Seven ways to get a grip on implementing Competency-Based Medical Education at the program level

Competency-based medical education (CBME) curricula are becoming increasingly common in graduate medical education. Put simply, CBME is focused on educational outcomes, is independent of methods and time, and is composed of achievable competencies.¹ In spite of widespread uptake, there remains much to learn about implementing CBME at the program level. Leveraging the collective experience of program leaders at Queen's University, where CBME simultaneously launched across 29 specialty programs in 2017, this paper leverages change management theory to provide a short summary of how program leaders can navigate the successful preparation, launch, and initial implementation of CBME within their residency programs.

Longitudinal effects of enrofloxacin or tulathromycin use in preweaned calves at high risk of bovine respiratory disease on the shedding of antimicrobial-resistant fecal Escherichia coli

The objective of this study was to longitudinally quantify Escherichia coli resistant to ciprofloxacin and ceftriaxone in calves treated with enrofloxacin or tulathromycin for the control of bovine respiratory disease (BRD). Dairy calves 2 to 3 wk of age not presenting clinical signs of pneumonia and at high risk of developing BRD were randomly enrolled in 1 of 3 groups receiving the following treatments: (1) single label dose of enrofloxacin (ENR); (2) single label dose of tulathromycin (TUL); or (3) no antimicrobial treatment (control, CTL). Fecal samples were collected immediately before administration of treatment and at d 2, 4, 7, 14, 21, 28, 56, and 112 d after beginning treatment. Samples were used for qualification of E. coli using a selective hydrophobic grid membrane filter (HGMF) master grid. The ENR group had a significantly higher proportion of E. coli resistant to ciprofloxacin compared with CTL and TUL at time points 2, 4, and 7. At time point 28, a significantly higher proportion of E. coli resistant to ciprofloxacin was observed only compared with CTL. The TUL group had a significantly higher proportion of E. coli resistant to ciprofloxacin compared with CTL at time points 2, 4, and 7. None of the treatment groups resulted in a significantly higher proportion of E. coli isolates resistant to ceftriaxone. Our study identified that treatment of calves at high risk of developing BRB with either enrofloxacin or tulathromycin resulted in a consistently higher proportion of ciprofloxacin-resistant E. coli in fecal samples.

Heat treatment of bovine colostrum: II. Effects on calf serum immunoglobulin, insulin, and IGF-I concentrations, and the serum proteome

In-depth analysis of colostrum components has identified hundreds of proteins, but data are sparse regarding their systemic uptake in the newborn calf. Moreover, heat treatment may influence these colostral components and their absorption. Our objectives were to describe the serum proteome of newborn calves before and after colostrum feeding and the possible effects of colostral heat treatment. Newborn Holstein heifer calves (n = 22) were randomized within pair and fed heat-treated (n = 11; 60°C, 60 min) or raw (n = 11) colostrum at 8.5% of birth body weight by esophageal feeder within 1 h of birth. After the single colostrum feeding, calves were not fed until after the 8-h time point, when milk was offered free-choice. Blood samples were taken immediately before feeding (0 h), as well as 4, 8, and 24 h after feeding. Whole blood packed cell volume (%), serum Brix percentage, and plasma glucose concentrations were determined for all time points. Plasma insulin and insulin-like growth factor-I concentrations were determined by radioimmunoassay for selected time points. Serum IgA and IgG were measured by radial immunodiffusion at 24 h. The serum proteome was analyzed using nano-scale reverse-phase chromatography and tandem mass spectrometry (nano LC-MS/MS) in 0- and 8-h samples. For proteomics analysis, ratios of results for 8-h to 0-h samples were analyzed with false discovery rate adjustment. For all other outcomes, repeated-measures ANOVA was performed with the fixed effects of group, time, and their interaction, and random effect of pair. Serum Brix percentage and glucose concentrations increased over time and were independent of colostrum treatment. Serum IgG and IgA concentrations at 24 h did not differ between groups. Nano LC-MS/MS identified a total of 663 unique proteins in serum, of which 261 increased in abundance, whereas 67 decreased in abundance after feeding in both groups. Among serum proteins that increased in abundance and that were previously identified in colostrum, many belonged to those involved in immune response, coagulation, the classical complement pathway, or the antimicrobial peptide class of cathelicidins. Serum proteins that decreased in abundance and that were identified in colostrum belonged to the alternative complement pathway and the membrane attack complex. Thirty-eight proteins differed in calves that were fed heat-treated colostrum compared with those fed raw colostrum. Decreased abundances in calves fed heat-treated colostrum included several enzymes involved in glycolysis or glycogenolysis, whereas the incretin gastric inhibitory polypeptide and serum insulin were increased in this group. Our findings point to important innate immune defense pathways associated with colostrum ingestion in newborn calves. Furthermore, calves fed heat-treated colostrum showed differences in serum proteins and enzymes associated with carbohydrate metabolism.

