Teaching, reflecting, and learning: The value of an intercalated medical education programme

Objectives: Teaching programmes within medicine focus primarily on pathways of a shorter length with little regard to teaching lasting longer than a month. This study is different from other studies as it examines the benefits of a nine month-long medical education degree programme and its impact beyond graduation. This study set out to explore the impact of a medical education intercalated degree programme for its graduates and their careers.Methods: A small scale, exploratory qualitative case study was conducted with 10 graduates of an intercalated degree programme.Results: The findings highlight the longer term value of an intercalated degree programme with particular emphasis on academic and personal skills; research and teaching skills; independence and confidence; its impact on future practice and the notion that 'student as teacher' programmes are a valuable asset to medical education as a whole. Participants advocated more teaching opportunities as a core longitudinal teaching component in preparation for the teaching responsibilities in their working lives.Conclusions: The programme enables the development of a range of academic and personal skills, with particular emphasis on research and teaching skills, independence and confidence.

Disseminating research findings using a massive online open course for maximising impact and developing recommendations for practice

Background

Developing recommendations for how we deliver healthcare is often left to leading experts in a field. Findings from the Integrated Palliative Care in cancer and chronic conditions (InSup-C) study, which aimed to identify best practice in integrated palliative care in cancer, chronic obstructive pulmonary disease (COPD) and heart failure, led to recommendations developed through an expert consultation process. We also wanted to develop these recommendations further with participants who were largely clinicians and members of the public.

Methods

Results from the InSup-C study were disseminated through a three-week massive open online course (MOOC) which ran in 2016, 2017 and 2019. The first course helped develop the final recommendations, which were ranked by MOOC participants in the subsequent courses. MOOC participants were predominantly clinicians, but also academics and members of the public. They rated how important each recommendation was on a 9 point scale (9 most important). Descriptive statistics were used to analyse the ratings. The results were compared to findings from the consultation.

Results

Five hundred fifteen completed the last part of the course where the recommendations were ranked, of which 195 (38%) completed the ratings. The top recommendations related to: need to expand palliative care to non-malignant conditions; palliative care needs to include different dimensions of care including physical, psychological and spiritual; policies and regulations assessments should be made regularly; palliative care integration should be mandatory; and there should be greater availability of medicines. These differed compared to the top ranked recommendations by the consultation panel in relation to the importance of leadership and policy making. This may indicate that clinicians are more focused on daily care rather than the (inter) national agenda.

Conclusions

Whilst both sets of recommendations are important, our study shows that we need to include the views of clinicians and the public rather than rely upon leading expert opinion alone. To keep recommendations fresh we need both the input of clinicians, the public and experts. When disseminating findings, MOOCs offer a useful way to gain greater reach with clinicians and the public, and importantly could be a vehicle to validate recommendations made by leading expert panels.

Exploring learning needs for general practice based pharmacist: Are behavioural and influencing skills needed?

Background

Embedding pharmacists in general practice has been shown to create cost efficiencies, improve patient care and free general practitioner capacity. Consequently, there is a drive to recruit additional pharmacists to work within general practices. However, equipping pharmacists with behaviour and influencing skills may further optimise their impact. Key elements which may enhance behaviour and influencing skills include self-efficacy and resilience.

Objective

This study aimed to: 1) Assess general practice pharmacists' self-efficacy and resilience. 2) Explore differences primarily between pharmacists reporting lower and higher self-efficacy, secondarily for those reporting lower and higher scores for resilience.

Methods

All 159 NHS Greater Glasgow and Clyde general practice pharmacists were invited to complete an online survey in May 2019. The survey captured anonymised data covering: demographics; professional experience; qualifications, prescribing status and preferred learning styles. Unconscious learning needs for behavioural and influencing skills were assessed using validated tools: the new general self-efficacy scale (GSES) and short general resilience scale (GRIT). Participants' responses were differentiated by the lowest quartile and higher quartiles of GSES and GRIT scores, and analysed to identify differences.

Results

The survey was completed by 57% (91/159) of eligible pharmacists; mean age 38 (range 24-60) years; 91% were of white ethnicity and 89% female. The median time qualified was 14 (1-38) years and 3 (1-22) years working in general practices. Overall pharmacists scored well on the GSES, mean 25 (SD 3; 95%CI 24.4-25.6), and GRIT, mean 30 (SD 4; 95%CI 29.6-30.4), out of a maximum 32 and 40 respectively. A significant positive correlation between GSES and GRIT scores was found (Pearson's r=0.284, p=0.006). However, no significant differences were identified between pharmacists scoring in the lower and upper quartiles by GSES or GRIT. Overall respondents reported their preferred learning styles were activists (46%) or pragmatists (29%). The majority (91%) preferred blended learning methods as opposed to 38% or less for a range of online methods.

