Development and implementation of a postgraduate medical education-wide initiative in quality improvement and patient safety

BACKGROUND

Quality improvement and patient safety (QIPS) have been assigned a higher profile in CanMEDS 2015, CanMEDS-Family Medicine 2017 and new accreditation standards, prompting an initiative at Dalhousie University to create a vision for integrating QIPS into postgraduate medical education.

OBJECTIVE

The purpose of this study is to describe the implementation of a QIPS strategy across residency education at Dalhousie University.

METHODS

A QIPS task force was formed, and a literature review and needs assessment survey were completed. A needs assessment survey was distributed to all Dalhousie residency programme directors. 12 programme directors were interviewed individually to collect additional feedback. The results were used to develop a 'road map' of recommendations with a graduated timeline.

RESULTS

A task force report was released in February 2018. 46 recommendations were developed with a timeframe and responsible party identified for each. Implementation of the QIPS strategy is underway, and evaluation and challenges faced will be described.

CONCLUSIONS

We have developed a multiyear strategy that is available to provide guidance and support to all programmes in QIPS. The development and implementation of this QIPS framework may serve as a template for other institutions who seek to integrate these competencies into residency training.

COVID‐19 and the shifting industrial landscape

The COVID‐19 coronavirus pandemic has fuelled debate about domestic industry and manufacturing in light of shocks to global supply chains and shortages of medical and personal protective equipment (PPE). Nevertheless, debates have been poorly attuned to geography and history. Calls for reinvigorated domestic manufacturing conceal the degree to which industrial landscapes are already entwined in geometries of power. This is especially so at ports—increasingly privatised—that have become sites of policy focus and biosecurity panic. Crucial trading zones, ports are being refashioned as growth machines for commodity export, energy, and logistics, undergirding national manufacturing capacity via trade and material commodity flows. Yet ports have also always been vectors for disease transmission and are central places for COVID‐19 crises. Writing from Port Kembla, south of Sydney, Australia, we catalogue five themes warranting geographical analysis and global comparison in light of coronavirus: disruptions to supply chains (with implications for global production networks); domestic industrial capacity and the future of manufacturing; biosecuring industrial sites; precarious labour and work; and vernacular emergency response capacities within industrial communities. Amidst heightened geopolitical tensions, geographers reveal how industrial landscapes are contested. Logistical and biosecurity roles are enveloped by enduring infrastructural materialities, local histories, and regional legacies of skill and ingenuity.

Utilization of evidence-based tools and medical education literature by Canadian postgraduate program directors in the teaching and assessment of the CanMEDS roles

BACKGROUND

Researchers have shown that clinical educators feel insufficiently informed about how to teach and assess the CanMEDS roles. Thus, our objective was to examine the extent to which program directors utilize evidence-based tools and the medical education literature in teaching and assessing the CanMEDS roles.

METHODS

In 2016, the authors utilized an online questionnaire to survey 747 Canadian residency program directors (PD's) of Royal College of Physicians and Surgeons of Canada (RCPSC) accredited programs.

RESULTS

Overall, 186 PD's participated (24.9%). 36.6% did not know whether the teaching strategies they used were evidence-based and another third (31.9%) believed they were "not at all" or "to a small extent" evidence-based. Similarly, 31.8% did not know whether the assessment tools they used were evidence-based and another third (39.7%) believed they were "not at all" or "to a small extent" evidence-based. PD's were aware of research on teaching strategies (62.4%) and assessment tools (51.9%), but felt they did not have sufficient time to review relevant literature (72.1% for teaching and 64.1% for assessment).

CONCLUSIONS

Canadian PD's reported low awareness of evidence-based tools for teaching and assessment, implying a potential knowledge translation gap in medical education research.