Heat treatment of bovine colostrum: I. Effects on bacterial and somatic cell counts, immunoglobulin, insulin, and IGF-I concentrations, as well as the colostrum proteome

The objective of this study was to investigate the effects of heat treatment on colostral low-abundant proteins, IgG and IgA, insulin, and insulin-like growth factor I (IGF-I), as well as bacteria and somatic cells. First-milking colostrum samples >8 L and Brix % > 22.0 were harvested from 11 Holstein cows on a commercial dairy in New York State and split into 2 aliquots using single-use colostrum bags. One aliquot of each pair was cooled on ice immediately after harvest (raw, R; n = 11), and the other was heat-treated for 60 min at 60°C (heat, H; n = 11). All samples were analyzed for IgG and IgA via radial immunodiffusion assay and insulin and IGF-I concentrations by radioimmunoassay. Total bacterial counts and somatic cell counts (SCC) were determined using standard plate culture techniques and flow cytometry, respectively. Samples from a subset of 5 pairs (n = 10) were further analyzed by nano liquid chromatography-tandem mass spectroscopy, after ultracentrifugation at 100,000 × g for 60 min at 4°C to enrich the low-abundant protein whey fraction. Data were analyzed using either paired t-test or Wilcoxon signed-rank test or using an online software package to analyze proteomics data. Outcomes of proteomics analysis were fold change ≥1.5 between pairs, and paired t-tests with false discovery rate-adjusted P-value < 0.05. The median reduction of IgA concentrations was 8.5% (range: 0-38.0%) due to heat treatment, whereas IgG concentrations did not change due to treatment. Insulin concentrations decreased by a median of 22% (7-45%), and IGF-I decreased by 10% (0-18%) in H samples. Heat treatment was associated with a median reduction of SCC of 36% (0-90%) in paired samples, as well as a median reduction in total bacterial count of 93% (45-100%) in H versus R samples. Proteomics analysis identified a total of 328 unique proteins that were present in all 10 samples. Nine of the 25 proteins that decreased by at least 1.5-fold in H compared with R were identified as complement proteins. We conclude that heat treatment of colostrum is associated with a reduction in the concentration of bacterial counts and SCC, IgA, insulin, and IGF-I. In addition, proteomics analysis of colostral whey identified several complement components and other proteins that decreased in abundance due to heat treatment. Although IgG concentrations were unaffected and a reduction in bacterial counts was achieved, the change in several immunologically active proteins and growth factors may have biologically important effects on the developing immune system of the neonate fed heat-treated colostrum.

