A Comparison Between In-Person and Virtual Communication Skills OSCE for Medical Students

Objectives

This study investigates the effectiveness of a virtual format of an advanced communication skills observed structured clinical examination (OSCE) for senior medical students in comparison to an in-person format. The study also examines the emotional support students experience in the virtual setting. Our analysis was based on quantitative data collected through objective checklists and post-OSCE survey results.

Methods

The virtual OSCE was a revision of an earlier in-person formative advanced communication skills OSCE for fourth-year medical students. Student performances were assessed by self and peers using objective checklists-the modified Master Interview Rating Scale (mMIRS) and Communication Behavior Checklist (CBC). The mMIRS measured interview process such as avoiding jargon and demonstrating empathy. The CBC examined interview content which included tasks specific to the content of the case. The OSCE was followed by a faculty-led debrief and quantitative survey. The virtual OSCE was conducted in 2021, and the results of the checklists and survey were compared with those collected from two earlier in-person OSCEs.

Results

Eighty-three students participated in the virtual OSCE. There was no difference in mMIRS scores between the virtual and in-person OSCE. Overall CBC scores were lower in the virtual OSCE compared to in-person (p < 0.05). Sixty-seven out of 83 (80.7%) students completed the post-OSCE survey. There were no differences between the virtual and in-person OSCE in terms of educational value, whether the OSCE would change the way participants talk to patients, and preparedness to have serious conversations with patients. All respondents somewhat or strongly agreed with feeling emotionally supported during the virtual OSCE.

Conclusion

The virtual format was a suitable alternative to an in-person, formative, advanced communication skills OSCE for medical students. The virtual OSCE was educationally effective and was met with student satisfaction and a sense of emotional support. Future virtual iterations must ensure adequate instruction on interview content.

What Are the Challenges Related to Family Planning, Pregnancy, and Parenthood Faced by Women in Orthopaedic Surgery? A Systematic Review

BACKGROUND

Orthopaedic surgery is the surgical specialty with the lowest proportion of women. Conflicting evidence regarding the potential challenges of pregnancy and parenthood in orthopaedics, such as the implications of delayed childbearing, may be a barrier to recruitment and retainment of women in orthopaedic surgery. A summary of studies is needed to ensure that women who have or wish to have children during their career in orthopaedic surgery are equipped with the relevant information to make informed decisions.

QUESTIONS/PURPOSES

In this systematic review, we asked: What are the key gender-related barriers pertaining to (1) family planning, (2) pregnancy, and (3) parenthood that women in orthopaedic surgery face?

METHODS

Embase, MEDLINE, and PsychINFO were searched on June 7, 2021, for studies related to pregnancy or parenthood as a woman in orthopaedic surgery. Inclusion criteria were studies in the English language and studies describing the perceptions or experiences of attending surgeons, trainees, or program directors. Studies that sampled surgical populations without specific reference to orthopaedics were excluded. Quantitative and qualitative analyses were performed to identify important themes. Seventeen articles including surveys (13 studies), selective reviews (three studies), and an environmental scan (one study) met the inclusion criteria. The population sampled included 1691 attending surgeons, 864 trainees, and 391 program directors in the United States and United Kingdom. The Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices tool was used to evaluate the risk of bias in survey studies. A total of 2502 women and 560 men were sampled in 13 surveys addressing various topics related to pregnancy, parenthood, and family planning during an orthopaedic career. Three selective reviews provided information on occupational hazards in the orthopaedic work environment during pregnancy, while one environmental scan outlined the accessibility of parental leave policies at 160 residency programs. Many of the survey studies did not report formal clarity, validity, or reliability assessments, therefore increasing their risk of bias. However, our analysis of the provided instruments as well as the consistency of identified themes across multiple survey studies suggests the evidence we aggregated was sufficiently robust to answer the research questions posed in the current systematic review.

RESULTS

These data revealed that many women have witnessed or experienced discrimination related to pregnancy and parenthood, at times resulting in a decision to delay family planning. In one study, childbearing was reportedly delayed by 67% of respondents (304 of 452) because of their career choice in orthopaedics. Orthopaedic surgeons were more likely to experience pregnancy complications (range 24% to 31%) than the national mean in the United States (range 13% to 17%). Lastly, despite these challenging conditions, there was often limited support for women who had or wished to start a family during their orthopaedic surgery career. Maternity and parental leave policies varied across training institutions, and only 55% (56 of 102) of training programs in the United States offered parental leave beyond standard vacation time.

CONCLUSION

The potential negative effects of these challenges on the orthopaedic gender gap can be mitigated by increasing the availability and accessibility of information related to family planning, parental leave, and return to clinical duties while working as a woman in orthopaedic surgery. Future research could seek to provide a more global perspective and specifically explore regional variation in the environment faced by pregnancy or parenting women in orthopaedic surgery.

LEVEL OF EVIDENCE

Level III, prognostic study.

CONFERD-HP: recommendations for reporting COmpeteNcy FramEwoRk Development in health professions

BACKGROUND

Competency frameworks outline the perceived knowledge, skills, attitudes, and other attributes required for professional practice. These frameworks have gained in popularity, in part for their ability to inform health professions education, assessment, professional mobility, and other activities. Previous research has highlighted inadequate reporting related to their development which may then jeopardize their defensibility and utility.

METHODS

This study aimed to develop a set of minimum reporting criteria for developers and authors of competency frameworks in an effort to improve transparency, clarity, interpretability and appraisal of the developmental process, and its outputs. Following guidance from the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network, an expert panel was assembled, and a knowledge synthesis, a Delphi study, and workshops were conducted using individuals with experience developing competency frameworks, to identify and achieve consensus on the essential items for a competency framework development reporting guideline.

RESULTS

An initial checklist was developed by the 35-member expert panel and the research team. Following the steps listed above, a final reporting guideline including 20 essential items across five sections (title and abstract; framework development; development process; testing; and funding/conflicts of interest) was developed.

CONCLUSION

The COmpeteNcy FramEwoRk Development in Health Professions (CONFERD-HP) reporting guideline permits a greater understanding of relevant terminology, core concepts, and key items to report for competency framework development in the health professions.

