Implementation of Critical Threshold Concept in Clinical Transplantation: A New Horizon in Distance Learning

While variations in medical practice are a norm and each patient poses a multitude of challenges, many clinicians are not comfortable in dealing with unexpected complex issues even though they may have enough knowledge as demonstrated by passing a number of tricky certifying (or exit) examinations. One reason for the lack of self-efficacy, even if being endowed with good knowledge, is that we are not good in learning from errors. A regular reflective practice offers superb learning opportunities when a clinician is “stuck in a mire”. Difficult clinical situations warrant a flexible and, at the same time, an evidence-based approach to ensure that crucial decision-making process is correct and efficient. Each clinical case offers a great opportunity to reinforce these “threshold concepts”, however, not everyone of us is “blessed” with these crucial not-so-difficult-to-acquire skills so necessary to be a life-long learner. The faculty of this course (a totally on-line MSc in Transplant Sciences) aims for unceasing engagement with students in order to facilitate them to negotiate through “stuck places” and “tricky bends” in their own work place. This course, not just meant for knowledge transfer, provides a platform that allows participants (the students and faculty) to learn from each other’s experience by using “e-blackboard”. The mainstay of this course are twofold: (a) Emphasis on achieving critical decision-making skills, (b) Regular feedback to allow reflective practice and, thereby, constantly learning from errors and reinforcing good practices. The aim of this article is to assess the performance of educators and how well the “ethos of critical threshold” has been accepted from the perspective of students. Methods: The critical thresholds of each chapter in 4 modules of this totally on-line course were defined to a razor-sharp precision. Learning objectives of learning activity were defined to achieve constructive alignment with critical threshold. We employed level 1, 2, 4 and 5 of Kirkpatrick pyramid, (a) for the evaluation of performance of educators of program, and (b) to evaluate the acceptance of this non-traditional format in clinical medicine education by postgraduate 80 students in 22 countries. Results: Students’ survey (Kirkpatrick level 1) was done only for module 1 of cohort 1 reported students’ satisfaction rate of 93%. Excluding a total of 12 drop-outs in 2 modules (n=10 in first cohort’s module 1, and n=2 in module 2), as many as 93% of students of first cohort passed module. Nine out of 60 registrants of module 1 in 2nd cohort took recess for one year requesting to join back as a part of 3rd cohort commencing one year later, all 51 who continued passed though 3 of them had to resit. All those who passed module 1 (both cohorts) and 2 (1st cohort) registered for their respective next module (return on investment Kirkpatrick level 5). Conclusion: For a successful model in distance learning in clinical transplantation it is imperative for the students to accomplish well defined “critical-decision making” skills. In order to learn critical thresholds, a regular feedback is integral to learning from reflective practice. This course equips the students to develop skills of negotiating “sticky mire”, as obvious from perceived high return of investment

Efficacy and cost-effectiveness of a community-based model of care for older patients with complex needs: A study protocol for a multicentre randomised controlled trial using a stepped wedge cluster design

© 2018 The Author(s). Background: Community-dwelling older persons with complex care needs may deteriorate rapidly and require hospitalisation if they receive inadequate support for their conditions in the community. Intervention: A comprehensive, multidimensional geriatric assessment with care coordination was performed in a community setting - Older Persons ENablement And Rehabilitation for Complex Health conditions (OPEN ARCH). Objectives: This study will assess the acceptability and determine the impact of the OPEN ARCH intervention on the health and quality of life outcomes, health and social services utilisation of older people with multiple chronic conditions and emerging complex care needs. An economic evaluation will determine whether OPEN ARCH is cost-effective when compared to the standard care. Methods/design: This multicentre randomised controlled trial uses a stepped wedge cluster design with repeated cross-sectional samples. General practitioners (GPs; n ≥ 10) will be randomised as 'clusters' at baseline using simple randomisation. Each GP cluster will recruit 10-12 participants. Data will be collected on each participant at 3-month intervals (- 3, 0, 3, 6 and 9 months). The primary outcome is health and social service utilisation as measured by Emergency Department presentations, hospital admissions, in-patient bed days, allied health and community support services. Secondary outcomes include functional status, quality of life and participants' satisfaction. Cost-effectiveness of the intervention will be assessed as the change to cost outcomes, including the cost of implementing the intervention and subsequent use of services, and the change to health benefits represented by quality adjusted life years. Discussion: The results will have direct implications for the design and wider implementation of this new model of care for community-dwelling older persons with complex care needs. Additionally, it will contribute to the evidence base on acceptability, efficacy and cost-effectiveness of the intervention for this high-risk group of older people. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12617000198325p. Registered on 6 February 2017

