Facing hierarchy: a qualitative study of residents\u27 experiences in an obstetrical simulation scenario

BACKGROUND: Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety. METHODS: Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30-45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached. RESULTS: Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging - a mere reporting of existing clinical information; (2) interpretive - a deliberate construction of clinical facts aimed at swaying supervising physician\u27s clinical decision; and (3) advocative - a readiness to confront the staff physician\u27s clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety. CONCLUSIONS: Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization

Delineating ADHD and bipolar disorder: A comparison of clinical profiles in adult women

OBJECTIVE: Overlapping symptoms can make the diagnostic differentiation of attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) challenging in adults using current clinical assessments. This study sought to determine if current clinical measures delineate ADHD from BD in adults, comparing relative levels of ADHD, BD and emotional lability (EL) symptoms. METHODS: Sixty adult women with ADHD, BD or controls were compared on self-report and interview measures for ADHD symptoms, mania, depression, EL, and impairment. RESULTS: ADHD interview measures and self-ratings of ADHD symptoms best discriminated between ADHD and BD. Self-report measures of EL and depression showed non-specific enhancement in both clinical groups. BD-specific items may distinguish BD from ADHD if a retrospective time-frame is adopted. CONCLUSIONS: Using measures which capture specific symptoms of ADHD and chronicity/episodicity of symptoms facilitates the delineation of ADHD from BD in adult women

The theory of the marketing firm

The theory of the marketing firm locates the rationale of the modern business enterprise that lies in its responding profitably to the imperatives of marketing orientation. Economic theories of the firm generally fail to recognize these imperatives, enhanced consumer choice and sophistication, which entail marketing orientation as the rationale of the firm. The paper propose a competence theory of the firm as a metacontingency and examines the bilateral contingencies by which firms link to their consumerates, which indicate their capacities for customer orientation. The marketing firm emerges as a means of encapsulating entrepreneurship, economizing on transaction costs, and enabling the management of marketing specialization

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

HUMAN LABOR & BIRTH

725 hlm.; 15 x 23 c

Simulation in the clinical setting: towards a standard lexicon

Abstract Simulation-based educational activities are happening in the clinical environment but are not all uniform in terms of their objectives, delivery, or outputs. While these activities all provide an opportunity for individual and team training, nuances in the location, timing, notification, and participants impact the potential outcomes of these sessions and objectives achieved. In light of this, there are actually many different types of simulation-based activity that occur in the clinical environment, which has previously all been grouped together as “in situ” simulation. However, what truly defines in situ simulation is how the clinical environment responds in its’ natural state, including the personnel, equipment, and systems responsible for care in that environment. Beyond individual and team skill sets, there are threats to patient safety or quality patient care that result from challenges with equipment, processes, or system breakdowns. These have been labeled “latent safety threats.” We submit that the opportunity for discovery of latent safety threats is what defines in situ simulation and truly differentiates it from what would be more rightfully called “on-site” simulation. The distinction between the two is highlighted in this article, as well as some of the various sub-types of in situ simulation

The Masculine Masquerade : Masculinity and Representation

Tracing the developments in gender theory, Broad identifies masculinity as a construct to contextualize works by 11 artists examining the way in which the masculinity is represented (as discussed by Posner). Five authors contribute additional texts on: the mythologization of Jackson Pollock, representation in Hitchcock's "North by Northwest" (1959), the imaging of people with AIDS and black masculinity. Includes a photo-essay by Ligon and a comprehensive subject bibliography (25 p.). Biographical notes