Quality of Telehealth-Delivered Inpatient Palliative Care During the Early COVID-19 Pandemic

CONTEXT

Consequent to increasing COVID-19 infection rates, the Palliative Care (PC) service at a large New England hospital shifted from in-person to telehealth-delivered PC (TPC).

OBJECTIVES

We compared the quality of TPC to in-person PC during the early COVID-19 pandemic.

METHODS

We conducted an electronic health record review of PC consultations of patients hospitalized during three periods: pre-COVID January, 2020-February, 2020 (in-person); peak-COVID March, 2020-June, 2020 (majority TPC); and post-peak September, 2020-October, 2020 (majority in-person). We examined the relationship between these periods and PC delivery characteristics and quality measures using descriptive and bivariate statistics.

RESULTS

Of 377 patients, 50 were pre-COVID (TPC=0%), 271 peak-COVID (TPC=79.3%), and 56 post-peak (TPC<2%) (representation of PC consult: pre- and post-peak=samples; peak-COVID=all consults). Mean age was 69.3 years (standard deviation=15.5), with 54.9% male, 68.7% White, and 22.8% Black. Age and sex did not differ by period. PC consultations were more likely for goals of care (pre=30.0% vs. peak=53.9% vs. post=57.1%; P = 0.005) or hospice (4.0% vs. 14.4% vs. 5.4%, P = 0.031) during peak-COVID compared to pre-COVID. Rates of assessment of physical (98.0% vs. 63.5% vs. 94.6%, P < 0.001) and psychological symptoms (90.0% vs. 33.1% vs. 67.9%, P < 0.001) were lower during peak relative to pre-COVID and post-peak periods. There were no differences in assessment of patients' social needs, family burden, or goals of care across periods.

CONCLUSION

The PC service provided high-quality inpatient PC using TPC despite significant strain during the early COVID-19 pandemic. Developing and testing strategies to promote comprehensive symptom control using TPC remains a priority to adjust to potential unmet PC needs.

An Advanced Communication Skills Workshop Using Standardized Patients for Senior Medical Students

INTRODUCTION

Medical students often lack training in advanced communication skills encompassing emotionally fraught situations and those in which an intense emotional response is expected. Such skills are required for clinical situations encountered during residency. We created and evaluated an advanced communication skills workshop (ACSW) using standardized patients for senior medical students. The workshop emphasized communication skills for four scenarios-strong emotion, goals of care, medical error, and palliative care assessment-and utilized formative peer assessment and feedback.

METHODS

We created the four ACSW cases with case-specific communication behavior checklists and a common modified Master Interview Rating Scale in a Capstone Course for senior medical students. In groups of three, students rotated through three of four stations. Each student conducted one of the interviews while the other two completed the checklists and provided verbal feedback. We performed one-way analyses of variance on Likert responses and content analysis on open responses on a post-ACSW survey.

RESULTS

Ninety-one students completed the ACSW and survey. Students assigned high value to all four ACSW student roles: interviewer, observer, feedback recipient, and feedback provider. Students rated the experience above average to excellent on nearly all survey items. Open-response themes included "liked the opportunity to give or receive peer feedback" (46%) and "found the checklists helpful" (45%).

DISCUSSION

Feasible and well received by senior medical students, our ACSW offers an opportunity to practice and observe advanced communication skills and peer feedback. A peer-assisted, formative learning model, the ACSW efficiently addresses a key aspect of residency preparation.

Launching the Next Steps to Improve Hospice and Palliative Medicine Fellow Performance Assessment: A Look Back to the Initial Toolkit of Assessment Methods

Education leaders in hospice and palliative medicine (HPM) have long acknowledged the challenge of fellow performance assessment and the need for HPM-specific fellow assessment tools. In 2010, and in alignment with the Accreditation Council for Graduate Medical Education's (ACGME's) directive toward competency-based medical education, the national HPM Competencies Workgroup curated a set of assessment tools, the HPM Toolkit of Assessment Methods. The Toolkit has been a resource for HPM fellowship directors in evolving practical, multifaceted fellow assessment strategies. Now, as American Academy of Hospice and Palliative Medicine plans for a national workgroup in 2020 to define current HPM fellow assessment methods and to propose strategies to strengthen and standardize future assessment, the Toolkit provides a strong base from which to launch. However, the field learned important lessons from the 2010 Workgroup about the consensus process, gaps in areas of assessment, opportunities to address gaps with new or adapted tools, and limitations in implementing the Toolkit over time in terms of tracking, accessibility, and dissemination. This article describes the development of the Toolkit, including recommended tools and methods for assessment within each ACGME competency domain, and links the lessons learned to recommendations for the 2020 workgroup to consider in creating the next HPM assessment strategy and toolkit. Effective implementation will be crucial in supporting fellows to reach independent practice, which will further strengthen the field and workforce to provide the highest quality patient and family-centered care in serious illness. This will require an inspired, committed effort from the HPM community, which we enthusiastically anticipate.

Education needed to improve antimicrobial use during end-of-life care of older adults with advanced cancer: A cross-sectional survey

BACKGROUND

Antimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined.

AIM

To evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention.

DESIGN

18-item single-center cross-sectional survey.

SETTING/PARTICIPANTS

Inpatient medicine subspecialists in 2018.

RESULTS

Of 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization (n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care (n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers (n = 64/67, 96%). Fifty-one percent (n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training.

CONCLUSIONS

Although the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.

Infectious Brachial Plexopathy and Septic Arthritis of the Shoulder due to Lemierre's Syndrome: A Case Report and Literature Review

CASE

We present a 20-year-old female with Lemierre's syndrome and an associated infectious brachial plexopathy and missed septic shoulder arthritis. She subsequently presented with advanced post-infectious glenohumeral joint arthritis. At the final 12-month follow-up, substantial shoulder pain and dysfunction persisted.

CONCLUSIONS

When Lemierre's syndrome has been diagnosed, patients with upper extremity symptoms suggestive of metastatic infection require a thorough assessment to rule out musculoskeletal involvement and site-specific intervention to prevent long-term morbidity.

