The Basic Course Using GIAs: One Department’s Journey through the Ups and Downs of Establishing a Lecture/Lab Delivery Model for the Basic Communication Course

The basic communication course has many demands placed upon it—and in turn, places many demands on communication departments and their faculty and staff

Pediatric Hypertension - Insights into Etiology, Diagnosis and Progression of Target Organ Damage

Statement of Problem: Over the last several decades the prevalence of pediatric hypertension has increased fourfold, thought to be partially attributable to the concurrent rise in pediatric obesity. Hypertensive children are at increased cardiovascular disease risk as they often manifest other cardiovascular disease risk factors such as obesity, dyslipidemia, and insulin resistance. Further, up to 40% have target organ damage in the form of left ventricular hypertrophy at initial diagnosis. Left ventricular hypertrophy, a pathological remodeling of the heart thought to be secondary to increased left ventricular afterload as seen in hypertension, causes arrhythmias, heart failure and myocardial infarction in adults. Its striking prevalence at initial diagnosis suggests that elevated blood pressure detection and hypertension diagnosis in children may be delayed or because other factors, specifically obesity, play a more substantial role in its development among hypertensive children. Methods: We conducted two studies: 1) a pre-post evaluation of a quality improvement initiative to improve elevated blood pressure recognition among children and adolescents seen for primary care. The intervention consisted of a one-time provider educational session and implementation of an ongoing real-time electronic medical record alert; and 2) a prospective, observational study of hypertensive children to investigate the association of obesity and obesity-related risk factors with the presence of left ventricular hypertrophy and with the change in left ventricular mass over a 12-month period of anti-hypertensive therapy. Results: We found that recognition of elevated blood pressure among patients seen for pediatric primary care was poor overall but increased from 12.5% pre-intervention to 42% during the intervention period (p<0.001). Recognition was no different by educational session attendance status. During both pre-intervention and intervention periods, systolic BP ≥120mmHg was associated with greater recognition. However, the prevalence ratio (PR) was smaller in the intervention period: intervention PR 1.3, 95% confidence interval (CI) 1.2 – 1.5 (p<0.001) versus pre-intervention PR 2.4, 95% CI 1.4-3.9 (p=0.001). Similar relationships were observed for other cardiovascular disease risk factors. Acute care visit encounters were associated with decreased recognition in the intervention period (PR 0.6, 95% CI 0.5- 0.7; p<0.001). We also found a high prevalence of cardiovascular disease risk factors among children with hypertension: 51% were overweight/obese and 41% had left ventricular hypertrophy. Children with LVH had greater BMI z-score and BMI percentile, higher serum uric acid level, a lower serum lipoprotein (a) level and a greater pro-B natriuretic peptide level than those without LVH. There was no difference in multiple measures of blood pressure between those children with and without LVH. Children who were obese at both study visits experienced the greatest increase in LVMI over time: mean change in LVMI was 6.4 g/m2.7 (95% CI 2.4, 10.5) among those overweight or obese at each visit, vs. 0.95 g/m2.7 (95%CI -3.2, 5.1) among children who were of healthy weight at each visit (p=0.056). Overweight/obese children with and without LVH at baseline demonstrated a larger increase in LVMI compared to healthy weight children. Healthy weight children with LVH were the only ones with decreased LVMI over time. BMI z-score at baseline was positively associated with change in LVMI over time (β 4.08, 95% confidence interval 1.54, 6.61, p=0.002) during multivariable regression analyses adjusting for age, sex, race, and LVMI at baseline. The association remained essentially unchanged after sequential adjustment for postulated mediating pathways between BMI z-score and LVMI with the exception of pulse pressure and serum aldosterone. When added to the model, those two risk factors decreased the point estimate and p-value. Conclusion/Implications: Elevated blood pressure in children is largely unrecognized, and those with minimal to no additional cardiovascular disease risk factors are least likely to be recognized in a primary care setting. Real time electronic medical record alerts substantially increase provider recognition of elevated BP in children and hold considerable promise as a means to improve adherence to practice guidelines. These alerts particularly aid in the recognition of elevated blood pressure among those not at obvious cardiovascular disease risk. However, the persistence of under-recognition of elevated BP in children highlights the need for additional strategies to further improve provider recognition. Hypertensive children referred for subspecialty care demonstrate not only a high prevalence of co-morbid cardiovascular risk factors at baseline, but an increase in both their prevalence and severity over time. Most striking of these cardiovascular risk factors is the presence and substantial degree of overweight and obesity. In fact, adiposity as determined by body mass index z-score was the greatest risk factor for left ventricular hypertrophy and change in LVMI over time. None of the many measures of blood pressure assessed during this study were associated with the presence of LVH or with the change in LVMI over time. And, two risk factors potentially modified by diet - pulse pressure, a marker of intravascular volume, and serum aldosterone, a hormonal regulator of blood pressure – appeared to be the most important partial mediators of the relationship between adiposity and change in LVMI. These findings support the overwhelming public health concern regarding the obesity epidemic and suggest that greater emphasis on overweight and obesity prevention and treatment should be made among hypertensive children. Future Directions: Our work emphasizes the substantial prevalence of cardiovascular disease risk factors among children and adolescents. It also suggests that current population estimates of the burden of pediatric hypertension may underestimate the true prevalence as a substantial number of children with elevated blood pressure are unrecognized in a primary care setting. A common underlying theme to this increased CVD risk is overweight and obesity. Despite providing standard of care guidance on weight loss and adherence to a heart healthy diet, the children in our study became more overweight/obese and demonstrated an increase in number and severity of CVD risk factors over a year of observation. Enhanced preventive and therapeutic strategies targeting overweight and obesity in children holds significant promise as we work towards primordial and primary prevention of adult cardiovascular disease. Further research should test innovative interventions designed to assist youth with adherence to a heart healthy lifestyle and determine the effect of these interventions on cardiovascular disease risk factors