Interprofessional Patient-Specific Simulation Preparation to Improve Management of Neonatal High-Acuity Low-Occurrence (HALO) Scenarios

Fetal compressive intrapericardial teratoma is a rare and life-threatening condition, qualifying as a high-acuity low-occurrence (HALO) event. To prepare for delivery and immediate neonatal management, specialists from pediatric cardiology, cardiac surgery, maternal-fetal-medicine, neonatology, cardiac anesthesia, critical care, clinical perfusion, obstetrical nursing, and operating room nursing convened. An in situ operating room simulation was used to identify and introduce key team members, derive and practice the anticipated clinical management algorithm, position human and equipment resources strategically, and ensure that each specialist team was familiar with the environment and available equipment. As rehearsed in the simulation, the cesarean delivery of the patient and neonatal cardiac surgery was uncomplicated and yielded a favourable clinical outcome. A patient-specific HALO simulation preparation (PSHSP) can facilitate positive clinical outcomes and improve health care team confidence in HALO scenarios such as the birth of newborns anticipated to have cardiorespiratory instabilty.

Abstract P878: Racial and Ethnic Disparities in Early Hypertension Control After Intracerebral Hemorrhage

Introduction: Survivors of Intracerebral Hemorrhage (ICH) are at high risk of recurrent stroke. This risk is inversely proportional to average Blood Pressure (BP) after ICH. Racial/ethnic minority ICH survivors in the US demonstrate greater hypertension severity after ICH and are at higher risk of recurrent cerebral bleeding. Since most recurrent strokes occur within 12-18 months of index ICH, rapidly achieving BP control is likely to be crucial. We investigated the frequency, prognostic impact, and racial/ethnic disparities in uncontrolled short-term hypertension (HTN) after ICH.

Methods: We analyzed data from prospective ICH cohort studies at Massachusetts General Hospital (MGH-ICH, n=1305) and the University of Hong Kong (HK-ICH, n=523). We classified HTN as controlled, uncontrolled or treatment-resistant and determined: 1) risk factors for uncontrolled and treatment-resistant HTN; and 2) whether HTN control at 3 months is associated with long-term BP control, stroke recurrence and mortality across self-reported race/ethnicity groups.

Results: We followed 1828 ICH survivors (1128 White, 565 Asian, 59 Hispanic, 49 Black, 27 other) for a median of 46.2 months. Only 9 of 172 (5%) recurrent strokes occurred before 3 months after ICH. At 3 months, 713 participants (39%) had controlled HTN, 755 (41%) had undertreated HTN, and 360 (20%) had treatment-resistant HTN. BP measurements at 3 months were highly correlated with measurements during follow-up (p<0.001). Black, Hispanic and Asian race/ethnicity were associated with higher prevalence of uncontrolled HTN at 3 months (all p<0.05). Both undertreated and uncontrolled HTN at 3 months were associated with increased risk of recurrent stroke and mortality during follow-up (all p<0.05).

Conclusions: Most ICH survivors have inadequate HTN control 3 months after ICH, with under-treatment accounting for the majority of cases. Three-month BP measurements are associated with inadequate long-term HTN control, higher recurrent stroke risk and mortality. ICH survivors self-reporting as Black, Hispanic or Asian appear to be at highest risk for uncontrolled HTN. Optimizing HTN control at 3 months is a unique opportunity to address racial/ethnic disparities in quality of care among survivors of primary ICH.

Lack of racial and ethnic-based differences in acute care delivery in intracerebral hemorrhage

Background and aim

Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH.

Methods

We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale.

Results

Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT (β = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request (β = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome.

Conclusions

We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes.

Practice Variation in Establishing the Adequacy of Beta-Blockers as an Antiarrhythmic Agent in School-Aged Children and Adolescents

Background

Beta-blockers (BBs) are commonly prescribed to manage arrhythmias in children and adolescents without any standardised approach to establish BB adequacy. We invited all Canadian pediatric cardiologists to participate in an anonymous survey to understand practice variation in the assessment of BB adequacy in school-aged children and adolescents with arrhythmia or the potential for arrhythmia.