Impact of a Novel Goals-of-Care Communication Skills Coaching Intervention for Practicing Oncologists

Background: Oncologists routinely have opportunities for goals-of-care (GoC) discussions with patients. GoC discussions increase the likelihood that patients receive care consistent with their values. However, oncologists often feel ill-equipped to discuss end-of-life care. Objective: To assess the impact of a communication training and coaching intervention (INT) for oncologists during GoC discussions. Design: We randomized oncologists to usual care (UC) or a communication skills training INT, which consisted of an interactive training session and four joint visits with communication coaches. Setting/Subjects: Solid tumor oncologists seeing advanced cancer patients at four hospitals in New York and Connecticut. Measurements: Three blinded coders evaluated recorded encounters before and after INT using a validated tool to assess skill attainment. Results: Oncologists (n = 22) were 32% female and averaged 46 years of age. In baseline visits, INT oncologists (n = 11) and UC oncologists (n = 11) had no difference in the number of mean skills employed out of 8 GoC skills (INT 3.5, UC 2.4; p = 0.18). Post-INT, INT oncologists were significantly more likely to elicit patient values (55% vs. 0%; p = 0.01). There was no significant difference in overall mean skills employed (INT 3.4, UC 2.2; p = 0.14). Assessing for understanding, offering "I wish" statements, and providing prognosis were the least utilized skills among all oncologists. Conclusion: Our real-time communication skills coaching INT resulted in a significant increase in oncologists' ability to elicit patient values during GoC discussions, suggesting that skill acquisition can occur in the face of less intensive training. Future studies can highlight gaps leading to the lack of differences in utilization of other skills.

Are Internal Medicine Residents Meeting the Bar? Comparing Resident Knowledge and Self-Efficacy to Published Palliative Care Competencies

Background:

There is a need for improved primary palliative care (PC) education and resident comfort with providing end-of-life care.

Objective:

Utilize a new instrument derived from published PC competencies to assess baseline Internal Medicine (IM) resident knowledge and self-efficacy in PC to identify educational gaps and create new PC curricula.

Design:

We created a 2-part instrument including a Knowledge Test (KT) and a Self-Efficacy Inventory (SEI) addressing 18 PC resident competencies across 5 domains: Pain and Symptom Management (PSM), Communication (COMM), Psychosocial, Spiritual, and Cultural Aspects of Care (PSC), Terminal Care and Bereavement (TCB), and Palliative Care Principles and Practice (PCPP).

Setting/Subjects:

The instrument was emailed to IM residents at our institution during academic years 2015-2016 and 2016-2017.

Measurements:

Basic descriptive statistics were performed for the KT and SEI. Mean Rank Analysis and One-way ANOVA were utilized for the KT and SEI, respectively. Congruence was calculated between knowledge and self-efficacy.

Results:

The mean score on the KT was 73% (range 33-80%). There was no significant difference in knowledge among post-graduate year cohorts. Self-efficacy scores were lower for interns overall and in PCPP, TCB, and COMM domains. Knowledge was concordant with self-efficacy in 42% of participants, higher than self-efficacy in 10% of participants, and lower than self-efficacy in 48% of participants.

Conclusions:

For approximately half of respondents, high self-efficacy in PC did not correlate with high PC knowledge. A more focused curriculum is needed to help IM residents facilitate mastery of PC competencies by graduation.

Development of Subspecialty-Specific Reporting Milestones for Hospice and Palliative Medicine Fellowship Training in the U.S

Continuing the transition to competency-based education, Hospice and Palliative Medicine (HPM) fellowship programs began using context-free reporting milestones (RMs) for internal medicine subspecialties in 2014 but quickly recognized that they did not reflect the nuanced practice of the field. This article describes the development of 20 subspecialty-specific RMs through consensus group process and vetting by HPM educators. A workgroup of content experts used an iterative consensus building process between December 2017 and February 2019 to draft new RMs and create a supplemental guide that outlines the intent of each RM, examples of each developmental trajectory, assessment methods, and resources to guide educators. Program directors, program coordinators, and designated institutional officers were contacted directly to solicit feedback. Most respondents agreed or strongly agreed that each RM represented a realistic progression of knowledge, skills, and behaviors, and that the set of milestones adequately discriminated between meaningful levels of competency. Similarly, respondents felt that the supplemental guide was a useful resource. The result is a set of carefully developed and broadly vetted RMs that represent a progression of development for HPM physicians during one year of clinical fellowship training.

Assessing Advanced Communication Skills via Objective Structured Clinical Examination: A Comparison of Faculty Versus Self, Peer, and Standardized Patient Assessors

Construct: The construct addressed in this study is assessment of advanced communication skills among senior medical students. Background: The question of who should assess participants during objective structured clinical examinations (OSCEs) has been debated, and options discussed in the literature have included peer, self, standardized patient, and faculty assessment models. What is not known is whether same-level peer assisted learning can be utilized for formative assessment of advanced communication skills when no faculty, standardized patients, or other trained assessors are involved in providing feedback. If successful, such an educational model would optimize resource utilization and broaden the scope of topics that could be covered in formative OSCEs. Approach: The investigators developed a 4-station formative OSCE focused on advanced communication skills for senior medical students, and evaluated the concordance of assessment done by same-level peers, self, standardized patients, and faculty for 45 students. After each station, examinees completed a self-assessment checklist and received checklist-based assessment and verbal feedback from same-level peers only. Standardized patients completed checklist-based assessments outside the room, and faculty did so after the OSCE via video review; neither group provided direct feedback to examinees. The investigators assessed inter-rater agreement and mean difference scores on the checklists using faculty score as the gold standard. Findings: There was fair to good overall agreement among self, same-level peer, standardized patient, and faculty-assessment of advanced communication skills. Relative to faculty, peer and standardized patient assessors overestimated advanced communication skills, while self-assessments underestimated skills. Conclusions: Self and same-level peer-assessment may be a viable alternative to faculty assessment for a formative OSCE on advanced communication skills for senior medical students.

Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Distress is defined in the NCCN Guidelines for Distress Management as a multifactorial, unpleasant experience of a psychologic (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. Early evaluation and screening for distress leads to early and timely management of psychologic distress, which in turn improves medical management. The panel for the Distress Management Guidelines recently added a new principles section including guidance on implementation of standards of psychosocial care for patients with cancer.