Conclusions

General practice pharmacists on average scored highly for self-efficacy and resilience. Higher scores did not appear to be associated with demographic, years of practice, professional or educational experience. Prospective interventions to support those with lower scores may enhance and optimise pharmacists' effectiveness in general practice.

Evaluating integrated surveillance of antimicrobial resistance: experiences from use of three evaluation tools

BACKGROUND

Integrated antimicrobial resistance (AMR) surveillance programmes require regular evaluation to ensure they are fit for purpose and that all actors understand their responsibilities. This will strengthen their relevance for the clinical setting, which depends heavily on continued access to effective treatment options. Several evaluation tools addressing different surveillance aspects are available.

OBJECTIVES

The aim was to understand the strengths and weaknesses of three evaluation tools, and to improve guidance on how to choose a fit-for-purpose tool.

SOURCES

Three tools were assessed: (a) AMR-PMP-the Progressive Management Pathway tool on AMR developed by the Food and Agriculture Organization (FAO) of the United Nations, (b) NEOH developed by the EU COST Action 'Network for Evaluation of One Health' and (c) SURVTOOLS developed in an FP7-EU project 'RISKSUR'. Each tool was assessed with regard to contents, required evaluation processes including stakeholder engagement and resource demands, integration coverage across relevant sectors and applicability. They were compared using a predefined scoring scheme and a strengths-weaknesses-opportunities-threats (SWOT)-like format for commenting.

CONTENT

All three tools address multiple decision-making levels and aspects of stakeholder engagement. NEOH focuses on system features, learning, sharing, leadership and infrastructure, and requires a description of the underlying system in which AMR develops. AMR-PMP focuses on four areas: awareness, evidence, governance and practices and assesses the implementation degree of pre-chosen aspects within these areas. This requires less of the evaluator, but warrants participation of multiple stakeholders. SURVTOOL provides information and references on how to evaluate effectiveness, process and comprehensiveness of surveillance programmes. All three tools require veterinary epidemiology expertise and varying levels of evaluation methodology training to use appropriately.

IMPLICATIONS

The tools covered AMR surveillance and One Health aspects to varying degrees. This study provides guidance on aspects to consider when choosing between available tools and embarking on an evaluation of integrated surveillance.

An international series on the integration of community pharmacy in primary health care

The interrelationship between governmental policies and objectives in primary health care and community pharmacy/pharmacists’ strategic plans are of the outmost importance, having significant professional, economic and practical consequences for the future of the pharmacy profession, research, education and health care. Sharing information of the potential and real impact on current and future practice of community pharmacy/pharmacists, be it in product or service, in primary care would benefit many stakeholders. In order to create and focus professional and scientific debate the journal has commissioned key experts to contribute a series of country case studies. The aim of the series is to promulgate and disseminate country-based information on primary health care and community pharmacy/pharmacist.

Primary health care policy and vision for community pharmacy and pharmacists in England

The United Kingdom health and care system is changing dramatically to meet the health challenges of the 21^st century. People will increasingly have multiple morbidities. The focus of service delivery is changing from hospital to community, patient to population and curative to preventive. This paper describes the NHS and primary care and community pharmacy in England at the start of 2020, a time of great change. The 10-year vison for the NHS is that everyone gets the best start in life, world class care for major health problems supporting people to age well. It has over 40 mentions of pharmacists and pharmacy. The key aims of the plan are to improve ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health service in England. All of England is covered by integrated care systems and the newly formed primary care networks which will form the foundation of these new systems. Pharmacy is involved at multiple levels. There are 11,569 community pharmacies and most of their total income comes from the NHS (range 68-85%). Around 60% pharmacies are part of multiple chains, with the remaining 40% independents or small chains of less than six outlets. The new five-year community pharmacy contract provides an opportunity to develop community pharmacy and move towards service delivery away from dispensing volume. The new services are described under medicines optimisation, prevention and urgent care. The pharmacy quality scheme is also described. The new deal will help many community pharmacies to plan their future, particularly for those pharmacies who are ready and able to change and work closely with pharmacists and other health professionals in collaboration with Primary Care Networks. There will be specific challenges around: dispensing efficiencies, freeing up pharmacists’ time, wider use of clinical skills of community pharmacists, community pharmacy viability and consolidations.