Methods

An electronic survey approved by the Institutional Ethics Board was distributed by e-mail to 96 Canadian pediatric cardiologists who had been active in practice for at least 1 year. Incomplete surveys were excluded.

Results

Forty-one cardiologists (43%) responded to all questions in the survey. Thirteen cardiologists (32%) reported always assessing BB adequacy, 17 (41%) did so only for specific arrhythmias, and 11 (27%) reported never performing such an assessment. A total of 19 cardiologists (46%) and 18 cardiologists (44%) reported using Holter monitoring and exercise testing, respectively, to assess beta receptor blockade adequacy. Thirteen cardiologists (32%) considered BB therapy adequate if Holter demonstrated a 20% decrease in heart rate (HR) from baseline, and 10 respondents (24%) defined adequate BB therapy using exercise testing as a 20% decrease in maximal HR or blood pressure from baseline.

Conclusion

Despite wide variation in practice, Holter monitoring and exercise testing are commonly used methods to measure the adequacy of BB therapy. There are no standard criteria, but the majority (56%) reported using a 20% decrease in HR or blood pressure from the pretreatment state as a criterion for adequate BB therapy in children and adolescents with arrhythmia or the potential for arrhythmia.

Feasibility of blood testing combined with PET-CT to screen for cancer and guide intervention

Cancer treatments are often more successful when the disease is detected early. We evaluated the feasibility and safety of multicancer blood testing coupled with positron emission tomography-computed tomography (PET-CT) imaging to detect cancer in a prospective, interventional study of 10,006 women not previously known to have cancer. Positive blood tests were independently confirmed by a diagnostic PET-CT, which also localized the cancer. Twenty-six cancers were detected by blood testing. Of these, 15 underwent PET-CT imaging and nine (60%) were surgically excised. Twenty-four additional cancers were detected by standard-of-care screening and 46 by neither approach. One percent of participants underwent PET-CT imaging based on false-positive blood tests, and 0.22% underwent a futile invasive diagnostic procedure. These data demonstrate that multicancer blood testing combined with PET-CT can be safely incorporated into routine clinical care, in some cases leading to surgery with intent to cure.

Mammography utilization among women with a negative circulating tumor DNA-based early cancer detection test

1563

Background: Blood-based tests may enable minimally invasive detection of multiple cancer types. One such test, CancerSEEK, employs ctDNA and protein biomarkers for this purpose. Test performance has been evaluated in women without a history of cancer in an ongoing prospective study called DETECT-A. The introduction of such blood tests holds promise, and their future utility lies in augmenting, not displacing, standard-of-care (SOC) cancer screening. One important safety concern is that a negative test result could provide false reassurance that discourages adherence to SOC cancer screening. To investigate this possibility, we studied delivery of mammography to DETECT-A participants before and after receipt of a negative CancerSEEK result. Methods: DETECT-A screened 10,000 women aged 65-75 using CancerSEEK. Participants completed a survey about cancer screening at enrollment and at one-year post-enrollment. We analyzed only those participants who had received a negative CancerSEEK result, were insured by Geisinger Health Plan (GHP), and had completed both surveys. GHP claims data were used to identify mammograms performed within one year prior-to and post-enrollment. Overall utilization was determined by combining claims and survey data at enrollment and one-year post-enrollment. In addition to comparing SOC screening rates pre- versus post-testing, we evaluated the impact of primary care physician (PCP) type (Geisinger versus any other institution), as screening reminder mechanisms differ between institutions. Results: Of the 2,241 participants who met analysis criteria, 73.6% (n = 1,650) had a mammogram in the year before enrollment while a significantly great number (79.3%, n = 1,777) did so during the one-year follow-up (χ2(1) = 59.05, p < 0.001). At enrollment, there were 591 participants who had not had a mammogram completed in the previous year, but 404 (68.4%) of them did have a mammogram during the one-year follow-up. The rate of change in mammography utilization did not differ between those who had a Geisinger versus a non-Geisinger PCP (χ2(2) = 1.83, p = 0.40). Conclusions: Participants in a study using a novel blood test for earlier cancer detection had a significantly higher rate of annual mammography after study enrollment and testing. These results indicate that introduction of a minimally invasive ctDNA and protein biomarker-based cancer screening test may engender greater, not lesser, utilization of SOC cancer screening. Further study is required to understand the root causes of increased utilization in this context.

