Meta-Techniques for Faculty Development: A Continuous Improvement Model for Building Capacity to Facilitate in a Large Interprofessional Program

Literature regarding faculty development in uniprofessional healthcare programs is prolific; however, little has been written about instructional programs designed for faculty delivering interprofessional education (IPE). In this paper, we describe the genesis, content, and improvement of a faculty development workshop which exemplifies a meta teaching model and was designed to serve faculty facilitators in a rapidly growing IPE program. Evaluations following initial delivery of the workshops in fall 2018 returned high faculty satisfaction ratings and feedback suggesting a need for even more pedagogical training with a stronger emphasis on meta techniques and less on a review of student content. In response, program developers incorporated additional teaching techniques in the spring 2019 training. Faculty evaluations in spring 2019 reflected even greater satisfaction with the increased focus on “meta skills”. The faculty development program described in this paper supports the need for a structured training process for faculty facilitating in IPE programs

Aspirin for prophylactic use in the primary prevention of cardiovascular disease and cancer : a systematic review and overview of reviews

Background: Prophylactic aspirin has been considered to be beneficial in reducing the risks of heart disease and cancer. However, potential benefits must be balanced against the possible harm from side effects, such as bleeding and gastrointestinal (GI) symptoms. It is particularly important to know the risk of side effects when aspirin is used as primary prevention - that is when used by people as yet free of, but at risk of developing, cardiovascular disease (CVD) or cancer. In this report we aim to identify and re-analyse randomised controlled trials (RCTs), systematic reviews and meta-analyses to summarise the current scientific evidence with a focus on possible harms of prophylactic aspirin in primary prevention of CVD and cancer. Objectives: To identify RCTs, systematic reviews and meta-analyses of RCTs of the prophylactic use of aspirin in primary prevention of CVD or cancer. To undertake a quality assessment of identified systematic reviews and meta-analyses using meta-analysis to investigate study-level effects on estimates of benefits and risks of adverse events; cumulative meta-analysis; exploratory multivariable meta-regression; and to quantify relative and absolute risks and benefits. Methods: We identified RCTs, meta-analyses and systematic reviews, and searched electronic bibliographic databases (from 2008 September 2012) including MEDLINE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, NHS Centre for Reviews and Dissemination, and Science Citation Index. We limited searches to publications since 2008, based on timing of the most recent comprehensive systematic reviews. Results: In total, 2572 potentially relevant papers were identified and 27 met the inclusion criteria. Benefits of aspirin ranged from 6% reduction in relative risk (RR) for all-cause mortality [RR 0.94, 95% confidence interval (CI) 0.88 to 1.00] and 10% reduction in major cardiovascular events (MCEs) (RR 0.90, 95% CI 0.85 to 0.96) to a reduction in total coronary heart disease (CHD) of 15% (RR 0.85, 95% CI 0.69 to 1.06). Reported pooled odds ratios (ORs) for total cancer mortality ranged between 0.76 (95% CI 0.66 to 0.88) and 0.93 (95% CI 0.84 to 1.03). Inclusion of the Women's Health Study changed the estimated OR to 0.82 (95% CI 0.69 to 0.97). Aspirin reduced reported colorectal cancer (CRC) incidence (OR 0.66, 95% CI 0.90 to 1.02). However, including studies in which aspirin was given every other day raised the OR to 0.91 (95% CI 0.74 to 1.11). Reported cancer benefits appeared approximately 5 years from start of treatment. Calculation of absolute effects per 100,000 patient-years of follow-up showed reductions ranging from 33 to 46 deaths (all-cause mortality), 60-84 MCEs and 47-64 incidents of CHD and a possible avoidance of 34 deaths from CRC. Reported increased RRs of adverse events from aspirin use were 37% for GI bleeding (RR 1.37, 95% CI 1.15 to 1.62), between 54% (RR 1.54, 95% CI 1.30 to 1.82) and 62% (RR 1.62, 95% CI 1.31 to 2.00) for major bleeds, and between 32% (RR 1.32, 95% CI 1.00 to 1.74) and 38% (RR 1.38, 95% CI 1.01 to 1.82) for haemorrhagic stroke. Pooled estimates of increased RR for bleeding remained stable across trials conducted over several decades. Estimates of absolute rates of harm from aspirin use, per 100,000 patient-years of follow-up, were 99-178 for non-trivial bleeds, 46-49 for major bleeds, 68-117 for GI bleeds and 8-10 for haemorrhagic stroke. Meta-analyses aimed at judging risk of bleed according to sex and in individuals with diabetes were insufficiently powered for firm conclusions to be drawn. Limitations: Searches were date limited to 2008 because of the intense interest that this subject has generated and the cataloguing of all primary research in so many previous systematic reviews. A further limitation was our potential over-reliance on study-level systematic reviews in which the person-years of follow-up were not accurately ascertainable. However, estimates of number of events averted or incurred through aspirin use calculated from data in study-level meta-analyses did not differ substantially from estimates based on individual patient data-level meta-analyses, for which person-years of follow-up were more accurate (although based on less-than-complete assemblies of currently available primary studies). Conclusions: We have found that there is a fine balance between benefits and risks from regular aspirin use in primary prevention of CVD. Effects on cancer prevention have a long lead time and are at present reliant on post hoc analyses. All absolute effects are relatively small compared with the burden of these diseases. Several potentially relevant ongoing trials will be completed between 2013 and 2019, which may clarify the extent of benefit of aspirin in reducing cancer incidence and mortality. Future research considerations include expanding the use of IPD meta-analysis of RCTs by pooling data from available studies and investigating the impact of different dose regimens on cardiovascular and cancer outcomes