Integration of Basic and Clinical Sciences: Student Perceptions

The integrated curriculum is becoming a popular concept among dental schools. The purpose of this study was to query dental students at the University of Texas Health Science Center at Houston - School of Dentistry (UTSD) to elucidate their level of interest in the integrated curriculum, perception of how much integration is currently occurring, and identify challenges to integration. To address this question, dental students at UTSD were invited to participate in a survey. Participants reported their perspectives on integration of sciences. All survey participants agreed that it is beneficial to integrate clinical and basic sciences and that basic science educators were incorporating clinical relevance in their regular teaching. The third and fourth year classes, classes that had been exposed to general as well as all specialty dentistry clinics, agreed that basic sciences are being incorporated into most clinical teaching. Top two barriers to integration identified by the students were lack of crossover knowledge of faculty, and insufficient time to explore connections between basic sciences and clinical sciences because of the volume of information that needs to be covered. In conclusion, student perception at UTSD is that overall basic and clinical sciences are being integrated throughout the curriculum.

Balancing assessment of depth and breadth in the dental curriculum: A bi-dimensional assessment strategy

Introduction

Integrated curricula are being increasingly adopted in health professions, owing to their advantages including patient-centred training and development of critical thinking. Similarly, the majority of dental Universities have either moved away from discipline-specific towards integrated curricula or have incorporated elements of integration. Despite several advantages offered by the integrated curriculum, one disadvantage is failure to assess depth of knowledge. Assessing the depth of knowledge is a characteristic of discipline-specific curriculum. This commentary describes the inclusion of both discipline-based and integrated assessments at Faculty of Dentistry, SEGi University, Malaysia.

Material and methods

Module tests (discipline-based assessments) comprising of discipline specific questions are conducted at the end of every term, mimicking the traditional discipline-specific assessment. Questions in the module tests are intended to assess the depth of knowledge of students. Mid semester examinations are conducted at the end of the semester, mimicking the integrated assessment. Integrated questions are intended to test the breadth of knowledge of students.

Results

Lecturers and students felt introduction of module tests, helped them to prepare for topics in a phased manner and better answer questions posed by lecturers during case discussions and clinical presentations. The 'borderline distinction' students felt that studying for module tests provided them with the depth of knowledge essential to answer questions during viva voce.

Discussion

Including both the traditional and integrated methods of assessments would engage students in a learning experience developing their breadth and depth of knowledge. Further prospective research is essential to assess the impact of this assessment strategy.

A Self-supported Graphene/Carbon Nanotube Hollow Fiber for Integrated Energy Conversion and Storage

Wearable fiber-shaped integrated energy conversion and storage devices have attracted increasing attention, but it remains a big challenge to achieve a common fiber electrode for both energy conversion and storage with high performance. Here, we grow aligned carbon nanotubes (CNTs) array on continuous graphene (G) tube, and their seamlessly connected structure provides the obtained G/CNTs composite fiber with a unique self-supported hollow structure. Taking advantage of the hollow structure, other active materials (e.g., polyaniline, PANI) could be easily functionalized on both inner and outer surfaces of the tube, and the obtained G/CNTs/PANI composite hollow fibers achieve a high mass loading (90%) of PANI. The G/CNTs/PANI composite hollow fibers can not only be used for high-performance fiber-shaped supercapacitor with large specific capacitance of 472 mF cm^-2, but also can replace platinum wire to build fiber-shaped dye-sensitized solar cell (DSSC) with a high power conversion efficiency of 4.20%. As desired, the integrated device of DSSC and supercapacitor with the G/CNTs/PANI composite hollow fiber used as the common electrode exhibits a total power conversion and storage efficiency as high as 2.1%. Furthermore, the self-supported G/CNTs hollow fiber could be further functionalized with other active materials for building other flexible and wearable electronics.

All together now: aggregating multiple records to develop a person-based dataset to integrate and enhance infectious disease surveillance in Ontario, Canada

Setting

Syndemics occur when two or more health conditions interact to increase morbidity and mortality and are exacerbated by social, economic, environmental, and political factors. Routine provincial surveillance in Ontario assesses and reports on the epidemiology of single infectious diseases separately. Therefore, we aimed to develop a method that allows disease overlaps to be examined routinely as a path to better understanding and addressing syndemics in Ontario.