A New Competency-Based Instrument to Assess Resident Knowledge and Self-Efficacy in Primary Palliative Care

CONTEXT

There is a need to improve both primary palliative care (PPC) education and its assessment in graduate medical education (GME). We developed an instrument based on published palliative care (PC) competencies to assess resident competency and educational interventions.

OBJECTIVES

To describe the development and psychometric properties of a novel, competency-based instrument to measure resident knowledge and self-efficacy in PPC.

METHODS

We created a 2-part instrument comprised of a knowledge test (KT) and a self-efficacy inventory (SEI) addressing 18 consensus, core PC resident competencies across 5 domains: pain and symptom management; communication; psychosocial, spiritual, and cultural aspects of care; terminal care and bereavement; and PC principles and practice. The instrument was distributed to 341 internal medicine residents during academic years 2015 to 2016 and 2016 to 2017. A standard item analysis was performed on the KT. Internal consistency (Cronbach α) and variable relationships (factor analysis) were measured for the SEI.

RESULTS

One hundred forty-four residents completed the survey (42% response). For 15 KT items, difficulty ranged from 0.17 to 0.98, with 7 items ranging 0.20 to 0.80 (typical optimum difficulty); discrimination ranged from 0.03 to 0.60 with 10 items ≥0.27 (good to very good discrimination). Cronbach α was 0.954 for 35 SEI items. Factor analysis of combined 2015 to 2016 items yielded 4 factors explaining the majority of variance for the entire set of variables.

CONCLUSION

Our instrument demonstrates promising psychometric properties and reliability in probing the constructs of PC and can be further utilized in PC GME research to assess learners and evaluate PPC educational interventions.

Development of Curricular Milestones for Hospice and Palliative Medicine Fellowship Training in the U.S

CONTEXT

A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define curricular milestones (CMs) for hospice and palliative medicine (HPM) Fellowship Programs. The developed list of CMs would serve as components upon which to organize curriculum and standardize what to teach during training. These would complement entrustable professional activities previously developed by this group and new specialty-specific reporting milestones (RMs) for HPM developed through the Accreditation Council for Graduate Medical Education.

OBJECTIVES

The objective of this study was to develop and vet CMs for HPM fellowships in the U.S.

METHODS

A draft of CMs was developed through an iterative consensus group process with repeated cycles of drafting, analyzing, and revising by a broadly representative expert workgroup who then gained input from HPM educators at a national meeting workshop. The CM draft was subsequently revised and then vetted through a national survey to 203 fellowship educators. Respondents were asked to "keep," "revise," or "exclude" each proposed CM with space for comments. An agreement of 75% among respondents was set as the criteria a priori for keeping a CM. Eighty-four of the 203 potential respondents participated in the survey. All items met the minimum agreement level of 75% or greater recommending keeping the CM. Greater than 85% of the respondents agreed to keep 19 of the 22 CMs with no revisions. Comments for revisions on other CMs were primarily related to changes in language and formatting, not conceptual underpinnings.

CONCLUSION

A group consensus method strengthened by inclusion of a national survey to HPM fellowship educators resulted in a CM document that is both carefully developed and broadly vetted. Along with entrustable professional activities and new specialty-specific RMs, these CMs offer educators and trainees tools to create more comprehensive curricula and behaviorally based assessment tools for HPM fellowships and their stakeholders.

Simulation training in palliative care: state of the art and future directions

BACKGROUND

The growing need for palliative care (PC) among patients with serious illness is outstripped by the short supply of PC specialists. This mismatch calls for competency of all health care providers in primary PC, including patient-centered communication, management of pain and other symptoms, and interprofessional teamwork. Simulation-based medical education (SBME) has emerged as a promising modality to teach key skills and close the educational gap. This paper describes the current state of SBME in training of PC skills.

METHODS

We conducted a systematic review of the literature reporting on simulation experiences addressing PC skills for clinical learners in medicine and nursing. We collected data on learner characteristics, the method and content of the simulation, and outcome assessments.

RESULTS

In a total of 78 studies, 76% involved learners from medicine and 38% involved learners from nursing, while social work (6%) and spiritual care (3%) learners were significantly underrepresented. Only 16% of studies involved collaboration between participants at different training levels. The standardized patient encounter was the most popular simulation method, accounting for 68% of all studies. Eliciting treatment preferences (50%), delivering bad news (41%), and providing empathic communication (40%) were the most commonly addressed skills, while symptom management was only addressed in 13% of studies. The most common method of simulation evaluation was subjective participant feedback (62%). Only 4% of studies examined patient outcomes. In 22% of studies, simulation outcomes were not measured at all.

DISCUSSION

We describe the current state of SBME in PC education, highlighting advances over recent decades and identifying gaps and opportunities for future directions. We recommend designing SBME for a broader range of learners and for interprofessional skill building. We advocate for expansion of skill content, especially symptom management education. Finally, evaluation of SBME in PC training should be more rigorous with a shift to include more patient outcomes.

Palliative Care Competencies and Readiness for Independent Practice: A Report on the American Academy of Hospice and Palliative Medicine Review of the U.S. Medical Licensing Step Examinations

CONTEXT

It is unknown whether the palliative care (PC) content tested in the U.S. Medical Licensing Examination (USMLE) step examinations reflects the consensus-developed PC competencies.

OBJECTIVES

To review the USMLE step examinations to determine whether they test the PC knowledge necessary for graduating medical students and residents applying for licensure.

METHODS

Eight PC physicians reviewed three complete examination forms and a focused 509-item bundle of multiple-choice questions (MCQs) identified by the USMLE content outline as potentially assessing PC content. Reviewers determined MCQs to be PC items if the patient was seriously ill and PC knowledge was required to answer correctly. PC items' competency domains were determined using reference domains from PC subspecialty consensus competencies.

RESULTS

Reviewers analyzed 1090 MCQs and identified 242 (22%) as PC items. PC items were identified in each step examination. Patients in PC items were mostly males (62.8%), older than 65 years (62%), and diagnosed with cancer (43.6%). Only 6.6% and 6.2%, respectively, had end-stage heart disease or multimorbid illness. Fifty-one percent of PC items addressed ethics (31%) or communication (19.8%), focusing on patient autonomy, surrogate decision makers, or conflict between decision makers. Pain and symptom management was assessed in 28.5% of PC items, and one-third of those addressed addiction or substance use disorder.