Using fMRI connectivity to define a treatment-resistant form of post-traumatic stress disorder

A mechanistic understanding of the pathology of psychiatric disorders has been hampered by extensive heterogeneity in biology, symptoms, and behavior within diagnostic categories that are defined subjectively. We investigated whether leveraging individual differences in information-processing impairments in patients with post-traumatic stress disorder (PTSD) could reveal phenotypes within the disorder. We found that a subgroup of patients with PTSD from two independent cohorts displayed both aberrant functional connectivity within the ventral attention network (VAN) as revealed by functional magnetic resonance imaging (fMRI) neuroimaging and impaired verbal memory on a word list learning task. This combined phenotype was not associated with differences in symptoms or comorbidities, but nonetheless could be used to predict a poor response to psychotherapy, the best-validated treatment for PTSD. Using concurrent focal noninvasive transcranial magnetic stimulation and electroencephalography, we then identified alterations in neural signal flow in the VAN that were evoked by direct stimulation of that network. These alterations were associated with individual differences in functional fMRI connectivity within the VAN. Our findings define specific neurobiological mechanisms in a subgroup of patients with PTSD that could contribute to the poor response to psychotherapy.

An Electroencephalography Connectomic Profile of Posttraumatic Stress Disorder

OBJECTIVE

The authors sought to identify brain regions whose frequency-specific, orthogonalized resting-state EEG power envelope connectivity differs between combat veterans with posttraumatic stress disorder (PTSD) and healthy combat-exposed veterans, and to determine the behavioral correlates of connectomic differences.

METHODS

The authors first conducted a connectivity method validation study in healthy control subjects (N=36). They then conducted a two-site case-control study of veterans with and without PTSD who were deployed to Iraq and/or Afghanistan. Healthy individuals (N=95) and those meeting full or subthreshold criteria for PTSD (N=106) underwent 64-channel resting EEG (eyes open and closed), which was then source-localized and orthogonalized to mitigate effects of volume conduction. Correlation coefficients between band-limited source-space power envelopes of different regions of interest were then calculated and corrected for multiple comparisons. Post hoc correlations of connectomic abnormalities with clinical features and performance on cognitive tasks were conducted to investigate the relevance of the dysconnectivity findings.

RESULTS

Seventy-four brain region connections were significantly reduced in PTSD (all in the eyes-open condition and predominantly using the theta carrier frequency). Underconnectivity of the orbital and anterior middle frontal gyri were most prominent. Performance differences in the digit span task mapped onto connectivity between 25 of the 74 brain region pairs, including within-network connections in the dorsal attention, frontoparietal control, and ventral attention networks.

CONCLUSIONS

Robust PTSD-related abnormalities were evident in theta-band source-space orthogonalized power envelope connectivity, which furthermore related to cognitive deficits in these patients. These findings establish a clinically relevant connectomic profile of PTSD using a tool that facilitates the lower-cost clinical translation of network connectivity research.

Effect of rumen-protected branched-chain amino acid supplementation on production- and energy-related metabolites during the first 35 days in milk in Holstein dairy cows

Essential AA are critical for multiple physiological processes. Branched-chain AA (BCAA) supplementation has beneficial effects on body weight, lipogenesis, and insulin resistance in several species. The BCAA are used for milk and body protein synthesis as well as being oxidized by the tricarboxylic acid cycle to produce ATP during catabolic states. The objective was to evaluate the effect of rumen-protected BCAA (375 g of 27% l-Leu, 85 g of 48% l-Ile, and 91 g of 67% l-Val) with or without propylene glycol (PG) oral administration on milk production, dry matter intake, nonesterified fatty acids, β-hydroxybutyrate, and plasma urea nitrogen during the first 35 d in milk (DIM) in dairy cattle. Multiparous Holstein cows were enrolled in blocks of three 28 d before expected calving and assigned randomly to either the control or 1 of 2 treatments. The control (n = 26) received 200 g/d of dry molasses, the BCAA treatment (n = 23) received BCAA mixed with 200 g/d of dry molasses from calving until 35 DIM, and the BCAA plus PG (BCAAPG) treatment (n = 25) received BCAA mixed with 200 g/d of dry molasses from calving until 35 DIM plus 300 mL of PG once daily from calving until 7 DIM. Postpartum, dry matter intake least squares means (LSM; 95% confidence interval) were 20.7 (19.9, 21.7), 21.3 (20.4, 22.3), and 21.9 (20.9, 22.8) kg for control, BCAA, and BCAAPG, respectively. Milk yield (1-35 DIM) LSM were 41.7 (39.4, 44.0), 42.7 (40.3, 45.0), and 43.7 (41.4, 46.0) kg for control, BCAA, and BCAAPG, respectively. Energy-corrected milk LSM were 50.3 (46.8, 53.7), 52.4 (48.9, 55.8), and 52.9 (49.5, 56.4) kg for control, BCAA, and BCAAPG, respectively. Milk urea nitrogen LSM in milk for control, BCAA, and BCAAPG were 8.60 (8.02, 9.22), 9.70 (9.01, 10.45), and 9.75 (9.08, 10.47) mg/dL. Plasma urea nitrogen concentrations LSM for control, BCAA, and BCAAPG were 8.3 (7.7, 8.9), 10.1 (9.4, 10.9), and 9.6 (9.4, 10.3) mg/dL, respectively. The numbers of plasma samples classified as hyperketonemia were 77, 44, and 57 in control, BCAA, and BCAAPG, respectively. The BCAA supplementation increased plasma urea nitrogen and milk urea nitrogen, free valine concentration in plasma, and decreased hyperketonemia events during the postpartum period.