The Mouse Genome Database: enhancements and updates

The Mouse Genome Database (MGD) is a major component of the Mouse Genome Informatics (MGI, http://www.informatics.jax.org/) database resource and serves as the primary community model organism database for the laboratory mouse. MGD is the authoritative source for mouse gene, allele and strain nomenclature and for phenotype and functional annotations of mouse genes. MGD contains comprehensive data and information related to mouse genes and their functions, standardized descriptions of mouse phenotypes, extensive integration of DNA and protein sequence data, normalized representation of genome and genome variant information including comparative data on mammalian genes. Data for MGD are obtained from diverse sources including manual curation of the biomedical literature and direct contributions from individual investigator’s laboratories and major informatics resource centers, such as Ensembl, UniProt and NCBI. MGD collaborates with the bioinformatics community on the development and use of biomedical ontologies such as the Gene Ontology and the Mammalian Phenotype Ontology. Recent improvements in MGD described here includes integration of mouse gene trap allele and sequence data, integration of gene targeting information from the International Knockout Mouse Consortium, deployment of an MGI Biomart, and enhancements to our batch query capability for customized data access and retrieval

Let's CHAT (community health approaches to) dementia in Aboriginal and Torres Strait Islander communities: protocol for a stepped wedge cluster randomised controlled trial

Background: Documented rates of dementia and cognitive impairment not dementia (CIND) in older Aboriginal and Torres Strait Islander Peoples is 3–5 times higher than the rest of the population, and current evidence suggests this condition is under-diagnosed and under-managed in a clinical primary care setting. This study aims to implement and evaluate a culturally responsive best practice model of care to optimise the detection and management of people with cognitive impairment and/or dementia, and to improve the quality of life of carers and older Aboriginal and Torres Islander Peoples with cognitive impairment. Methods/design: The prospective study will use a stepped-wedge cluster randomised controlled trial design working with 12 Aboriginal Community Controlled Health Services (ACCHSs) across four states of Australia. Utilising a co-design approach, health system adaptations will be implemented including (i) development of a best practice guide for cognitive impairment and dementia in Aboriginal and Torres Strait Islander communities (ii) education programs for health professionals supported by local champions and (iii) development of decision support systems for local medical software. In addition, the study will utilise a knowledge translation framework, the Integrated Promoting Action on Research Implementation in Health Services (iPARIHS) Framework, to promote long-term sustainable practice change. Process evaluation will also be undertaken to measure the quality, fidelity and contextual influences on the outcomes of the implementation. The primary outcome measures will be rates of documentation of dementia and CIND, and evidence of improved management of dementia and CIND among older Indigenous peoples attending Aboriginal and Torres Strait Islander primary care services through health system changes. The secondary outcomes will be improvements to the quality of life of older Indigenous peoples with dementia and CIND, as well as that of their carers and families. Discussion: The Let’s CHAT Dementia project will co-design, implement and evaluate a culturally responsive best practice model of care embedded within current Indigenous primary health care. The best practice model of care has the potential to optimise the timely detection (especially in the early stages) and improve the ongoing management of people with dementia or cognitive impairmentKate Bradley, Robyn Smith, Jo-anne Hughson, David Atkinson, Dawn Bessarab, Leon Flicker ... et al

LSD1 inhibition attenuates androgen receptor V7 splice variant activation in castration resistant prostate cancer models

Background: Castrate resistant prostate cancer (CRPC) is often driven by constitutively active forms of the androgen receptor such as the V7 splice variant (AR-V7) and commonly becomes resistant to established hormonal therapy strategies such as enzalutamide as a result. The lysine demethylase LSD1 is a co-activator of the wild type androgen receptor and a potential therapeutic target in hormone sensitive prostate cancer. We evaluated whether LSD1 could also be therapeutically targeted in CRPC models driven by AR-V7. Methods: We utilised cell line models of castrate resistant prostate cancer through over expression of AR-V7 to test the impact of chemical LSD1 inhibition on AR activation. We validated findings through depletion of LSD1 expression and in prostate cancer cell lines that express AR-V7. Results: Chemical inhibition of LSD1 resulted in reduced activation of the androgen receptor through both the wild type and its AR-V7 splice variant forms. This was confirmed and validated in luciferase reporter assays, in LNCaP and 22Rv1 prostate cancer cell lines and in LSD1 depletion experiments. Conclusion: LSD1 contributes to activation of both the wild type and V7 splice variant forms of the androgen receptor and can be therapeutically targeted in models of CRPC. Further development of this approach is warranted