Whole genome sequencing-based mapping and candidate identification of mutations from fixed zebrafish tissue

As forward genetic screens in zebrafish become more common, the number of mutants that cannot be identified by gross morphology or through transgenic approaches, such as many nervous system defects, has also increased. Screening for these difficult-to-visualize phenotypes demands techniques such as whole-mount in situ hybridization (WISH) or antibody staining, which require tissue fixation. To date, fixed tissue has not been amenable for generating libraries for whole genome sequencing (WGS). Here, we describe a method for using genomic DNA from fixed tissue and a bioinformatics suite for WGS-based mapping of zebrafish mutants. We tested our protocol using two known zebrafish mutant alleles, gpr126st49 and egr2bfh227, both of which cause myelin defects. As further proof of concept we mapped a novel mutation, stl64, identified in a zebrafish WISH screen for myelination defects. We linked stl64 to chromosome 1 and identified a candidate nonsense mutation in the F-box and WD repeat domain containing 7 (fbxw7) gene. Importantly, stl64 mutants phenocopy previously described fbxw7vu56 mutants, and knockdown of fbxw7 in wild-type animals produced similar defects, demonstrating that stl64 disrupts fbxw7. Together, these data show that our mapping protocol can map and identify causative lesions in mutant screens that require tissue fixation for phenotypic analysis

Redesigning inpatient care: testing the effectiveness of an Accountable Care Team model

BACKGROUND US healthcare underperforms on quality and safety metrics. Inpatient care constitutes an immense opportunity to intervene to improve care. OBJECTIVE Describe a model of inpatient care and measure its impact. DESIGN A quantitative assessment of the implementation of a new model of care. The graded implementation of the model allowed us to follow outcomes and measure their association with the dose of the implementation. SETTING AND PATIENTS Inpatient medical and surgical units in a large academic health center. INTERVENTION Eight interventions rooted in improving interprofessional collaboration (IPC), enabling data-driven decisions, and providing leadership were implemented. MEASUREMENTS Outcome data from August 2012 to December 2013 were analyzed using generalized linear mixed models for associations with the implementation of the model. Length of stay (LOS) index, case-mix index–adjusted variable direct costs (CMI-adjusted VDC), 30-day readmission rates, overall patient satisfaction scores, and provider satisfaction with the model were measured. RESULTS The implementation of the model was associated with decreases in LOS index (P < 0.0001) and CMI-adjusted VDC (P = 0.0006). We did not detect improvements in readmission rates or patient satisfaction scores. Most providers (95.8%, n = 92) agreed that the model had improved the quality and safety of the care delivered. CONCLUSIONS Creating an environment and framework in which IPC is fostered, performance data are transparently available, and leadership is provided may improve value on both medical and surgical units. These interventions appear to be well accepted by front-line staff. Readmission rates and patient satisfaction remain challenging

Group Visits to Improve Pediatric ADHD Chronic Care Management

Objective: Children with attention-deficit hyperactivity disorder (ADHD) may experience continued impairment at home and school even after medication initiation. Group visits offer a way for pediatricians to provide more time to address ongoing needs. A pilot study was undertaken to examine whether a group visit model improved ADHD management in the pediatric medical home. Methods: Parents and children aged 6 to 18 years with ADHD were recruited and randomized to group visits or a usual care control. Data included attendance at ADHD follow-up visits, parent-rated ADHD symptoms, adaptive functioning, and quality of life. Longitudinal linear mixed models (continuous variables) and generalized linear mixed models (binary outcomes) were used to compare groups. In our statistical models, child and family were random effects; study assignment was a fixed effect. Results: Twenty families representing 29 children participated (intervention: 9 parents/13 children and control: 11 parents/16 children). Aside from race, baseline characteristics of participants were similar. None of the intervention families missed the expected 5 ADHD follow-up visits over 1 year; control families missed 1 or more visits over the same period. Intervention families reported an improved level of adaptive functioning at 12 months compared with control (mean severity score: 3.7 vs 4.4, p = .003). All families reported greater limitations and poorer quality of life compared with national norms. Conclusion: Group visits in the pediatric medical home can improve adherence, and preliminary results show a variety of improvements for the family