A retrospective analysis of policy development on compliance with World Health Organization's physical activity recommendations between 2002 and 2005 in European Union adults: closing the gap between research and policy

Background

Physical inactivity (PIA) is a mortality risk factor defined as performing lower levels of physical activity than recommended by the World Health Organization (WHO). After 2002, the WHO released the WHA55.23 Resolution and the Global Strategy which produced several changes in policymaking, but with no subsequent analyses of the impact of these changes in European Union (EU) policymaking while examining PIA prevalence.

Methods

PIA of 31,946 adults as a whole sample and country-by-country were analyzed in the 2002 and 2005 EU Special Eurobarometers. PIA prevalence between countries was performed with the χ2 test and PIA between both years and between genders was analyzed with the Z-Score test for two population proportions. A retrospective analysis of national plans was performed to interpret the suitability of such policy documents, considering changes in PIA prevalence.

Results

Differences in PIA prevalence were observed between countries (p <  0.001) and years (p <  0.001) for the whole sample and men and women separately. Within-country samples showed no differences for Denmark, Finland, Ireland, Italy, Luxemburg, Portugal, and Spain (p > 0.05). When considering gender, there were no gender reductions in subsamples for Denmark, Finland, Ireland, Portugal, Spain, and United Kingdom, neither in Luxemburg for men, nor in France and Italy for women. When analyzing gender differences across the entire sample, PIA was higher in women than men for both years (p <  0.001). Greece and Luxemburg did not release national plans for promoting physical activity.

Conclusions

While large differences in PIA prevalence between EU countries prevailed, the overall PIA descended between both years for the whole sample, men, and women. While this points out a general suitability of policymaking for reducing PIA, not all countries reported reductions in PIA for men, women, or both genders. Also, PIA levels were higher for women in both years, suggesting a less than optimal policy implementation, or lack of women-specific focus across the EU. This analysis helps to identify the strengths and weaknesses of PIA policymaking in the EU and provides researchers with targeted intervention areas for future development.

Rare coding variant analysis in a large cohort of Ashkenazi Jewish families with inflammatory bowel disease

Rare variants are thought to contribute to the genetics of inflammatory bowel disease (IBD), which is more common amongst the Ashkenazi Jewish (AJ) population. A family-based approach using exome sequencing of AJ individuals with IBD was employed with a view to identify novel rare genetic variants for this disease. Exome sequencing was performed on 960 Jewish individuals including 513 from 199 multiplex families with up to eight cases. Rare, damaging variants in loci prioritized by linkage analysis and those shared by multiple affected individuals within the same family were identified. Independent evidence of association of each variant with disease was assessed. A number of candidate variants were identified, including in genes involved in the immune system. The ability to achieve statistical significance in independent case/control replication data was limited by power and was only achieved for variants in the well-established Crohn's disease gene, NOD2. This work demonstrates the challenges of identifying disease-associated rare damaging variants from exome data, even amongst a favorable cohort of familial cases from a genetic isolate. Further research of the prioritized rare candidate variants is required to confirm their association with the disease.

