Interprofessional Collaborator Curriculum

Background: Physicians are often expected to participate with teams of health professionals; however, postgraduate training infrequently includes interprofessional (IP) or team training. Purpose: This curriculum was developed to demonstrate the knowledge, skills and attitudes which lead to successful IP collaboration. Curriculum: During a four-week geriatrics rotation, medicine interns complete a fifty-minute, in-person, multimedia lecture to introduce the IP collaborator concept and the Canadian and American IP competency frameworks. The IP pocket card is demonstrated and interns complete a guided, team-meeting video observation exercise. Using a Survey Monkey, narrative reporting tool, interns analyze team competencies that they observe or initiate during geriatrics team meetings during the rotation. They report on two interactions. They complete a closing Survey Monkey questionnaire and have an in-person debriefing. Results: We will have quantitative and qualitative data on interns’ recognition of IP collaborator competencies. Conclusion: Recognition of IP collaborator competencies will provide a framework for improving health professional effectiveness for systems-based care. Relevance to IP education or practice: Disseminating IP competencies. Learning Objectives: 1. The audience will be able to describe a new strategy for teaching IP competencies to health professionals. 2. The audience will become aware of a new method for combining the Canadian and American IP competencies. Todd James, MD, FACP Assistant Professor of Clinical Medicine Indiana University School of Medicine, Geriatrics Faculty Office Building, Floor 2 720 Eskenazi Avenue Indianapolis, IN 46202 Phone: 317-880-6582 Fax: 317-880-0332 Email: [email protected]

The Tri-State Experience: Outcome Analysis of Patients with Triple Negative Breast Cancer Treated at Marshall University

Breast cancer is the most frequently diagnosed malignancy in women in the United States. It is the second most common malignancy to cause death, with approximately 39,000 women dying of breast cancer in the United States in 2013. Triple negative breast cancer is defined as the absence of estrogen, progesterone and human epidermal growth factor receptor 2 receptors. It has been associated with a higher incidence in African American women, a younger age and a more advanced stage at diagnosis, and an inferior overall survival. To recognize the differences of our West Virginia community population when compared to the national average, we conducted a retrospective review of all patients diagnosed with breast cancer from 2000-2012

Delaying Chemotherapy in the Treatment of Stage IV Non-Small Cell Lung Cancer Does Not Adversely Affect Survival Outcome

Background: Whether a delay in the initiation of chemotherapy for advanced non-small cell lung cancer (NSCLC) can affect overall survival is not well studied. We aim to evaluate the effect of the time interval between diagnosis and initiation of chemotherapy on overall survival in patients with stage IV NSCLC. Methods: A retrospective review of newly diagnosed stage IV NSCLC patients who received chemotherapy between 1995 and 2012 was conducted. Demographics, histology and site(s) of metastases of patients were reviewed. Time interval between the date of diagnosis and the date of starting chemotherapy was calculated in days. Patients were divided in two groups based on median time interval: Group A \u3c 46 days and group B \u3e 46 days. The primary end point was the difference in overall survival between the two groups. Results: A total of 172 patients were reviewed. Each group had 86 patients. Median age for both groups was 61 years. The most common histology was adenocarcinoma in A and B (43% vs. 45%, respectively). The sites of metastases in A and B were: brain (25% vs. 28%), liver (20% vs. 9%), bone (30% vs. 30%), respectively. Performance status of ECOG (Eastern Cooperative Oncology Group) :( 0-1) was 82% vs. 76% in A and B, respectively. The median overall survival for A was 7 months vs.12 months for B (p=0.04). Conclusion: In this single institution review, delayed chemotherapy for stage IV NSCLC more than 46 days did not have a detrimental effect on overall survival and even suggested a better outcome. Further larger and prospective studies are warranted to validate these findings

Recognizing Guttate Psoriasis and Initiating Appropriate Treatment

Guttate psoriasis is a less common form of psoriasis. It manifests with numerous small, teardrop shaped, scaly plaques on the trunk and extremities. The etiology includes both environmental and genetic factors. It commonly arises 3-4 weeks following a beta hemolytic streptococcal infection. In some cases, it may be misdiagnosed as an allergy to the antibiotics being used to treat the streptococcal infection. The treatment of guttate psoriasis can vary by severity, but the mainstay treatment includes photo therapy and topical steroids. This case report presents the etiology, clinical findings and current treatment options of guttate psoriasis. It also discusses importance of differentiating guttate psoriasis from an antibiotic allergy. The confusion between the two can often delay and make treatment more difficult

LEAD 2.0: An Interprofessional Leadership Curriculum

Purpose: To develop knowledge, skills, and attitudes about leadership for graduate medical education trainees, junior nurses, and allied health trainees. Background: Many graduate medical education (GME) trainees, junior nurses, and allied health professionals complete training with exceptional clinical skills, but are not equipped to assume leadership roles or work well within teams. The goal of LEAD 2.0 is fill the gap for those assuming leadership positions, and to enhance the leadership skills of all trainees. Intervention: Walter Reed National Military Medical Center’s Department of GME developed an interprofessional leadership curriculum called LEAD 2.0 in 2016. The curriculum of LEAD 2.0 was derived from a systematic review of existing leadership curricula as well as a local needs assessment focusing on content, format, barriers, and logistics. The curriculum is composed of 8 core topics, each with well-defined goals and objectives: leadership fundamentals (leadership styles, definitions, etc.), mentoring and coaching, emotional intelligence, conflict resolution, feedback, managing effectively, building an effective team, and implementing change). Teaching methods are interactive and based on the Kolb Learning Cycle and Adult Learning Theory. LEAD 2.0 sessions are 1.5 hours long and occur monthly. Preliminary Results: Four sessions have been completed with 106 interprofessionals attending at least one session. Survey results suggest that sessions are useful and leading to changes in leadership behaviors among participants. Ninety percent (18/20) of those attending Leadership 101 (n=53) who responded to a post-class survey said the session was useful and 95% (19/20) said they were inspired to learn more about leadership. Recommendations: 1. Participants want materials that allow for interactive teaching sessions to include personal leadership inventories and case studies. 2. Speakers should be a mix of local speakers and outside experts if possible. 3. Logistics and timing should be coordinated with all stakeholders well in advance to allow for maximal participation. Learning Objectives: Determine the key elements of a successful interprofessional leadership curriculum. Demonstrate potential teaching strategies for leadership development. Recognize optimal methods for evaluating a leadership curriculum