Intervention

We extracted data for individuals with a record of chlamydia, gonorrhea, infectious syphilis, hepatitis B and C, HIV/AIDS, invasive group A streptococcal disease (iGAS), or tuberculosis in Ontario’s reportable disease database from 1990 to 2018. We transformed the data into a person-based integrated surveillance dataset retaining individuals (clients) with at least one record between 2006 and 2018.

Outcomes

The resulting dataset had 659,136 unique disease records among 470,673 unique clients. Of those clients, 23.1% had multiple disease records with 50 being the most for one client. We described the frequency of disease overlaps; for example, 34.7% of clients with a syphilis record had a gonorrhea record. We quantified known overlaps, finding 1274 clients had gonorrhea, infectious syphilis, and HIV/AIDS records, and potentially emerging overlaps, finding 59 clients had HIV/AIDS, hepatitis C, and iGAS records.

Implications

Our novel person-based integrated surveillance dataset represents a platform for ongoing in-depth assessment of disease overlaps such as the relative timing of disease records. It enables a more client-focused approach, is a step towards improved characterization of syndemics in Ontario, and could inform other jurisdictions interested in adopting similar approaches.

The transfer of knowledge on integrated care among five European regions: a qualitative multi-method study

BACKGROUND

To examine how the knowledge transfer processes unfolded within SCIROCCO, a EU funded project (3rd Health Programme (2014-2020)) that aimed to facilitate the process of knowledge sharing across five European regions, to speed up adoption and scaling-up of integrated care initiatives.

METHODS

A qualitative multi-method design was used. Data collection methods included focus groups, project documents and action plans of the regions. The data was analysed using a qualitative content-analysis procedure, which was guided by the frameworks of knowledge exchange and the why, whose, what, how framework for knowledge mobilisers.

RESULTS

All five components (including the themes) of knowledge exchange could be identified in the approach developed on the knowledge transfer processes. The four questions and accompanying categories of the framework of knowledge mobilisation were also identified to a large degree.

CONCLUSIONS

The observed incorporation of distinct forms of knowledge from multiple sources and the observed dynamic and fluid knowledge transfer processes both suggest that SCIROCCO developed a comprehensive knowledge transfer approach aiming to enable the adoption and scaling-up of integrated care. Overall, the multi-method qualitative nature of this research has allowed some new and practical insights in the knowledge transfer activities on integrated care between several European regions. To obtain a clear understanding of the content of the knowledge transfer approaches, which could assist the operationalising of models to support the evaluation of knowledge transfer activities, it is strongly recommended that further research of this type should be conducted in other research settings.

The Impact of Training Pathway on Breast Surgery Cases Performed during Plastic Surgery Residency

BACKGROUND

Operative volume is a critical component of surgical resident education. This study compares reported breast surgery case volume between resident training pathways in plastic surgery.

METHODS

This retrospective cohort study reviewed case logs of plastic surgery residents in the independent/combined and integrated training pathways. Breast surgery case volume was compared via t tests across two major categories: reconstructive and aesthetic. Differences in intra-pathway variability were compared with F tests. Five consecutive cohorts of plastic surgery residents (n = 818): independent/combined (n = 526, 64%) and integrated (n = 292, 36%) at Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs, were included (2011-2015).

RESULTS

Independent/combined residents reported significantly more aesthetic cases than integrated residents, but similar reconstructive cases. Independent/combined residents reported more breast augmentations, mastopexy, cosmetic breast fat grafting, and other cosmetic breast cases. Within the reconstructive category, independent residents reported more breast reconstruction fat grafting cases while integrated residents reported more breast reconstruction with pedicle flap, other breast reconstruction, and breast reduction cases. Independent residents had greater intra-pathway variability in five case subcategories, while integrated residents had greater variability in one case subcategory.

CONCLUSIONS

Disparities in breast surgery case volume exist by plastic surgery residency training pathway. Given the importance of case volume to residents and faculty, these disparities may warrant greater attention.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Integrated microRNA/mRNA expression profiling of the skin of psoriasis patients

BACKGROUND

Psoriasis is a chronic inflammatory disease characterized by demarcated, raised, and scaling skin lesions. It often serves as a model for immune-mediated disorders. Gene expression profiling of affected skin has allowed insights into psoriasis pathogenesis. However, the mechanisms leading to specific mRNA expression alterations in psoriasis are barely understood.

OBJECTIVES

To perform integrated microRNA-mRNA expression studies of non-lesional, peri-lesional, and lesional skin from psoriasis patients.

METHODS

Cutaneous microRNA and mRNA expression profiles of 14 patients using Nanostring nCounter-technology and RNA sequencing as well as in vitro keratinocyte stimulation and qPCR studies.