CONCLUSION

We identified PC content in each step examination. However, heart disease and multimorbidity were under-represented in PC items relative to their prevalence. In addition, there was heavy overlap with ethics, a focus on conflict in assessing communication skills, and emphasis on addiction when testing pain management. Our findings highlight opportunities to enhance testing of clinical PC skills essential for all licensed physicians practicing medicine.

Advance Care Planning in Cognitively Impaired Older Adults

Older adults with cognitive impairment face many healthcare challenges, chief among them participating in medical decision-making about their own health care. Advance care planning (ACP) is the process whereby individuals communicate their wishes for future care with their clinicians and surrogate decision-makers while they are still able to do so. ACP has been shown to improve important outcomes for individuals with cognitive impairment, but rates of ACP for these individuals are low because of individual-, clinician-, and system-related factors. Addressing ACP early in the illness trajectory can maximize the chances that people can participate meaningfully. This article recommends best practices for approaching ACP for older adults with cognitive impairment. The importance of providing anticipatory guidance and eliciting values to guide future care to create a shared framework between clinicians, individuals, and surrogate decision-makers is emphasized. It is recommended that ACP be approached as an iterative process to continue to honor and support people's wishes as cognitive impairment progresses and increasingly threatens independence and function. The article describes effective strategies for assessing decision-making capacity, identifying surrogate decision-makers, and using structured communication tools for ACP. It also provides guidelines for documentation and billing. Finally, special considerations for individuals with advanced dementia are described, including the use of artificial hydration and nutrition, decisions about site of care, and the role of hospice care.

Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial

RATIONALE

Targeted temperature management (TTM) improves survival with good neurological outcome after out-of-hospital cardiac arrest (OHCA), but is delivered inconsistently and often with delay.

OBJECTIVE

To determine if prehospital cooling by paramedics leads to higher rates of 'successful TTM', defined as achieving a target temperature of 32-34°C within 6h of hospital arrival.

METHODS

Pragmatic RCT comparing prehospital cooling (surface ice packs, cold saline infusion, wristband reminders) initiated 5min after return of spontaneous circulation (ROSC) versus usual resuscitation and transport. The primary outcome was rate of 'successful TTM'; secondary outcomes were rates of applying TTM in hospital, survival with good neurological outcome, pulmonary edema in emergency department, and re-arrest during transport.

RESULTS

585 patients were randomized to receive prehospital cooling (n=279) or control (n=306). Prehospital cooling did not increase rates of 'successful TTM' (30% vs 25%; RR, 1.17; 95% confidence interval [CI] 0.91-1.52; p=0.22), but increased rates of applying TTM in hospital (68% vs 56%; RR, 1.21; 95%CI 1.07-1.37; p=0.003). Survival with good neurological outcome (29% vs 26%; RR, 1.13, 95%CI 0.87-1.47; p=0.37) was similar. Prehospital cooling was not associated with re-arrest during transport (7.5% vs 8.2%; RR, 0.94; 95%CI 0.54-1.63; p=0.83) but was associated with decreased incidence of pulmonary edema in emergency department (12% vs 18%; RR, 0.66; 95%CI 0.44-0.99; p=0.04).

CONCLUSIONS

Prehospital cooling initiated 5min after ROSC did not increase rates of achieving a target temperature of 32-34°C within 6h of hospital arrival but was safe and increased application of TTM in hospital.

Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States

CONTEXT

Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a trainee demonstrates competence in an activity, they can then be "entrusted" to practice without supervision. A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define Hospice and Palliative Medicine (HPM) EPAs.

OBJECTIVE

The objective of this study was to describe the development of a set of consensus EPAs for HPM fellowship training in the United States.

METHODS

A set of HPM EPAs was developed through an iterative consensus process involving an expert workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national registry of 3550 HPM physicians. Vetting feedback was reviewed, and survey data were statistically analyzed. Final EPA revisions followed from the multisource feedback.

RESULTS

Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors (46%). Respondents indicated that the set of 17 EPAs well represented the core activities of HPM physician practice (mean 4.72 on a five-point Likert scale) and considered all EPAs to either be "essential" or "important" with none of the EPAs ranking "neither essential, nor important."

CONCLUSIONS

A set of 17 EPAs was developed using national input of practicing physicians and program directors and an iterative expert workgroup consensus process. The workgroup anticipates that EPAs can assist fellowship directors with strengthening competency-based training curricula.

Preclinical Medical Students' Diverse Educational and Emotional Responses to a Required Hospice Experience

BACKGROUND

Physicians' lack of comfort and skill in communicating about hospice care results in deficits and delays in hospice referrals. Preclinical exposure to hospice may lay a foundation to improve medical students' knowledge and comfort with hospice care.

OBJECTIVE

To understand how preclinical medical student (MS)-2s respond both educationally and emotionally to a required hospice care experience (HCE).

DESIGN

Accompanied by hospice clinicians, MS-2s spent 3 hours seeing inpatient or home hospice patients followed by a 1-hour debriefing. Students submitted written reflections to e-mailed educational and emotional prompts.

SETTING/PATIENTS

Two hundred and two MS-2s from 2 academic cohorts completed the HCE at 1 of 2 hospice sites.

MEASUREMENTS

Written reflective responses were analyzed qualitatively, where salient themes extracted and responses were coded.

RESULTS

Ninety-two students submitted 175 responses to Prompt #1 (educational impact) and 85 students entered 85 responses to prompt #2 (emotional impact) of the HCE. Eleven themes were identified for prompt #1, most frequently focusing on hospice services and goals and hospice providers' attitudes and skills. Prompt #2 elicited a diverse spectrum of emotional responses, spanning positive and negative emotions. Most often, students reported "no specified emotional reaction," "sad/depressed," "difficult /challenging," "heartened/encouraged," and "mixed emotions."

CONCLUSION

In an HCE, preclinical students reported learning core aspects of hospice care and experiencing a broad spectrum of emotional responses. These findings may assist educators in the planning of HCEs for preclinical students, including debriefing sessions with skilled clinicians and opportunities for triggered reflection.