Subjective SES is Associated with Children's Neurophysiological Response to Auditory Oddballs

Language and reading acquisitions are strongly associated with a child’s socioeconomic status (SES). There are a number of potential explanations for this relationship. We explore one potential explanation—a child’s SES is associated with how children discriminate word-like sounds (i.e., phonological processing), a foundational skill for reading acquisition. Magnetoencephalography data from a sample of 71 children (aged 6 years and 11 months–12 years and 3 months), during a passive auditory oddball task containing word and nonword deviants, were used to test “where” (which sensors) and “when” (at what time) any association may occur. We also investigated associations between cognition, education, and this neurophysiological response. We report differences in the neural processing of word and nonword deviant tones at an early N200 component (likely representing early sensory processing) and a later P300 component (likely representing attentional and/or semantic processing). More interestingly we found “parental subjective” SES (the parents rating of their own relative affluence) was convincingly associated with later responses, but there were no significant associations with equivalized income. This suggests that the SES as rated by their parents is associated with underlying phonological detection skills. Furthermore, this correlation likely occurs at a later time point in information processing, associated with semantic and attentional processes. In contrast, household income is not significantly associated with these skills. One possibility is that the subjective assessment of SES is more impactful on neural mechanisms of phonological processing than the less complex and more objective measure of household income

Characterizing the effect of glutamine supplementation on asparagine and glutamine metabolism using 13C metabolic flux analysis

Upstream development efforts often focus on improved productivity. Among those efforts, improvements in medium formulations have translated into greater titers. To continue this historical trend, a better understanding of the cell metabolism is warranted for guiding efficient utilization of medium components to improve titer while minimizing byproducts. 13C Metabolic Flux Analysis (13C MFA) offers opportunities to study metabolic phenotypes by applying isotope tracers to estimate the intracellular fluxes through metabolic pathways. In this work, 13C MFA was applied to study the effects of glutamine supplementation by 13C parallel labelling of cultures with [U-13C]asparagine, [U-13C]glutamine and an a mixture of [U-13C]glucose with [1,2-13C]glucose. The study was focused on two metabolic states characterized by glutamine consumption in the early exponential phase and glutamine production in the late exponential phase of a fed-batch culture. To quantify individual metabolic pathway activity, metabolic flux maps were generated for the glutamine supplemented feeds compared to a control case with glutamine in the initial medium. The glutamine supplementation condition resulted in redistribution of the fluxes in the TCA cycle. Furthermore, measurements of the enrichment of cell protein indicate different allocations of the fed nutrients into generated biomass for the glutamine supplemented condition. Comparison between the early and the late exponential phases provided novel insights on how glutamine modulates CHO central carbon metabolism and supports the important role of glutamine as a major source of energy for cell proliferation. These findings contribute towards an improved characterization of the metabolism of industrial cells with useful implications for optimizing medium and feed development

Intestinal fibrosis is reduced by early elimination of inflammation in a mouse model of IBD: Impact of a “Top‐Down” approach to intestinal fibrosis in mice

Background: The natural history of Crohn's disease follows a path of progression from an inflammatory to a fibrostenosing disease, with most patients requiring surgical resection of fibrotic strictures. Potent antiinflammatory therapies reduce inflammation but do not appear to alter the natural history of intestinal fibrosis. The aim of this study was to determine the relationship between intestinal inflammation and fibrogenesis and the impact of a very early “top‐down” interventional approach on fibrosis in vivo. Methods: In this study we removed the inflammatory stimulus from the Salmonella typhimurium mouse model of intestinal fibrosis by eradicating the S. typhimurium infection with levofloxacin at sequential timepoints during the infection. We evaluated the effect of this elimination of the inflammatory stimulus on the natural history of inflammation and fibrosis as determined by gross pathology, histopathology, mRNA expression, and protein expression. Results: Fibrogenesis is preceded by inflammation. Delayed eradication of the inflammatory stimulus by antibiotic treatment represses inflammation without preventing fibrosis. Early intervention significantly ameliorates but does not completely prevent subsequent fibrosis. Conclusions: This study demonstrates that intestinal fibrosis develops despite removal of an inflammatory stimulus and elimination of inflammation. Early intervention ameliorates but does not abolish subsequent fibrosis, suggesting that fibrosis, once initiated, is self‐propagating, suggesting that a very early top‐down interventional approach may have the most impact on fibrostenosing disease. (Inflamm Bowel Dis 2012;)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90367/1/21812_ftp.pd