Continuous-flow left ventricular assist device outflow graft stenting: Indications and outcomes

Introduction: Stenosis in the continuous-flow left ventricular assist device (CF-LVAD) outflow graft can be caused by various mechanical and anatomical factors. Increasingly, percutaneous management has been utilized to re-establish adequate CF-LVAD flow. We sought to evaluate indications for such interventions and their outcomes. Methods: An electronic search was performed to identify all studies in the English literature reporting CF-LVAD outflow graft stenting for various etiologies. Twenty-one studies consisting of 26 patients were included in the analysis. Results: Median patient age was 59 years [45.8-67.0] and 65.4% (17/26) were male. 58.3% (14/24) of patients had HeartWare HVAD, 37.5% (9/24) had HeartMate II LVAD, and 4.2% (1/24) had HeartMate III LVAS. Median time from device placement to outflow graft stenting was 24.0 months [7.8-30.4]. 76.9% of patients (20/26) presented with heart failure. 34.6% (9/26) had outflow graft thrombosis, 34.6% (9/26) stenosis, 11.5% (3/26) kinking, 11.5% (3/26) pseudoaneurysm, 3.8% (1/26) external graft compression, and 3.8% (1/26) had a bronchialarterial fistula. 88.5% (23/26) procedures led to immediate flow improvement with the remaining 11.5% (3/26) receiving additional stenting. Post-intervention flows were significantly improved (4.7 L/min [4.1-4.8] post-intervention vs 2.9 L/min [2.0-3.5] initial, p=0.01). 96.2% (25/26) patients were discharged from the hospital. The 30-day mortality was 6.7% (1/15). Overall mortality during the median follow-up of 90 days [7.0-240.0] was 9.5% (2/21). Discussion: Outflow graft stenting appears to effectively alleviate CF-LVAD outflow graft obstruction with low mortality. Longer-term follow up is necessary to determine the longevity of such an intervention but early results are promising

Angiotensin 1-7 Rescues Cognitive Decline and Neuronal Loss Following Traumatic Brain Injury in Mice

Purpose of study: Traumatic brain injury (TBI) is a leading cause of death and disability in the U.S., accounting for approximately 30% of all injury deaths and 3 million TBI-related emergency visits yearly. There is limited research in the area of mitigating the post-inflammatory effects of non-fatal traumatic brain injury. Angiotensin 1-7, an endogenous peptide that acts on the MAS receptor, has recently shown to be anti-inflammatory, anti-oxidative, and vasodilatory unlike its relative, angiotensin II. We asked the question of whether Ang 1-7 modulates neuroinflammation and improves cognitive function in mice following traumatic brain injury. Methods: A controlled cortical impactor with a retractable piston was used to model a mild traumatic brain injury (mTBI). Mice either received Ang 1-7 (1 mg/kg, n=12) or normal saline (0.9%, n=12) 2 hours post-TBI and 30 minutes prior to novel objection recognition (NOR) testing on days 1, 3, 7, 14 post-TBI with tissue harvesting for hematoxylin and eosin (H&E) staining. Results: Between-group studies showed that Ang 1-7 treated mice showed significantly higher NOR ratios compared to that of the control group. Additionally, statistically significant higher neuronal count in the ipsilateral hippocampal and cortical tissues days 1, 3, 7, and 14 post-TBI was observed in the Ang-1-7 group. Conclusion: Together, these results demonstrate that Ang 1-7 significantly improves cognitive function and rescues further cell loss against secondary intrinsic injury following extrinsic mTBI and suggest that it may be a novel therapy to the effects of mild traumatic brain injury

Neurologic improvement after thoracic, thoracolumbar, and lumbar spinal cord (conus medullaris) injuries

Study Design. Retrospective. Objective. With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord. Summary of Background Data. Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients. Methods. Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology. Results. A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P \u3c 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury. Conclusion. Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others

Content of exercise programmes targeting older people with sarcopenia or frailty – findings from a UK survey

Objectives: To establish whether existing exercise programmes offered to people with sarcopenia or frailty adhere to the current evidence base. Methods: We conducted a national survey of practitioners delivering exercise programmes to older people with sarcopenia or frailty in the UK. The link to the online survey was distributed through email lists of professional societies, practice networks and social media. Questions covered target population and programme aims, type, duration and frequency of exercise, progress assessment and outcome measures. Results: One hundred and thirty-six responses were received. 94% of respondents reported prescribing or delivering exercise programmes to people with sarcopenia or frailty. Most programmes (81/135 [60%]) were primarily designed to prevent or reduce falls. Resistance training was the main focus in only 11/123 (9%), balance training in 61/123 (50%) and functional exercise in 28/123 (23%). Exercise was offered once a week or less by 81/124 (65%) of respondents. Outcome measures suitable for assessing the effect of resistance training programmes were reported by fewer than half of respondents (hand grip: 13/119 [11%]; chair stands: 55/119 [46%]). Conclusions: Current UK exercise programmes offered to older people with sarcopenia or frailty lack the specificity, frequency or duration of exercise likely to improve outcomes for this patient group