Learning from errors:Assessing final year medical students' reflection on safety improvement, five year cohort study

Abstract Background Investigation of real incidents has been consistently identified by expert reviews and student surveys as a potentially valuable teaching resource for medical students. The aim of this study was to adapt a published method to measure resident doctors’ reflection on quality improvement and evaluate this as an assessment tool for medical students. Methods The design is a cohort study. Medical students were prepared with a tutorial in team based learning format and an online Managing Incident Review course. The reliability of the modified Mayo Evaluation of Reflection on Improvement tool (mMERIT) was analysed with Generalizability G-theory. Long term sustainability of assessment of incident review with mMERIT was tested over five consecutive years. Results A total of 824 students have completed an incident review using 167 incidents from NHS Tayside’s online reporting system. In order to address the academic practice gap students were supervised by Senior Charge Nurses or Consultants on the wards where the incidents had been reported. Inter-rater reliability was considered sufficiently high to have one assessor for each student report. There was no evidence of a gradient in student marks across the academic year. Marks were significantly higher for students who used Section Questions to structure their reports compared with those who did not. In Year 1 of the study 21 (14%) of 153 mMERIT reports were graded as concern. All 21 of these students achieved the required standard on resubmission. Rates of resubmission were lower (3% to 7%) in subsequent years. Conclusions We have shown that mMERIT has high reliability with one rater. mMERIT can be used by students as part of a suite of feedback to help supplement their self-assessment on their learning needs and develop insightful practice to drive their development of quality, safety and person centred professional practice. Incident review addresses the need for workplace based learning and use of real life examples of mistakes, which has been identified by previous studies of education about patient safety in medical schools

A cohort study of reproductive and hormonal factors and renal cell cancer risk in women

We examined the association of reproductive and hormonal factors with renal cell cancer risk in a cohort study of 89 835 Canadian women. Compared with nulliparous women, parous women were at increased risk (hazard ratio (HR) 1.78, 95% confidence interval (CI) 1.02–3.09), and there was a significant gradient of risk with increasing levels of parity: relative to nulliparous women, women who had X5 pregnancies lasting 4 months or more had a 2.4-fold risk (HR 1⁄4 2.41, 95% CI 1⁄4 1.27–4.59, P for trend 0.01). Ever use of oral contraceptives was associated with a modest reduction in risk. No associations were observed for age at first live birth or use of hormone replacement therapy. The present study provides evidence that high parity may be associated with increased risk of renal cell cancer, and that oral contraceptive use may be associated with reduced risk

Phone and e-mail counselling are effective for weight management in an overweight working population: a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>The work setting provides an opportunity to introduce overweight (i.e., Body Mass Index ≥ 25 kg/m²) adults to a weight management programme, but new approaches are needed in this setting. The main purpose of this study was to investigate the effectiveness of lifestyle counselling by phone or e-mail on body weight, in an overweight working population. Secondary purposes were to establish effects on waist circumference and lifestyle behaviours, and to assess which communication method is the most effective.</p> <p>Methods</p> <p>A randomized controlled trial with three treatments: intervention materials with phone counselling (phone group); a web-based intervention with e-mail counselling (internet group); and usual care, i.e. lifestyle brochures (control group). The interventions used lifestyle modification and lasted a maximum of six months. Subjects were 1386 employees, recruited from seven companies (67% male; mean age 43 (SD 8.6) y; mean BMI 29.6 (SD 3.5) kg/m²). Body weight was measured by research personnel and by questionnaire. Secondary outcomes fat, fruit and vegetable intake, physical activity and waist circumference were assessed by questionnaire. Measurements were done at baseline and after six months. Missing body weight was multiply imputed.</p> <p>Results</p> <p>Body weight reduced 1.5 kg (95% CI -2.2;-0.8, p < 0.001) in the phone group and 0.6 kg (95% CI -1.3; -0.01, p = 0.045) in the internet group, compared with controls. In completers analyses, weight and waist circumference in the phone group were reduced with 1.6 kg (95% CI -2.2;-1.0, p < 0.001) and 1.9 cm (95% CI -2.7;-1.0, p < 0.001) respectively, fat intake decreased with 1 fatpoint (1 to 4 grams)/day (95% CI -1.7;-0.2, p = 0.01) and physical activity increased with 866 METminutes/week (95% CI 203;1530, p = 0.01), compared with controls. The internet intervention resulted in a weight loss of 1.1 kg (95% CI -1.7;-0.5, p < 0.001) and a reduction in waist circumference of 1.2 cm (95% CI -2.1;-0.4, p = 0.01), in comparison with usual care. The phone group appeared to have more and larger changes than the internet group, but comparisons revealed no significant differences.</p> <p>Conclusion</p> <p>Lifestyle counselling by phone and e-mail is effective for weight management in overweight employees and shows potential for use in the work setting.</p> <p>Trial registration</p> <p>ISCRTN04265725.</p

