to BDD rFVIII at doses up to 500 IU/kg. Treatment with rVIII-SingleChain did not cause anaphylactic reaction or local intolerance in safety and toxicity studies, and demonstrated an excellent overall safety profile. CONCLUSIONS: rVIII-SingleChain showed convincing hemostatic efficacy and excellent tolerability in animal studies, warranting continued investigation in human Phase I/III trials (AFFINITY).

Supersaturated polymeric micelles for oral cyclosporine A delivery.

Polymeric micelles provide a promising platform for improving oral absorption of poorly soluble drugs. However, improved understanding of how drug retention within the hydrophobic micelle core can reduce drug absorption is required. We designed supersaturated polymeric micelles (Super-PMs) to increase molecularly dissolved drug concentration and gain an insight into the effect of the degree of supersaturation on oral absorption of cyclosporine A (CsA) in rats. The drug release from Super-PMs increased with an increase in initial supersaturation degrees in micelles. The cellular uptake of coumarin-6 was reduced by the retention of drug in polymer micelles. The transport flux of CsA across Caco-2 monolayer was increased with initial supersaturation degrees of 0.81-3.53 (p < 0.05). However, increase in supersaturation to 5.64 actually resulted in decreased CsA transport. The same trend was observed in a rat in vivo absorption study, in which the highest bioavailability of 134.6 ± 24.7% (relative to a commercial product, Sandimmun Neoral®, p<0.01) was achieved when the supersaturation degree was 3.53. These results demonstrated that Super-PMs were a promising drug delivery system for compounds with low aqueous solubility. This study also provided an experimental proof for the hypothesis that moderately supersaturated formulations are valuable alternative to high supersaturation formulations, resulting in optimal in vivo performance, and the degree of supersaturation should be carefully controlled to optimize drug absorption.