Evaluation of a vaccine passport to improve vaccine coverage in people living with HIV

An increased risk of vaccine-preventable infections (VPIs) is seen in people living with HIV (PLWH), and current vaccine coverage and immunity is variable. Vaccine passports have the potential to improve vaccine coverage. The objective was to assess how successful a vaccine passport was in improving vaccine coverage in PLWH. Baseline immunity to VPIs was established in PLWH attending a single HIV clinic and vaccinations required were determined based on the BHIVA Vaccination Guidelines (2015). The passport was completed and the PLWH informed about additional vaccines they should obtain from primary care. After 6-9 months the passport was reviewed including confirmation if vaccines were given. PLWH satisfaction with the system was evaluated by a survey. Seventy-three PLWH provided sufficient data for analysis. At baseline significant proportions of PLWH were not immune/unvaccinated to the main VPIs, especially human papillomavirus, pneumococcus and measles. After the passport was applied immunity improved significantly (56% overall, p < 0.01) for most VPIs; however, full coverage was not achieved. The system was popular with PLWH. The passport was successful in increasing vaccination coverage although full or near-full coverage was not achieved. A more successful service would probably be achieved by commissioning English HIV clinics to provide all vaccines.

Diagnostic performance of cytology for assessment of hepatic lipid content in dairy cattle

The objective of our study was to characterize the diagnostic performance of cytology for assessing hepatic lipid content (HLC) in dairy cows by comparing microscopic evaluation of lipid vacuolation in touch imprint slide preparations of liver biopsies with quantitative measurement of triglyceride concentration ([TG]; mg/mg of wet weight) in paired biopsy samples. Our study also sought to compare the diagnostic performance of liver cytology, plasma nonesterified fatty acid concentration ([NEFA]), and plasma β-hydroxybutyrate concentration ([BHB]) derived from a measurement performed on whole blood, for assessing HLC. Chemical extraction of TG from liver tissue remains the gold standard for quantifying HLC, largely because available blood tests, although useful for detecting some types of pathology, such as increased lipid mobilization, ketosis, or hepatocellular injury, are nonspecific as to etiology. Veterinary practitioners can sample bovine liver for cytological evaluation in a fast, minimally invasive, and inexpensive manner. Thus, if highly predictive of HLC, cytology would be a practical diagnostic tool for dairy veterinarians. In our study, liver biopsy samples from Holstein cows (219 samples from 105 cows: 52 from cows 2 to 20 d prepartum, 105 from cows 0 to 10 d in milk, 62 from cows 18 to 25 d in milk) were used to prepare cytology slides and to quantify [TG] using the Folch extraction method followed by the Hantzch condensation reaction and spectrophotometric measurement. An ordinal scale (0-4) based on amount of hepatocellular cytoplasm occupied by discrete clear vacuoles was used by 3 blinded, independent observers to rank HLC in Wright-Giemsa-stained slides. Interobserver agreement in cytology scoring was good. Corresponding plasma [NEFA] and [BHB] measurements were available for 187 and 195 of the 219 samples, respectively. Liver [TG] correlated more strongly with cytology score than with NEFA or BHB, and receiver operating characteristic curve analysis showed that cytology had better diagnostic performance than either NEFA or BHB for correctly categorizing [TG] at thresholds of 5, 10, and 15%. Hepatic lipidosis in high-producing dairy cows is of major clinical and economic importance, and this study demonstrates that cytology is an accurate means of assessing HLC. Additional work is indicated to evaluate the diagnostic utility of liver cytology.

A formative review of physical activity interventions for minority ethnic populations in England

Background

Physical activity (PA) levels are lower among some UK Black and minority ethnic (BME) groups than the majority White British population and a variety of tailored interventions have emerged. This study documents the characteristics and logic of local adaptations, a vital first step in evaluating such innovations.