Efficient Algorithms for Generating Provably Near-Optimal Cluster Descriptors for Explainability

Improving the explainability of the results from machine learning methods has become an important research goal. Here, we study the problem of making clusters more interpretable by extending a recent approach of [Davidson et al., NeurIPS 2018] for constructing succinct representations for clusters. Given a set of objects S, a partition π of S (into clusters), and a universe T of tags such that each element in S is associated with a subset of tags, the goal is to find a representative set of tags for each cluster such that those sets are pairwise-disjoint and the total size of all the representatives is minimized. Since this problem is NP-hard in general, we develop approximation algorithms with provable performance guarantees for the problem. We also show applications to explain clusters from datasets, including clusters of genomic sequences that represent different threat levels.

Evaluating the impact of international airline suspensions on the early global spread of COVID-19

Global airline networks play a key role in the global importation of emerging infectious diseases. Detailed information on air traffic between international airports has been demonstrated to be useful in retrospectively validating and prospectively predicting case emergence in other countries. In this paper, we use a well-established metric known as effective distance on the global air traffic data from IATA to quantify risk of emergence for different countries as a consequence of direct importation from China, and compare it against arrival times for the first 24 countries. Using this model trained on official first reports from WHO, we estimate time of arrival (ToA) for all other countries. We then incorporate data on airline suspensions to recompute the effective distance and assess the effect of such cancellations in delaying the estimated arrival time for all other countries. Finally we use the infectious disease vulnerability indices to explain some of the estimated reporting delays.

Abstract WP238: Atrial Fibrillation is Associated With Severe Basal Ganglia Perivascular Spaces

Introduction: High burdens of basal ganglia-perivascular spaces (BG-PVS) are often attributed to underlying hypertensive cerebral small vessel disease (HTN-CSVD). Although PVS are thought to arise from decreased perivascular drainage related to changes in arterial pulsatility, the contribution of pulsatility changes from nonvalvular atrial fibrillation (NVAF) has not been studied.

Hypothesis: We hypothesized that NVAF patients have a higher burden of BG-PVS than HTN-CSVD patients, possibly through hemodynamic factors related to NVAF.

Methods: Through an observational single-center study of consecutive stroke patients, we compared BG-EPVS severity between 136 patients with NVAF-related ischemic stroke (NVAF-IS) and 107 patients with HTN-CSVD-related intracerebral hemorrhage (HTN-ICH) without NVAF. Within the NVAF cohort, we also built multiple regression models to evaluate independent effects of NVAF-related factors on BG-PVS. All multiple regression models were adjusted for age, hypertension, sex, and neuroimaging markers of CSVD (extent of white matter hyperintensities (WMH), presence of lacunes, and cerebral microbleeds).

Results: Patients with NVAF-IS were older than patients with HTN-ICH (75 + 12 vs. 64 + 13, p < 0.0001); however, there was no difference in sex between groups ( p = 0.6). Severe BG-PVS (defined as > 20 PVS in the BG) were found in 42.6% of NVAF-IS patients vs. 8.4% of HTN-ICH ( p < 0.0001). Even after multivariate adjustment, the presence of NVAF remained significantly related to BG-PVS ( p = 0.001). Within the NVAF cohort, CHA2DS2-VASc was associated with the presence of severe BG-PVS ( p = 0.003) despite controlling for other covariates. When CHA2DS2-VASc was replaced with its individual components in the same regression model, congestive heart failure (CHF, p = 0.017), WMH burden ( p = 0.009), and age ( p = 0.02) were found to be predictors of severe BG-PVS.