Developing a Research Mentorship Program: The American Society of Pediatric Nephrology's Experience

Background: Most pediatric nephrologists work in academia. Mentor-mentee relationships provide support and guidance for successful research career. Mentorship program implementation is valuable in medical fields for providing research opportunities to young faculty. Methods: The American Society of Pediatric Nephrology (ASPN) established a research mentorship program to (a) assist with matching of appropriate mentor-mentee dyads and (b) establish metrics for desirable mentor-mentee outcomes with two independent components: (1) the grants review workshop, a short-term program providing mentor feedback on grant proposals, and (2) the longitudinal program, establishing long-term mentor-mentee relationships. Regular surveys of both mentors and mentees were reviewed to evaluate and refine the program. Results: Twelve mentees and 17 mentors participated in the grant review workshop and 19 mentees were matched to mentors in the longitudinal program. A review of NIH RePORTER data indicated that since 2014, 13 NIH grants have been awarded. Mentees in the longitudinal program reported that the program helped most with identifying an outside mentor, improving grant research content, and with general career development. Mentors perceived themselves to be most helpful in assisting with overall career plans. Email communications were preferred over phone or face-to-face communications. Mentees endorsed strong interest in staying in touch with their mentors and 100% of mentors expressed their willingness to serve in the future. Conclusion: This mentorship program was initiated and supported by a relatively small medical society and has shown early success in cultivating mentoring relationships for a future generation of clinician-scientists

Pallium Canada's curriculum development model: A framework to support large-scale courseware development and deployment