TRIMETHYLAMINE N-OXIDE IS ASSOCIATED WITH VASCULAR DYSFUNCTION AND PHYSICAL ACTIVITY IN LIVER TRANSPLANT RECIPIENTS

Domenico A. Chavez, Marie-Claire Evans, Natalie J. Bohmke, Chandra Bhati, Susan Wolver, Mohammad S. Siddiqui, Danielle L. Kirkman. Virginia Commonwealth University, Richmond, VA. BACKGROUND: Liver transplant (LT) recipients have an increased risk of cardiovascular disease (CVD), but the underlying mechanisms are not fully understood. In the general population, the gut microbial metabolite trimethylamine n-oxide (TMAO) is associated with atherosclerotic CVD. Physical activity is known to reduce CVD risk, and recent evidence also suggests that exercise can positively modify the gut microbiome. The purpose of this study was to examine the relationship between serum TMAO, vascular endothelial function, and physical activity levels in LT recipients. We hypothesized that higher levels of TMAO would be associated with vascular endothelial dysfunction and low physical activity levels. METHODS: We enrolled 21 LT recipients (11 Female; 6 African American, 1 Asian; Median [Interquartile Range]: Age, 56 [49-64] years; body mass index (BMI), 35.3 [32.1-40.9] kg/m2). Conduit artery endothelial function was assessed by flow-mediated dilation of the brachial artery (FMDBA) with duplex ultrasound. Venous blood samples were analyzed for levels of TMAO by nuclear magnetic resonance spectroscopy. Patients wore accelerometers at the waist for 7 consecutive days, and data were averaged to obtain daily habitual physical activity levels. After evaluation of statistical assumptions, nonparametric associations were assessed using Spearman’s rho. RESULTS: Conduit artery endothelial function (4.09 [3.69-5.50] %) was negatively associated with TMAO (4.73 [2.94-7.81] µM; ρ = -0.49, p = 0.03). TMAO levels were negatively associated with total physical activity (vector magnitude: 262079 [165640-319673] counts; ρ = -0.49, p = 0.03) and time spent in moderate intensity physical activity (19 [10-25] minutes; ρ = -0.44, p = 0.048) but not with daily step counts, sedentary time, or time spent in light physical activity. CONCLUSIONS: Our findings show that higher TMAO levels are associated with worse vascular endothelial function in LT recipients indicating a higher risk for the development of atherosclerotic CVD. Furthermore, higher levels of total and moderate intensity physical activity were associated with lower levels of TMAO. Future LT studies should investigate the efficacy of moderate intensity exercise interventions to improve vascular function by attenuating TMAO. FUNDING: Supported by NIH UL1TR00264

EXERCISE CAPACITY AND CENTRAL ARTERIAL HEMODYNAMICS IN HEART FAILURE WITH PRESERVED EJECTION FRACTION

Natalie J. Bohmke1, Domenico A. Chavez1, Hayley E. Billingsley1, Michele Golino1, Sebastian Pinel1, Roshanak Markley1, Antonio Abbate2, Salvatore Carbone1, Danielle L. Kirkman1. 1Virginia Commonwealth University, Richmond, VA. 2University of Virginia, Charlottesville, VA. BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is characterized by exertional intolerance. Magnified arterial wave reflections that increase the left ventricular (LV) late systolic pulsatile load may contribute to HFpEF related exercise intolerance. Our aim was to investigate the relationship between resting aortic hemodynamics and exercise capacity. METHODS: 35 patients with HFpEF (24 female, 27 African American; Median [IQR]: Age 63 [54, 69] years; BMI 37.9 [33.4, 40.9] kg/m2) underwent vascular testing and cardiopulmonary exercise testing. Peak oxygen consumption (VO2 peak) was measured via breath-by-breath gas analysis during a 0.6 MET•min-1 graded treadmill test to volitional fatigue. Resting aortic pressure waveforms were synthesized from radial artery waveforms obtained by applanation tonometry. Specifically, we report the augmentation index normalized to a heart rate of 75bpm (AIx75): an indicator of arterial stiffness and surrogate for the magnitude of the LV systolic load; the round-trip transit time (Tr): the travel time of the pressure wave from the heart to the major reflecting sites and back; and the reflection index (RIx): the magnitude of reflected wave relative to the forward travelling wave. We compared exercise capacity according to a median split for AIx75 (\u3c25\u3e), Tr (\u3c137s\u3e) and RIx (\u3c73\u3e). RESULTS: Patients with a higher AIx75, signifying increased arterial stiffness and increased LV systolic load, had a lower absolute VO2peak (1.28 [1.17, 1.40] vs. 1.85 [1.50, 2.21] L/min, p\u3c0.001) and shorter exercise time (505 [384, 545] vs. 637 [458, 765] seconds, p=0.041). Patients with a faster Tr signifying reflected waves that arrive at the heart earlier in systole, had lower relative VO2peak (13.1 [11.57, 14.6] vs. 17.1 [13.1, 18.6] mL/kg/min, p=0.044) and a trend for shorter exercise times (466 [354, 550] vs. 637 [503, 658] seconds, p=0.056). Patients with higher RIx had a lower absolute VO2peak (1.28 [1.17, 1.66] vs. 1.66 [1.37, 2.12] L/min, p=0.009). CONCLUSIONS: Our results show that in a cohort of patients with HFpEF, aberrant resting arterial hemodynamics that increase LV systolic afterload are associated with worse exercise capacity. Future research should investigate arterial hemodynamics during exercise to provide insight into their potential contribution to exercise intolerance in HFpEF. Supported by AHA 19CDA3474002 & 19CDA34660318 and NIH UL1TR00264