Conclusions: Severe BG-PVS were significantly more common in NVAF patients compared to HTN-CSVD patients. NVAF-related features (CHA2DS2-VASc score) and CHF were associated with higher burdens of BG-PVS. These findings suggest that NVAF might play a role in the development of BG-PVS, conceivably through hemodynamic factors.

Injury profiles in elite women's T20 cricket

OBJECTIVES

To Describe the injury incidence and prevalence during two years of a professional women's T20 cricket tournament.

DESIGN

Prospective cohort study.

METHODS

Injuries were recorded prospectively for 68 matches during a professional women's T20 tournament in 2016 and 2017. There were six teams of 15 players. Participants were female, aged between 16-38 years (mean 23.4±4.8). Time-loss and non time-loss incidence and prevalence were calculated for match days, region, skill group, mode and activity at time of injury.

RESULTS

The greatest incidence occurred in the shoulder (1.8 injuries per 100 match days), lower back (1.7 injuries per 100 match days) and knee (1.7 injuries per 100 match days). The highest time-loss prevalence occurred in hand (1.7%), head/face (0.8%) and thigh (0.6%). All head injuries were concussion. Catching related injuries caused the most time-loss (2.5% prevalence) and throwing related shoulder injury had the highest incidence (2.3 injuries per 100 match days). Gradual onset injuries had the highest overall incidence (7.9 injuries per 100 match days).

CONCLUSIONS

In elite female T20 cricket, time-loss injuries, particularly impact/traumatic injuries are most likely to occur during fielding, suggesting pitch side support and trauma training is a priority. The high incidence of gradual onset injuries, particularly throwing related shoulder pain, indicates that managing workload and ensuring physical preparedness is vital.

Cord milking versus immediate clamping in preterm infants: a randomised controlled trial

OBJECTIVE

To investigate whether umbilical cord milking (UCM) at birth improves systemic blood flow and short-term outcomes, as compared with immediate cord clamping (ICC).

DESIGN

Randomised clinical trial.

SETTING

Single tertiary care centre.

PATIENTS

Infants born to eligible women presenting in preterm labour between 24 and 31 weeks' gestation.

INTERVENTIONS

UCM three times at birth or ICC.

OUTCOME MEASURES

Primary outcome included systemic blood flow as represented by echo-derived superior vena cava(SVC) flow at 4-6 hours after birth. The echocardiographer and interpreter were blinded to the randomisation. Secondary outcomes included cardiac output, neonatal morbidities and mortality. Analysis was by intention to treat.

RESULTS

A total of 73 infants were randomised (37 to UCM and 36 to ICC). Mean (SD) gestational age was 27 (2) weeks and mean (SD) birth weight was 1040 (283) g. Haemoglobin on admission was higher in the UCM than in the ICC group (16.1 vs 15.0 g/L), p=0.049 (mean difference 1.1, 95% CI 0.003 to 2.2). No statistically significant differences were found between groups in SVC flow at 4-6 hours (88.9±37.8 and 107.3±60.1 mL/kg/min), p=0.13 (mean difference -18.4, 95% CI -41.7 to 5.0 mL/kg/min) or at 10-12 hours of age (102.5±41.8 and 90.6±28.4 mL/kg/min), p=0.17 (mean difference 12.0, 95% CI -4.7 to 28.7 mL/kg/min), cardiac output or neonatal morbidities.

CONCLUSIONS

Cord milking was not shown to improve functional cardiac outcomes, neonatal morbidity or mortality. More research is needed before routine cord milking can be recommended for very preterm infants.

TRIAL REGISTRATION

NCT01487187.

Abstract TMP109: Loss of Gray-White Contrast in Cerebral Amyloid Angiopathy: An in-vivo and Ex-Vivo Exploratory Approach

Background/Purpose: Cerebral Amyloid Angiopathy (CAA) is associated with cortical and white matter atrophy. We hypothesized that changes in neural tissue signal properties could reflect microstructural alterations in diffusion, and hence demyelination.