Systematic review and meta-analysis of hemodynamic-directed feedback during cardiopulmonary resuscitation in cardiac arrest

BACKGROUND/OBJECTIVE

Physiologic monitoring of resuscitative efforts during cardiac arrest is gaining in importance, as it provides a real-time window into the cellular physiology of patients. The aim of this review is to assess the quality of evidence surrounding the use of physiologic monitoring to guide cardiopulmonary resuscitation (CPR), and to examine whether the evidence demonstrates an improvement in patient outcome when comparing hemodynamic-directed CPR versus standard CPR.

METHODS

Studies were obtained through a search of the PubMed, Embase and Cochrane databases. Peer-reviewed randomized trials, case-control studies, systematic reviews, and cohort studies that titrated CPR to physiologic measures, compared results to standard CPR, and examined patient outcome were included.

RESULTS

Six studies met inclusion criteria, with all studies conducted in animal populations. Four studies examined the effects of hemodynamic-directed CPR on survival, with 35/37 (94.6%) animals surviving in the hemodynamic-directed CPR groups and 12/35 (34.3%) surviving in the control groups (p<0.001). Two studies examined the effects of hemodynamic-directed CPR on ROSC, with 22/30 (73.3%) achieving ROSC in the hemodynamic-directed CPR group and 19/30 (63.3%) achieving ROSC in the control group (p=0.344).

DISCUSSION/CONCLUSION

These results suggest a trend in survival from hemodynamic-directed CPR over standard CPR, however the small sample size and lack of human data make these results of limited value. Future human studies examining hemodynamic-directed CPR versus current CPR standards are needed to enhance our understanding of how to effectively use physiologic measures to improve resuscitation efforts and ultimately incorporate concrete targets into international resuscitation guidelines.

Cattle trypanosomosis: the diversity of trypanosomes and implications for disease epidemiology and control

Trypanosomosis is one of the most significant infectious threats to cattle in sub-Saharan Africa, and one form has also spread to Asia and South America. The disease is caused by a complex of trypanosome species, and the species and strain of parasite can have a profound influence upon the epidemiology of the host-parasite-vector relationships, the severity and course of infection, and, consequently, the implementation and development of control methods. This review will summarise our current knowledge of the relationship between trypanosome species/genotype and the phenotype of disease in cattle, and the implications that this has for ongoing efforts to develop diagnostics, drugs and vaccines for the control of cattle trypanosomosis.

Functional trajectories in the year before hospice

PURPOSE

We undertook a study to identify distinct functional trajectories in the year before hospice, to determine how patients with these trajectories differ according to demographic characteristics and hospice diagnosis, and to evaluate the association between these trajectories and subsequent outcomes.

METHODS

From an ongoing cohort study of 754 community-living persons aged 70 years or older, we evaluated data on 213 persons who were subsequently enrolled in hospice from March 1998 to December 2011. Disability in 13 basic, instrumental, and mobility activities was assessed during monthly telephone interviews through June 2012.

RESULTS

In the year before hospice, we identified 5 clinically distinct functional trajectories, representing worsening cumulative burden of disability: late decline (10.8%), accelerated (10.8%), moderate (21.1%), progressively severe (24.9%), and persistently severe (32.4%). Participants with a cancer diagnosis (34.7%) had the most favorable functional trajectories (ie, lowest burden of disability), whereas those with neurodegenerative disease (21.1%) had the worst. Median survival in hospice was only 14 days and did not differ significantly by functional trajectory. Compared with participants in the persistently severe trajectory, those in the moderate trajectory had the highest likelihood of surviving and being independent in at least 1 activity in the month after hospice admission (adjusted odds ratio = 5.5; 95% CI, 1.9-35.9).

CONCLUSIONS

The course of disability in the year before hospice differs greatly among older persons but is particularly poor among those with neurodegenerative disease. Late admission to hospice (as shown by the short survival), coupled with high levels of severe disability before hospice, highlight potential unmet palliative care needs for many older persons at the end of life.

Developing competencies for pediatric hospice and palliative medicine

In 2006, hospice and palliative medicine (HPM) became an officially recognized subspecialty. This designation helped initiate the Accreditation Council of Graduate Medical Education Outcomes Project in HPM. As part of this process, a group of expert clinician-educators in HPM defined the initial competency-based outcomes for HPM fellows (General HPM Competencies). Concurrently, these experts recognized and acknowledged that additional expertise in pediatric HPM would ensure that the competencies for pediatric HPM were optimally represented. To fill this gap, a group of pediatric HPM experts used a product development method to define specific Pediatric HPM Competencies. This article describes the development process. With the ongoing evolution of HPM, these competencies will evolve. As part of the Next Accreditation System, the Accreditation Council of Graduate Medical Education uses milestones as a framework to better define competency-based, measurable outcomes for trainees. Currently, there are no milestones specific to HPM, although the field is designing curricular milestones with multispecialty involvement, including pediatrics. These competencies are the conceptual framework for the pediatric content in the HPM milestones. They are specific to the pediatric HPM subspecialist and should be integrated into the training of pediatric HPM subspecialists. They will serve a foundational role in HPM and should inform a wide range of emerging innovations, including the next evolution of HPM Competencies, development of HPM curricular milestones, and training of adult HPM and other pediatric subspecialists. They may also inform pediatric HPM outcome measures, as well as standards of practice and performance for pediatric HPM interdisciplinary teams.

Sleep disorders and fatigue: special issues in the older adult with cancer

Older adults with cancer reporting fatigue and sleep disorders often have coexisting geriatric syndromes and are at high risk of further functional decline. This review summarizes special considerations in the diagnosis and treatment of sleep disorders and fatigue when older persons with cancer present with multiple comorbidities, polypharmacy, dementia, delirium, and/or falls. Physicians caring for these older adults need to be aware of the unique diagnostic and treatment concerns in this population so that these patients can receive optimal care.

The Quality Improvement Knowledge Application Tool Revised (QIKAT-R)

PURPOSE

Quality improvement (QI) has been part of medical education for over a decade. Assessment of QI learning remains challenging. The Quality Improvement Knowledge Application Tool (QIKAT), developed a decade ago, is widely used despite its subjective nature and inconsistent reliability. From 2009 to 2012, the authors developed and assessed the validation of a revised QIKAT, the "QIKAT-R."