RESULTS

Only 3.5 % of microRNAs manifested a robust gradual expression trend from non-lesional to paired lesional skin, with 61 % being upregulated and 39 % being downregulated. Relevance of these microRNA regulations was supported by their inverse association with 57 % of the mRNA species found to be regulated during psoriatic lesion development. Many of the involved mRNAs were downregulated and functionally related to keratinocyte metabolism, barrier function, and neuronal signaling, and were already regulated in peri-lesional skin. An integrated correlation analysis revealed a robust interaction for 134 microRNAs/mRNAs pairs. In vitro keratinocyte studies of selected microRNAs/mRNAs revealed regulations of all analyzed microRNAs in a psoriasis-like manner by IL-17A/TNF-α (e.g. hsa-miR-23a-3p), IFN-γ (e.g. hsa-miR-106a-5p/miR-17-5p), or IL-24 (e.g. hsa-miR-203a-3p). Moreover, most of their predicted target mRNAs (e.g. ID4, EPHB2) were respectively altered by the same cytokines.

CONCLUSION

Our study suggests that, during development of psoriatic lesions, defined aspects of psoriasis pathogenesis are regulated by the action of microRNAs.

The experiences of midwives in integrated maternity care: A qualitative metasynthesis

OBJECTIVES

To conduct a metasynthesis of eight qualitative studies of the experiences of midwives in integrated maternity practice; to identify common motifs among the eight studies through a thematic interpretive integration known as reciprocal translation; and to explore the effects on midwifery processes of care in the setting of integrated maternity practice.

DESIGN

A qualitative metasynthesis to analyze, synthesize, and interpret eight qualitative studies on the experiences of midwives and the effect on the midwifery processes of care in the setting of integrated maternity practice.

SAMPLE AND SETTING

Participants from the primary studies included a total of 160 midwives providing hospital-based intrapartum care. All primary studies were conducted in settings with midwives and obstetricians working together in an integrated or collaborative manner.

FINDINGS

Three overarching themes emerged from the data: professional dissonance, functioning from a position of risk, and practicing down.

KEY CONCLUSIONS

The findings indicated that integrated maternity practice affects the professional experience of midwives. Through a qualitative exploration, a clear process of deprofessionalization and deviation from the midwifery model of care is detailed. Midwives experienced decreasing opportunity to provide the quality woman-centered physiologic care that evidence shows benefits childbearing women.

IMPLICATIONS FOR PRACTICE

Integrated maternity practice, where low-risk and high-risk pregnancies are managed by midwife/physician teams, have proliferated as a solution to the need for quality, safe, and efficient health care. Insufficient evidence exists detailing the success or failure of this model of care. Qualitative studies suggest that the increasing medicalization occurring in integrated maternity practices minimizes the profession of midwifery and the ability to provide evidence-based quality midwifery care.

Feasibility and acceptability of an integrated behavioral medicine service within a post-bariatric surgery clinic

BACKGROUND

Long-term medical and psychological follow-up after weight loss surgery is associated with improved patient outcomes. Weight regain after weight loss surgery is a common concern that has behavioral and psychological components; however, most patients do not attend behavioral medicine (BMED) follow-up appointments post-surgery. Innovative treatment models are needed to improve access to BMED to optimize long-term outcomes.

OBJECTIVES

This study aimed to examine the feasibility and acceptability of an integrated BMED service within a bariatric surgery clinic.

SETTING

University medical center, outpatient clinic.

METHODS

Patients (n = 198) in a post-bariatric surgery clinic were screened for psychosocial/behavioral concerns and offered a same-day BMED consult, when appropriate. Patients rated their satisfaction with the consult and their confidence in being able to carry out the plan created during the consult.

RESULTS

The top 3 concerns identified during screenings were emotional eating, body image, and cravings. The top 3 concerns addressed during consults were emotional eating, mood, and cravings. The mean length of consult was 26.1 minutes. The mean severity of problems addressed was 7 of 10. Patients' confidence ratings had a mean of 9.4 of 10 (1 = low, 10 = high) and satisfaction ratings had a mean of 9.8 of 10.

CONCLUSIONS

In this clinic, the integration of a BMED service provided 40% of patients with behavioral intervention for psychosocial/behavioral concerns during routine surgery follow-up appointments. Patients indicated high satisfaction with consults and reported high confidence in being able to carry out the plan created during the consult.

Detecting episomal or integrated human papillomavirus 16 DNA using an exonuclease V-qPCR-based assay

Screening for human papillomavirus (HPV) integration into host cell chromosomes typically requires large amounts of time and reagents. We developed a rapid and sensitive assay based on exonuclease V (ExoV) and quantitative polymerase chain reaction (qPCR) to determine HPV genome configurations in cell lines and tissues. We established the assay using genomic DNA from cell lines known to harbor integrated or episomal HPV16. DNA was incubated with ExoV, which is specific for linear DNA, and the DNA fraction resistant to digestion was measured by qPCR. The percent of DNA resistant to ExoV digestion was calculated relative to undigested DNA for determination of episomal or integrated HPV16. The ExoV assay was accurate, capable of distinguishing episomal from integrated HPV16 in cell lines and tissues. Future applications of the ExoV assay may include screening of HPV genome configurations in the progression of HPV-associated cancers.

Trends in high intensity statin use among secondary prevention patients 76 years and older

Background:

High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD.

Objectives:

The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe.

Methods:

The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016.

Results:

Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p<0.001 for trend). Conversely, the rates of moderate and low intensity statin use decreased from 61.8% and 9.8% to 41.2% and 4.8%, respectively (both p<0.001 for trend). Similar trends were identified for females and males.

Conclusions:

The percentage of patients with ASCVD 76 years and older who received HIST substantially increased from 2007 to 2016. This trend was identified in both females and males. Future comparative effectiveness research should be conducted in this patient population to examine cardiac-related outcomes with HIST and Non-HIST use.

Continuous Manufacturing of Recombinant Therapeutic Proteins: Upstream and Downstream Technologies

Continuous biomanufacturing of recombinant therapeutic proteins offers several potential advantages over conventional batch processing, including reduced cost of goods, more flexible and responsive manufacturing facilities, and improved and consistent product quality. Although continuous approaches to various upstream and downstream unit operations have been considered and studied for decades, in recent years interest and application have accelerated. Researchers have achieved increasingly higher levels of process intensification, and have also begun to integrate different continuous unit operations into larger, holistically continuous processes. This review first discusses approaches for continuous cell culture, with a focus on perfusion-enabling cell separation technologies including gravitational, centrifugal, and acoustic settling, as well as filtration-based techniques. We follow with a review of various continuous downstream unit operations, covering categories such as clarification, chromatography, formulation, and viral inactivation and filtration. The review ends by summarizing case studies of integrated and continuous processing as reported in the literature.

Program Development of Integrated Psychological Services for Hospitalized Patients with Intravenous Drug Use Histories

Amid rising trends in opioid use, hospitalizations for health conditions secondary to intravenous drug use are becoming more common. Such patients often require prolonged hospitalizations and frequently present with substance use histories, co-occurring mental health diagnoses, and unique behavioral health needs. These issues can adversely impact completion of medical treatment and place added burden on hospital staff. There is a growing need for medical institutions to develop policies and procedures which address the specific emotional, behavioral, and substance use needs of this patient population. Because guidelines for doing so are sparse in the literature, this study outlines the University of Vermont Medical Center's process of developing an in-hospital care agreement intended to (1) increase patient access to in-hospital need assessments, psychotherapy, and medication for opioid use disorders, (2) increase referrals for opioid use treatment beyond hospitalization, (3) standardize staff response to common challenging behaviors, and (4) provide staff with education and support for interacting with patients in effective ways. The multidisciplinary process of developing this care agreement, its specific details, lessons learned, and anticipated future directions are also discussed.

Recommendations on priorities for integrated palliative care: transparent expert consultation with international leaders for the InSuP-C project

BACKGROUND

The World Health Organisation (WHO) endorses integrated palliative care which has a significant impact on quality of life and satisfaction with care. Effective integration between hospices, palliative care services, hospitals and primary care services are required to support patients with palliative care needs. Studies have indicated that little is known about which aspects are regarded as most important and should be priorities for international implementation. The Integrated Palliative Care in cancer and chronic conditions (InSup-C) project, aimed to investigate integrated practices in Europe and to formulate requirements for effective palliative care integration. It aimed to develop recommendations, and to agree priorities, for integrated palliative care linked to the InSuP-C project.

METHODS

Transparent expert consultation was adopted at the approach used. Data were collected in two phases: 1) international transparent expert consultation using face-to-face roundtable discussions at a one day workshop in Brussels, and 2) via subsequent online cross-sectional survey where items were rated to indicate degree of agreement on their importance and ranked to indicate priority for implementation. Workshop discussions used content analysis to develop a list of 23 recommendations, which formed the survey questionnaire. Survey analysis used descriptive statistics and qualitative content analysis of open responses.