Methods: Two cohorts of non-demented CAA patients were examined (3T: 45 CAA patients vs 16 age-matched Healthy Controls [HC]; 1.5T: 66 CAA patients vs 18 matched HC), and dichotomized into moderate (3T: n=19; 1.5T: n=24) and severe CAA. FreeSurfer was employed to calculate gray and white (GW) matter signal intensities from a T1-weighted sequence, and their ratio was used to assess GW contrast. Two diffusion markers (fractional anisotropy [FA]; apparent diffusion coefficient [ADC]) were measured via Diffusion Weighted Imaging. In addition, brains of 13 deceased patients with CAA were scanned ex-vivo, sectioned, and stained using Luxol Fast Blue, to assess myelin content. GW ratio was calculated the same way as in the in-vivo cohorts.

Results: CAA patients displayed loss of GW contrast, expressed by increased GW intensity ratio (3T: 0.802±0.01; 1.5T: 0.757±0.02), when compared to HC (3T: 0.789±0.01,p=0.003; 1.5T: 0.738±0.01,p<0.0001). Patients with severe CAA showcased even lower GW contrast (3T: 0.806±0.01; 1.5T: 0.763±0.02) than patients with moderate CAA (3T: 0.797±0.01,p<0.05; 1.5T: 0.745±0.02,p<0.05) [ Fig ]. Moreover, loss of GW contrast within CAA correlated with lower FA (r=-0.30,p=0.049) and increased ADC (r=0.52,p<0.0001). Within the ex-vivo CAA cohort, loss of GW contrast was highly linked to a decrease in underlying myelin concentration (p=0.0025).

Conclusions: CAA patients consistently displayed lower GW contrast compared to HC. This loss of contrast became more pronounced with increased disease severity, and correlated with lower anisotropy and increased water diffusivity. Indeed, an ex-vivo CAA cohort revealed that loss of GW contrast corresponded to a decrease in myelin concentration.

Remediation in Canadian medical residency programs: Established and emerging best practices

BACKGROUND

Policies to guide remediation in postgraduate medical education exist in all Canadian medical schools. This study examines concordance between these policies and processes, and published "best practices" in remediation.

METHOD

We conducted a literature review to identify best practices in the area of remediation. We then reviewed remediation policies from all 13 English medical schools in Canada other than our own and conducted interviews with key informants from each institution. Each policy and interview transcript pair was then reviewed for evidence of pre-defined "best practices." Team members also noted additional potential policy or process enablers of successful remediation.

RESULTS

Most policies and processes aligned with some but not all published best practices. For instance, all participating schools tailored remediation strategies to individual resident needs, and a majority encouraged faculty-student relationships during remediation. Conversely, few required the teaching of goal-setting, strategic planning, self-monitoring, and self-awareness. In addition, we identified avoidance of automatic training extension and the use of an educational review board to support the remediation process as enablers for success.

DISCUSSION

Remediation policies and practices in Canada align well with published best practices in this area. Based on key informant opinions, flexibility to avoid training extension and use of an educational review board may also support optimal remediation outcomes.