METHOD

Phase 1: Using an iterative, consensus-building process, a national group of QI educators developed a scoring rubric with defined language and elements. Phase 2: Five scorers pilot tested the QIKAT-R to assess validity and inter- and intrarater reliability using responses to four scenarios, each with three different levels of response quality: "excellent," "fair," and "poor." Phase 3: Eighteen scorers from three countries used the QIKAT-R to assess the same sets of student responses.

RESULTS

Phase 1: The QI educators developed a nine-point scale that uses dichotomous answers (yes/no) for each of three QIKAT-R subsections: Aim, Measure, and Change. Phase 2: The QIKAT-R showed strong discrimination between "poor" and "excellent" responses, and the intra- and interrater reliability were strong. Phase 3: The discriminative validity of the instrument remained strong between excellent and poor responses. The intraclass correlation was 0.66 for the total nine-point scale.

CONCLUSIONS

The QIKAT-R is a user-friendly instrument that maintains the content and construct validity of the original QIKAT but provides greatly improved interrater reliability. The clarity within the key subsections aligns the assessment closely with QI knowledge application for students and residents.

Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents

PURPOSE

Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts.

METHOD

Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains.

RESULTS

The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains.

CONCLUSIONS

This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

IR action spectroscopy shows competitive oxazolone and diketopiperazine formation in peptides depends on peptide length and identity of terminal residue in the departing fragment

The interplay between the entropically and enthalpically favored products of peptide fragmentation is probed using a combined experimental and theoretical approach. These b2 ion products can take either an oxazolone or diketopiperazine structure. Cleavage after the second amide bond is often a favorable process because the products are small ring structures that are particularly stable. These structures are structurally characterized by action IRMPD spectroscopy and semi-quantified using gas-phase hydrogen-deuterium exchange. The formation of the oxazolone and diketopiperazine has been thought to be largely governed by the identity of the first two residues at the N-terminus of the peptide. We show here that the length of the precursor peptide and identity of the third residue play a significant role in the formation of the diketopiperazine structure in peptides containing an N-terminal asparagine residue. This is additionally the first instance showing an N-terminal residue with an amide side chain can promote formation of the diketopiperazine b2 ion structure.

The utility of reflective writing after a palliative care experience: can we assess medical students' professionalism?

BACKGROUND

Medical education leaders have called for a curriculum that proactively teaches knowledge, skills, and attitudes required for professional practice and have identified professionalism as a competency domain for medical students. Exposure to palliative care (PC), an often deeply moving clinical experience, is an optimal trigger for rich student reflection, and students' reflective writings can be explored for professional attitudes.

OBJECTIVE

Our aim was to evaluate the merit of using student reflective writing about a PC clinical experience to teach and assess professionalism.

METHODS

After a PC patient visit, students wrote a brief reflective essay. We explored qualitatively if/how evidence of students' professionalism was reflected in their writing. Five essays were randomly chosen to develop a preliminary thematic structure, which then guided analysis of 30 additional, randomly chosen essays. Analysts coded transcripts independently, then collaboratively, developed thematic categories, and selected illustrative quotes for each theme and subtheme.

RESULTS

Essays revealed content reflecting more rich information about students' progress toward achieving two professionalism competencies (demonstrating awareness of one's own perspectives and biases; demonstrating caring, compassion, empathy, and respect) than two others (displaying self-awareness of performance; recognizing and taking actions to correct deficiencies in one's own behavior, knowledge, and skill).

CONCLUSIONS

Professional attitudes were evident in all essays. The essays had limited use for formal summative assessment of professionalism competencies. However, given the increasing presence of PC clinical experiences at medical schools nationwide, we believe this assessment strategy for professionalism has merit and deserves further investigation.

Caring for oneself to care for others: physicians and their self-care

It is well known that clinicians experience distress and grief in response to their patients' suffering. Oncologists and palliative care specialists are no exception since they commonly experience patient loss and are often affected by unprocessed grief. These emotions can compromise clinicians' personal well-being, since unexamined emotions may lead to burnout, moral distress, compassion fatigue, and poor clinical decisions which adversely affect patient care. One approach to mitigate this harm is self-care, defined as a cadre of activities performed independently by an individual to promote and maintain personal well-being throughout life. This article emphasizes the importance of having a self-care and self-awareness plan when caring for patients with life-limiting cancer and discusses validated methods to increase self-care, enhance self-awareness and improve patient care.

A required third-year medical student palliative care curriculum impacts knowledge and attitudes

BACKGROUND

Despite broad support for palliative and end-of-life care training in medical schools, required clinical palliative care and end-of-life experiences are rare. In this study, we assess the impact of a required palliative care educational intervention on medical students' palliative care pain knowledge and end-of-life attitudes.

METHODS

In this wait-list control crossover design, third-year medical students from two sequential classes (n=157) completed a palliative care workshop at the beginning of a required year-long course. Students then completed a patient experience, online pain management module, and reflective essay in either the first or second half of the course. Fifteen validated multiple choice palliative care pain management items and the Thanatophobia Scale (7 items) were administered to measure knowledge and attitudes for all students at baseline, 5.5 months, and 11 months. Multivariate repeated measures ANOVA was used to determine differences between groups and across time.

RESULTS

Analysis found statistically significant increases in knowledge and improvements in attitudes (p<0.001) across the time points as well as a statistically significant interaction effect between time and groups (p=0.006). These changes correspond to specific curricular intervention components in which attitudinal improvements are seen after the workshop, and knowledge increases are seen after the patient experience, online pain module, and reflective essay.

CONCLUSION

A modest, required palliative care curriculum can yield improvements in medical student knowledge and attitudes. However, expansion of the experiential component and palliative care skills training and assessment are needed for students to have more meaningful outcomes and to ultimately contribute to better patient outcomes.