RESULTS

Thirty-six international experts in palliative care and cancer care, including senior clinicians, researchers, leaders of relevant international organisations and funders, were invited to a face-to-face workshop. Data were collected from 33 (19 men, 14 women), 3 declined. They mostly came from European countries (31), USA (1) and Australia (1). Twenty one of them also completed the subsequent online survey (response rate 63%). We generated 23 written statements that were grouped into the organisational constructs: macro (10), meso (6) and micro (7) levels of integration of palliative care. Highest priority recommendations refer to education, leadership and policy-making, medium priority recommendations focused on funding and relationship-building, and lower priority recommendations related to improving systems and infrastructure.

CONCLUSIONS

Our findings suggest that amongst a group of international experts there was overall good agreement on the importance of recommendations for integrated palliative care. Understanding expert's priorities is important and can guide practice, policymaking and future research.

Cross-sectional comparison of spiral versus block integrated curriculums in preparing medical students to diagnose and manage concussions

BACKGROUND

An integrated curriculum is designed to be repetitive yet progressive and the concept has rapidly established itself within medical education. National organizations have recommended a shift to a spiral curriculum design, which uses both vertical and horizontal integration. This study examined differences between the recently implemented integrated spiral (class of 2019) and conventional block (classes of 2016-2018) MD curricula at the University of British Columbia (UBC) with respect to knowledge of concussion.

METHODS

Cross-sectional online survey (FluidSurveys: Fluidware, Ottawa, ON), distributed via email to UBC medical students during the 2015-2016 academic year. Questions focused on demographic data, knowledge of concussion definition, and management considerations. Differences in responses across the two groups were assessed using chi-square tests. Ordinal Likert-scale data were analyzed using Mann-Whitney U-Tests. Statistical significance was determined a priori at p < 0.05.

RESULTS

One hundred forty eight medical students (57% female) responded with 78 students in the spiral curriculum and 70 students the block curriculum. Important differences between responses from spiral versus block curricula students included: formal exposure to concussion-related educational material (10.8 h spiral vs. 3.95 h block), understanding concussions can occur without direct head impacts (90% spiral vs. 70% block, X21,148 = 9.41, p = 0.002) and identifying long-term consequences (dementia: 90% spiral vs. 66% block, X21,148 = 12.57, p < 0.0001; second impact syndrome: 80% spiral vs. 57% block, X21,148 = 8.60, p = 0.003; Parkinsonism: 47% spiral vs. 17% block, X21,148 = 14.87, p < 0.001). Block students identified the need for a full neurological exam (X21,148 = 17.63, p < 0.001) and had greater clinical exposure to acute concussion (47% block vs. 14% spiral, X21,148 = 19.27, p < 0.001) and post-concussion syndrome (37% block vs. 19% spiral, X21,148 = 5.91, p = 0.015).

CONCLUSIONS

The findings from this preliminary study suggest the spiral curriculum design, which emphasizes and revisits clinical competencies, promotes a strong understanding and retention of knowledge in highly prevalent clinical conditions such as concussion.

Process evaluation of a National Primary Eye Care Programme in Rwanda

Background

Visual impairment is a global public health problem, with an estimated 285 million affected globally, of which 43% are due to refractive error. A lack of specialist eye care in low and middle-income countries indicates a new model of care would support a task-shifting model and address this urgent need. We describe the features and results of the process evaluation of a national primary eye care (PEC) programme in Rwanda.

Methods

We used the Medical Research Council process evaluation framework to examine the implementation of the PEC programme, and to determine enablers and challenges to implementation. The process evaluation uses a mixed methods approach, drawing on results from several sources including a survey of 574 attendees at 50 PEC clinics, structured clinical observations of 30 PEC nurses, in-depth interviews with 19 key stakeholders, documentary review and a participatory process evaluation workshop with key stakeholders to review collated evidence and contextualize the results.

Results

Structured clinical assessment indicated that the PEC provided is consistent with the PEC curriculum, with over 90% of the clinical examination processes conducted correctly. In 4 years, programme monitoring data showed that nearly a million PEC eye examinations had been conducted in every health centre in Rwanda, with 2707 nurses trained. The development of the eye health system was an important enabler in the implementation of PEC, where political support allowed key developments such as inclusion of eye-drops on the essential medicines list, the inclusion of PEC on insurance benefits, the integration of PEC indicators on the health management information systems and integration of the PEC curriculum into the general nursing school curriculum. Challenges included high turnover of primary care nurses, lack of clarity and communication on the future funding of the programme, competing priorities for the health sector and sustained supervision to assure quality of care.