The need to improve access to palliative care across multiple settings and disease groups has been identified. This requires equipping health care professionals from many different professions, including physicians and nurses, among others, with basic palliative care competencies to provide a palliative care approach. Pallium Canada’s Curriculum Development Framework supports the development, deployment, and dissemination, on a large scale, of multiple courses targeting health care professionals across multiple settings of care and disease groups. The Framework is made up of eight phases: (1) Concept, (2) Decision, (3) Curriculum Planning, (4) Prototype Development, (5) Piloting, (6) Dissemination, (7) Language and Cultural Adaptation, and (8) Ongoing Maintenance and Updates. Several of these phases include iterative cyclical activities. The framework allows multiple courses to be developed simultaneously, staggered in a production line with each phase and their corresponding activities requiring different levels of resources and stakeholder engagement. The framework has allowed Pallium Canada to develop, launch, and maintain numerous versions of its Learning Essential Approaches to Palliative Care (LEAP) courses concurrently. It leverages existing LEAP courses and curriculum materials to produce new LEAP courses, allowing significant efficiencies and maximizing output. This article describes the framework and its various activities, which we believe could be very useful for other jurisdictions undertaking the work of developing education programs to spread the palliative care approach across multiple settings, specialties, and disease groups

Improving the development, monitoring and reporting of stroke rehabilitation research: consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable (SRRR)

Recent reviews have demonstrated that the quality of stroke rehabilitation research has continued to improve over the last four decades but despite this progress there are still many barriers in moving the field forward. Rigorous development, monitoring and complete reporting of interventions in stroke trials are essential in providing rehabilitation evidence that is robust, meaningful and implementable. An international partnership of stroke rehabilitation experts committed to develop consensus-based core recommendations with a remit of addressing the issues identified as limiting stroke rehabilitation research in the areas of developing, monitoring and reporting stroke rehabilitation interventions. Work exploring each of the three areas took place via multiple teleconferences and a two-day meeting in Philadelphia in May 2016. A total of 15 recommendations were made. To validate the need for the recommendations the group reviewed all stroke rehabilitation trials published in 2015 (n=182 papers). Our review highlighted that the majority of publications did not clearly describe how interventions were developed or monitored during the trial. In particular, under-reporting of the theoretical rationale for the intervention and the components of the intervention calls into question many interventions that have been evaluated for efficacy. More trials were found to have addressed the reporting of interventions recommendations than those related to development or monitoring. Nonetheless the majority of reporting recommendations were still not adequately described. To progress the field of stroke rehabilitation research and to ensure stroke patients receive optimal evidence based clinical care we urge the research community to endorse and adopt our recommendations

The 2020 “WHO technical specifications for automated non-invasive blood pressure measuring devices with cuff”

High systolic blood pressure (BP) is the single leading modifiable risk factor for death worldwide. Accurate BP measurement is the cornerstone for screening, diagnosis, and management of hypertension. Inaccurate BP measurement is a leading patient safety challenge. A recent World Health Organization report has outlined the technical specifications for automated noninvasive clinical BP measurement with cuff. The report is applicable to ambulatory, home, and office devices used for clinical purposes. The report recommends that for routine clinical purposes, (1) automated devices be used, (2) an upper arm cuff be used, and (3) that only automated devices that have passed accepted international accuracy standards (eg, the International Organization for Standardization 81060-2; 2018 protocol) be used. Accurate measurement also depends on standardized patient preparation and measurement technique and a quiet, comfortable setting. The World Health Organization report provides steps for governments, manufacturers, health care providers, and their organizations that need to be taken to implement the report recommendations and to ensure accurate BP measurement for clinical purposes. Although, health and scientific organizations have had similar recommendations for many years, the World Health Organization as the leading governmental health organization globally provides a potentially synergistic nongovernment government opportunity to enhance the accuracy of clinical BP assessment.The 2020 “WHO Technical Specifications for Automated Non-Invasive Blood Pressure Measuring Devices With Cuff” was supported financially by the World Health Organization and Resolve to Save Lives. O. John is a recipient of Australia University International Postgraduate Awards scholarship from University of New South Wales, Sydney. T.M. Brady received support from Resolve to Save Lives, which is funded by Bloomberg Philanthropies, the Bill and Melinda Gates Foundation, and Gates Philanthropy.http://hyper.ahajournals.orgam2022School of Health Systems and Public Health (SHSPH

The urgency to regulate validation of automated blood pressure measuring devices: a policy statement and call to action from the world hypertension league

No abstract available

Genetic mechanisms of critical illness in COVID-19.

Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 × 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 × 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 ×  10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 × 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice