Transitioning towards senior medical resident: identification of the required competencies using consensus methodology

Background: Residency programs are facing significant restructuring through the “Competence by Design” (CBD) framework proposed by the Royal College of Physicians and Surgeons of Canada (RCPSC). Our goal was to establish the competencies to be acquired during the transition to a senior role within Internal Medicine (IM) training.     Methods: Using a modified Delphi technique, practicing IM physicians and recent graduates were polled to develop consensus on the required competencies to effectively transition from junior to senior medical resident. Participants rated each competency on a three-point Likert scale. Each competency was linked to an Entrustable Professional Activity (EPA) identified by the RCPSC IM Specialty Committee.Results: A total of eighteen participants took part in item generation (16% response rate) and nineteen in the initial ranking with seventeen completing all three iterations (89% completion rate). Eighty-three competencies were identified during questionnaire development. A final list of seventy-seven competencies reached consensus after three rounds. Most competencies matched to core of discipline EPAs.Conclusion: This consensus-based list of competencies will help create a framework and tools for the assessment of junior residents as they prepare to transition to the role of senior in the new CBD curricula for IM trainees at our institution.

Implications of serial measurements of natriuretic peptides in heart failure: insights from BIOSTAT‐CHF

No abstract available

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Integrating Direct Observations in Clinical Teachers' Workflow: An Exploratory Cognitive Task Analysis

Background: Successful implementation of competency-based assessments is largely contingent on Direct Observation (DO). However, its uptake remains problematic and threatens its educational mandate. DO-focused research has primarily been examined from a psychometric and sociocultural perspective. Cognitive Task Analysis (CTA) provides tools to elicit knowledge from experienced users and understand their performance in complex environments, which is then used to design tools to enhance task performance. The purpose of this study was to understand, using CTA, the cognitive functions and cues that drive CTs’ decision-making in integrating DO in their workflow while balancing the competing demands of simultaneously being an educator and healthcare provider. Methods: We conducted an qualitative study guided by Applied Cognitive Task Analysis (ACTA). We interviewed CTs in internal medicine-based specialties who work on inpatient medical units at a single academic institution. CTs were purposively sampled following a nomination process to find participants who excel at using DO in inpatient settings. Data were analyzed using reflexive thematic analysis. Results: Six CTs with a median of 8 (range 2-13) years of experience participated and described a dual responsibility in attending to patients’ and learners’ needs, with patient safety ultimately prioritized as the key driver for DO. Participants shared three cognitive functions underlying their work on inpatient units and describing the judgements and decisions needed for DO to occur: (1) making tasks count twice to promote efficient use of DO, (2) planning and re-planning DO as clinical activities unfold, and (3) self-reflections that mold educational practices that integrate DO. CTs described multiple cues that inform the need for DO and categorized them in relation to (1) patients and their care, (2) learners, (3) teachers’ experiences and (4) the learning environment. Discussion: ACTA was a useful and systematic approach to tap into the expertise of a select group of CTs. The insight gained on patient safety as the primary cognitive driver for DO provides an opportunity to shift faculty development initiatives. Using the identified cognitive functions and cues, we discuss potential opportunities for faculty development to better prepare and engage CTs in integrating DO in their workflow

Tube Suction Test for Evaluating Durability of Cementitiously Stabilized Soils (FHWA-OK-11-05 2215)

In a comprehensive laboratory study, different tests namely, unconfined compressive strength (UCS) at the end of freeze-thaw/wet-dry (F-T/W-D) cycles, resilient modulus (Mr) at the end of F-T/W-D cycles, vacuum saturation, tube suction, and moisture susceptibility tests were used for evaluating durability of cementitiously stabilized subgrade soils. Five clay soils commonly encountered as subgrades in Oklahoma, namely, Port (silty clay with sand), Kingfisher (lean clay), Carnasaw (fat clay), Dennis (fat clay), and Lomill (fat clay) series, were utilized. These soils were stabilized with 6% hydrated lime (or lime), 10% class C fly ash (CFA), and 10% cement kiln dust (CKD). Cylindrical specimens of three different sizes were compacted and cured for 7 days. Then, Harvard miniature specimens were tested for UCS at the end of F-T/W-D cycles and moisture susceptibility (5-hour soaking). Additionally, cylindrical specimens were tested for Mr at the end of F-T and W-D cycles for evaluating the effect of F-T and W-D cycles on Mr values. Further, Proctor size specimens were tested for UCS after vacuum saturation test. Additionally, a total of three different methods were used for conducting tube suction tests by taking into account different specimen sizes (4.0 in. x 4.0 in., 6.0 in. x 6.0 in., 4.0 in. x 8.0 in.) and compaction methods (standard Proctor and Superpave gyratory compactor). All the specimens showed a decrease in the UCS values at the end of F-T cycles and vacuum saturation. All the specimens tested in this study, in general, showed an increase in the UCS values at the end of 1 W-D cycle. The Mr values of both raw and stabilized soil specimens were found to decrease with an increase in the number of F-T or W-D cycles. Overall, the Port series soil specimens (silty clay with sand) stabilized with 10% CKD offered maximum resistance towards F-T and W-D cycles. A similar trend of behavior is evident from the results obtained by moisture susceptibility and vacuum saturation tests where the Port series soil specimens stabilized with 10% CKD produced the highest retained UCS values. The Kingfisher series soil specimens (lean clay) did not show any clear trend with one particular additive. However, specimens stabilized with 6% lime and 10% CKD showed better performance, as compared to specimens stabilized with 10% CFA. All three fat clays used in this study (Carnasaw, Dennis, and Lomill) showed maximum resistance towards F-T and W-D cycles after stabilizing with 6% lime as compared to 10% CFA and 10% CKD. This fact was also evident from both moisture susceptibility and vacuum saturation tests. Further, a strong correlation (R2 ? 0.70 – 0.86) between retained UCS after moisture susceptibility test and other durability indicators such as retained UCS after 1 F-T cycle, retained UCS after 1 W-D cycle, and retained Mr after 1 F-T cycle is evident from this study. This is an indication that moisture susceptibility could be used for evaluating long-term performance of stabilized soil specimens.Final Report, July 2008-December 2010N

Intrinsic Disorder in Human Proteins Encoded by Core Duplicon Gene Families

Segmental duplications (i.e., highly homologous DNA fragments greater than 1 kb in length that are present within a genome at more than one site) are typically found in genome regions that are prone to rearrangements. A noticeable fraction of the human genome (∼5%) includes segmental duplications (or duplicons) that are assumed to play a number of vital roles in human evolution, human-specific adaptation, and genomic instability. Despite their importance for crucial events such as synaptogenesis, neuronal migration, and neocortical expansion, these segmental duplications continue to be rather poorly characterized. Of particular interest are the core duplicon gene (CDG) families, which are replicates sharing common “core” DNA among the randomly attached pieces and which expand along single chromosomes and might harbor newly acquired protein domains. Another important feature of proteins encoded by CDG families is their multifunctionality. Although it seems that these proteins might possess many characteristic features of intrinsically disordered proteins, to the best of our knowledge, a systematic investigation of the intrinsic disorder predisposition of the proteins encoded by core duplicon gene families has not been conducted yet. To fill this gap and to determine the degree to which these proteins might be affected by intrinsic disorder, we analyzed a set of human proteins encoded by the members of 10 core duplicon gene families, such as NBPF, RGPD, GUSBP, PMS2P, SPATA31, TRIM51, GOLGA8, NPIP, TBC1D3, and LRRC37. Our analysis revealed that the vast majority of these proteins are highly disordered, with their disordered regions often being utilized as means for the protein–protein interactions and/or targeted for numerous posttranslational modifications of different nature