Conclusions

A model of a national primary eye care programme is presented, with service delivery to all areas in Rwanda. Key learning from this evaluation is the importance of strengthening the eye health care system, together with a strong focus on training primary care nurses using a PEC curriculum.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3718-1) contains supplementary material, which is available to authorized users.

Midwives' attitudes towards pregnant women using substances: Informing a care pathway

OBJECTIVE

The purpose of this study was to identify midwives' attitudes towards women using substances during pregnancy, which informed the development of an integrated care pathway for the provision of optimal care.

METHODS

A mixed methods research design was used, that included an online survey via the online survey tool Qualtrics™ which collected quantitative data, and interviews and focus groups were used to collect qualitative data.

FINDINGS

Participants held a positive or neutral view towards women who used substances during pregnancy, and the participants had an empathetic perception of the issue of substance use within pregnancy, believing that women were using substances due to the environment and circumstances that they lived in, and that they had been raised and socialised in.

CONCLUSION

Caring for women during pregnancy with substance misuse issues is complex and requires coordination and multidisciplinary care. Midwives have the capacity to provide sensitive midwifery care but require the framework to ensure women needing additional resources during pregnancy receive the services available and specific to their needs. The midwives in this study were supportive of developing an integrated care pathway to allow for collaborative care, and to enable a specialised midwifery approach.

The Global Spine Care Initiative: resources to implement a spine care program

PURPOSE

The purpose of this report is to describe the development of a list of resources necessary to implement a model of care for the management of spine-related concerns anywhere in the world, but especially in underserved communities and low- and middle-income countries.

METHODS

Contents from the Global Spine Care Initiative (GSCI) Classification System and GSCI care pathway papers provided a foundation for the resources list. A seed document was developed that included resources for spine care that could be delivered in primary, secondary and tertiary settings, as well as resources needed for self-care and community-based settings for a wide variety of spine concerns (e.g., back and neck pain, deformity, spine injury, neurological conditions, pathology and spinal diseases). An iterative expert consensus process was used using electronic surveys.

RESULTS

Thirty-five experts completed the process. An iterative consensus process was used through an electronic survey. A consensus was reached after two rounds. The checklist of resources included the following categories: healthcare provider knowledge and skills, materials and equipment, human resources, facilities and infrastructure. The list identifies resources needed to implement a spine care program in any community, which are based upon spine care needs.

CONCLUSION

To our knowledge, this is the first international and interprofessional attempt to develop a list of resources needed to deliver care in an evidence-based care pathway for the management of people presenting with spine-related concerns. This resource list needs to be field tested in a variety of communities with different resource capacities to verify its utility. These slides can be retrieved under Electronic Supplementary Material.

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people

BACKGROUND

Over the last 20 years, integrated care programs for frail elderly people aimed to prevent functional dependence and reduce hospitalization and institutionalization. However, results have been inconsistent and merely modest. To date, evidence on the cost-effectiveness of these programs is scarce. We evaluated the cost-effectiveness of the CareWell program, a multicomponent integrated care program for frail elderly people.

METHODS

Economic evaluation from a healthcare perspective embedded in a cluster controlled trial of 12 months in 12 general practices in (the region of) Nijmegen. Two hundred and four frail elderly from 6 general practices in the intervention group received care according to the CareWell program, consisting of multidisciplinary team meetings, proactive care planning, case management, and medication reviews; 165 frail elderly from 6 general practices in the control group received usual care. In cost-effectiveness analyses, we related costs to daily functioning (Katz-15 change score i.e. follow up score minus baseline score) and quality adjusted life years (EQ-5D-3 L).

RESULTS

Adjusted mean costs directly related to the intervention were €456 per person. Adjusted mean total costs, i.e. intervention costs plus healthcare utilization costs, were €1583 (95% CI -4647 to 1481) higher in the intervention group than in the control group. Incremental Net Monetary Benefits did not show significant differences between groups, but on average tended to favour usual care.

CONCLUSIONS

The CareWell primary program was not cost-effective after 12 months. From a cost-effectiveness perspective, widespread implementation of the program in its current form cannot be recommended.

TRIAL REGISTRATION

The study was registered in the ClinicalTrials.govProtocol Registration System: ( NCT01499797 ; December 26, 2011). Retrospectively registered.