Methods

An English PA data set was examined to identify and characterize PA programmes focussed on BME populations. Three case studies were conducted, employing documentary analysis and qualitative interviews. Netto et al.'s principles of adapting health promotion interventions for BME populations guided the analysis.

Results

Out of 861 PA interventions, 57 focussed on BME populations. These were typically aimed to engage the most inactive groups, improve both health and social outcomes and were largely publically/charitably funded. Tailored approaches matched Netto et al.'s five principles: using community resources for publicity, identifying and addressing barriers, developing sensitive communication strategies, working with values and accommodating cultural identification. Another common principle was identified: building community capacity for sustainability.

Conclusions

PA interventions tailored to the needs of BME groups reflect their largely disadvantaged position in society and focus on inactivity. The six principles could be used as a framework for developing, designing and evaluating tailored interventions for BME populations.

Primary Care Provider Management of Congenital Hypothyroidism Identified Through Newborn Screening

OBJECTIVE

To assess Primary Congenital Hypothyroidism (CH) management patterns and feasibility of providing long-term care for patients with CH identified through newborn screening by Primary Care Providers (PCPs) in California and Hawaii.

STUDY DESIGN

A survey was mailed to all physicians (N=823) listed as the referral doctor for confirmed patients with CH identified through newborn screening programs in both states between 01/01/2009-12/31/2013. Information was collected on CH management patterns, barriers to providing care, and knowledge on CH treatment. Descriptive statistics and bivariate logistic regression results were reported.

RESULTS

206 PCPs completed the survey. Among these, 78% currently have patients with CH and 91% indicated willingness to provide long-term care to new patients with CH. Among PCPs currently caring for patients with CH, 17% managed CH by themselves with limited assistance from endocrinologists; 63% were involved in managing CH but endocrinologists played a larger role than PCPs; 19% were not involved in CH care. Only 49% of PCPs correctly answered questions regarding recommended follow-up frequencies and 23% knew the correct age for a trial off levothyroxine for suspected transient CH. Top two perceived barriers to providing long-term care included "need guidance or support from endocrinologists" (61%) and "not familiar with CH treatment guidelines" (28%).

CONCLUSION

The majority of PCPs surveyed are willing to provide long-term care to patients with CH, but need support from endocrinologists and increased knowledge about current treatment guidelines.

Hepatic Lipodystrophy in Galloway Calves

Hepatic lipodystrophy in Galloway calves is a fatal liver disease affecting a small proportion of the Galloway breed described in different parts of Europe and North America during the past decades. The clinical findings include a diversity of neurological signs. Clinical pathology findings frequently indicate hepatobiliary disease. Postmortem examination reveals an enlarged, pale yellow, and firm liver. Histologic lesions include hepatic fibrosis, hepatic lipidosis, and bile duct hyperplasia. To date, the etiopathogenesis remains obscure. Infectious causes, intoxications, and a hereditary origin have been considered. We describe hepatic lipodystrophy in Galloway calves from an extensively farmed cow-calf operation in southern Germany. Main clinical findings in 6 calves were consistent with hepatic encephalopathy. Clinical pathology findings in 5 of 6 tested animals revealed increased concentration of total bilirubin (maximum value [MV], 54 μmol/l; reference range [RR], <8.5 μmol/l), direct bilirubin (MV, 20 μmol/l; RR, <3.4 μmol/l), increased activity of gamma glutamyl transferase (MV, 162 U/l; RR, <36 U/l) and glutamate dehydrogenase (MV, 420 U/l; RR, <16 U/l). In addition, activity of glutathione peroxidase was decreased in all tested ( n = 5) animals (MV, 61 U/g hemoglobin [Hb]; RR, >250 U/g Hb). Postmortem examination in 6 calves revealed a firm, diffusely enlarged yellow liver with a finely nodular surface. Histologic lesions included hepatic fibrosis, hepatic lipidosis, and bile duct hyperplasia. Our findings add to the existing data on hepatic lipodystrophy in the Galloway breed and outline a protocol to aid in the diagnosis of this disorder.