Ambient Pollutants and Spontaneous Intracerebral Hemorrhage in Greater Boston

Background and Purpose- Associations between exposures to ambient air pollution and spontaneous intracerebral hemorrhage (ICH) have been inconsistent, and data on stroke subtypes are currently limited. Methods- We obtained information on all cases of deep or lobar hematomas from ICH patients who were admitted to the Massachusetts General Hospital in Boston, MA, between 2006 and 2011. We linked the date of admission with 1- to 7-day moving averages of fine particulate matter (PM2.5), black carbon, nitrogen dioxide, and ozone from area monitors. We conducted time-stratified bidirectional case-crossover analyses to assess associations between pollutants and stroke. We also investigated whether associations differed by hemorrhage location and type. Results- There were 577 cases of ICH (295 deep, 282 lobar). Overall, there was no evidence of elevated ICH risk after increases in PM2.5, black carbon, or nitrogen dioxide in the whole population. However, there was suggestion of heightened risk with higher levels of ozone for averages longer than 1 day although CIs were wide. In models stratified by ICH location, associations with ozone remained positive for patients with lobar (3-day moving average odds ratio, 1.62; 95% CI, 1.18-2.22) but not deep ICH (odds ratio, 0.88; 95% CI, 0.65-1.20). Larger estimates were observed among participants with a probable diagnosis of cerebral amyloid angiopathy (odds ratio, 2.23; 95% CI, 1.25-3.96). Conclusions- Exposure to ozone may be associated with incidence of lobar ICH, especially among those who have confirmed or probable cerebral amyloid angiopathy.

The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use?

PURPOSE

The authors previously developed and tested a reflective model for facilitating performance feedback for practice improvement, the R2C2 model. It consists of four phases: relationship building, exploring reactions, exploring content, and coaching. This research studied the use and effectiveness of the model across different residency programs and the factors that influenced its effectiveness and use.

METHOD

From July 2014-October 2016, case study methodology was used to study R2C2 model use and the influence of context on use within and across five cases. Five residency programs (family medicine, psychiatry, internal medicine, surgery, and anesthesia) from three countries (Canada, the United States, and the Netherlands) were recruited. Data collection included audiotaped site assessment interviews, feedback sessions, and debriefing interviews with residents and supervisors, and completed learning change plans (LCPs). Content, thematic, template, and cross-case analysis were conducted.

RESULTS

An average of nine resident-supervisor dyads per site were recruited. The R2C2 feedback model, used with an LCP, was reported to be effective in engaging residents in a reflective, goal-oriented discussion about performance data, supporting coaching, and enabling collaborative development of a change plan. Use varied across cases, influenced by six general factors: supervisor characteristics, resident characteristics, qualities of the resident-supervisor relationship, assessment approaches, program culture and context, and supports provided by the authors.

CONCLUSIONS

The R2C2 model was reported to be effective in fostering a productive, reflective feedback conversation focused on resident development and in facilitating collaborative development of a change plan. Factors contributing to successful use were identified.

Hepatic connexin 32 associates with nonalcoholic fatty liver disease severity

Emerging data highlight the critical role for the innate immune system in the progression of nonalcoholic fatty liver disease (NAFLD). Connexin 32 (Cx32), the primary liver gap junction protein, is capable of modulating hepatic innate immune responses and has been studied in dietary animal models of steatohepatitis. In this work, we sought to determine the association of hepatic Cx32 with the stages of human NAFLD in a histologically characterized cohort of 362 patients with NAFLD. We also studied the hepatic expression of the genes and proteins known to interact with Cx32 (known as the connexome) in patients with NAFLD. Last, we used three independent dietary mouse models of nonalcoholic steatohepatitis to investigate the role of Cx32 in the development of steatohepatitis and fibrosis. In a univariate analysis, we found that Cx32 hepatic expression associates with each component of the NAFLD activity score and fibrosis severity. Multivariate analysis revealed that Cx32 expression most closely associated with the NAFLD activity score and fibrosis compared to known risk factors for the disease. Furthermore, by analyzing the connexome, we identified novel genes related to Cx32 that associate with NAFLD progression. Finally, we demonstrated that Cx32 deficiency protects against liver injury, inflammation, and fibrosis in three murine models of nonalcoholic steatohepatitis by limiting initial diet-induced hepatoxicity and subsequent increases in intestinal permeability. Conclusion: Hepatic expression of Cx32 strongly associates with steatohepatitis and fibrosis in patients with NAFLD. We also identify novel genes associated with NAFLD and suggest that Cx32 plays a role in promoting NAFLD development. (Hepatology Communications 2018;2:786-797).