Parasite-driven pathogenesis in Trypanosoma brucei infections

Trypanosomes are protozoan parasites of medical and veterinary importance. It is well established that different species, subspecies and strains of trypanosome can cause very different disease in the mammalian host, exemplified by the two human-infective subspecies of Trypanosoma brucei that cause either acute or chronic disease. We are beginning to understand how the host response shapes the course of the disease and how genetic variation in the host can be a factor in disease severity, particularly in the mouse model, but until recently the role of parasite genetic variation that determines differential disease outcome has been a neglected area. This review will discuss the recent advances in this field, covering both our current knowledge of the T. brucei genes involved and the approaches that are leading towards the identification of T. brucei virulence genes. Finally, the potential for using parasite genotype variation to examine the evolutionary context of virulence will be discussed.

Managing cardiac devices near the end of life: a survey of hospice and palliative care providers

Implantable cardioverter defibrillators (ICDs) and pacemakers may change the character of an individual's eventual death. The objective of this study was to explore hospice and palliative care provider attitudes and experience in managing ICDs and pacemakers for patients near the end of life. A voluntary survey was distributed to session attendees at a national conference. Doctors and nurses surveyed overwhelmingly agreed it is appropriate to disable these devices in a terminally ill patient who does not wish to be resuscitated or prolong life. However, respondents emphasized a less defined burden for pacemakers. Respondents also reported limited involvement in such cases and few institutional protocols. As more terminal patients have these devices, research and education on device management protocols/guidelines and on provider communication skills are critical.

Developing Initial Competency-based Outcomes for the Hospice and Palliative Medicine Subspecialist: phase I of the hospice and palliative medicine competencies project

As a newly recognized subspecialty, the field of hospice and palliative medicine (HPM) must transition existing pathways for board certification, fellowship standards, and fellowship accreditation to one based on the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties competency framework. The Competencies Work Group of the American Board of Hospice and Palliative Medicine, using an iterative process informed by the field, has developed a set of Initial Competency-based Outcomes for the HPM Subspecialist. These competencies will set the standard for the "competent hospice and palliative medicine subspecialist physician," guiding future HPM fellowship training and potential midcareer HPM training opportunities. Lessons learned are highlighted.

Palliative Care for the Older Adult

The majority of deaths in the United States occur in the geriatric population. These older adults often develop multiple chronic medical problems and endure complicated medical courses with a variety of disease trajectories. Palliative care physicians need to be skilled in addressing the needs of these frail elders with life-limiting illness as they approach the end of life. Although geriatrics and palliative medicine share much in common, including an emphasis on optimizing quality of life and function, geriatric palliative care is distinct in its focus on the geriatric syndromes and on the provision of care in a variety of long-term care settings. Expertise in the diagnosis and management of the geriatric syndromes and in the complexities of long-term care settings is essential to providing high-quality palliative care to the elderly patient. This paper is a practical review of common geriatric syndromes, including dementia, delirium, urinary incontinence, and falls, with an emphasis on how they may be encountered in the palliative care setting. It also highlights important issues regarding the provision of palliative care in different long-term care settings.

Palliative care and pain management

Palliative care aims to improve quality of life and relieve suffering for patients with advanced illness and those close to them by specifically addressing communication, symptom management, coordination of care, psychosocial and spiritual realms, grief and bereavement support, and legal and ethical concerns. It has an interdisciplinary focus and may co-exist with curative and life-prolonging treatment. Palliative care is a key component of appropriate, routine medical care, especially for clinicians caring for older adults. In revisiting Mrs. B, the many needs of a typical elderly patient are apparent, as are the gaps in the current level of care. A discussion of prognosis and goals of care is a potential starting point. This includes obtaining input from an oncologist with regard to treatment options for Mrs. B's metastatic breast cancer and her pathologic hip fracture. Soliciting her treatment goals in the context of her chronic obstructive pulmonary disease and significant recent decline is the next challenge. Pain, dyspnea, constipation, anorexia, and anxiety could then be addressed with pointed assessment and symptom-specific management. Code status discussion, communication with her support network, and care coordination for her increased care needs would follow. Hospice should be introduced as a potential option. Advance care planning might also be initiated. Psychological and spiritual support needs could also be explored in time. Clearly, there is much to be done for Mrs. B and her loved ones in clarifying and coordinating whatever path comes to be. Older patients and their families face prolonged courses of chronic disease and gradual decline. Physicians caring for these patients need to be expert in the domains of palliative care so these patients and their families can receive the best quality of care while they are still living full lives and later as they approach the end of life.

What the genome sequence is revealing about trypanosome antigenic variation

African trypanosomes evade humoral immunity through antigenic variation, whereby they switch expression of the gene encoding their VSG (variant surface glycoprotein) coat. Switching proceeds by duplication of silent VSG genes into a transcriptionally active locus. The genome project has revealed that most of the silent archive consists of hundreds of subtelomeric VSG tandem arrays, and that most of these are not functional genes. Precedent suggests that they can contribute combinatorially to the formation of expressed, functional genes through segmental gene conversion. These findings from the genome project have major implications for evolution of the VSG archive and for transmission of the parasite in the field.

International Resuscitation Network Registry: design, rationale and preliminary results

There is a lack of high-quality information about the effectiveness of resuscitation interventions and international differences in structure, process and outcome after out-of-hospital cardiac arrest and cardiopulmonary resuscitation because data are not collected uniformly. An internet-based international registry could make such evaluations possible, and enable the conduct of large randomized controlled trials of resuscitation therapies. A prospective international cohort study was performed that included 571 infants, children and adults (a) who experienced cardiac arrest requiring chest compressions or external defibrillation, (b) outside the hospital in the study communities and (c) upon whom resuscitation was attempted by EMS personnel. Cardiac arrest was defined as lack of responsiveness, breathing or movement in individuals for whom the EMS system is activated for whom an arrest record is completed. All data were collated via a secure and confidential web-based method by using automated forms processing software with appropriate variable range checks, logic checks and skip rules. Median number of missing responses for each variable was 0 (interquartile range 0, 0). Twenty-seven percent of the patients had a first recorded rhythm of ventricular fibrillation or ventricular tachycardia, 60% had a witnessed arrest, and 34% received bystander CPR. Mean time from call to arrival on scene was 7.1+/-5.1 min. Six percent of the patients survived to hospital discharge. The resuscitation process was highly variable across centers, and survival and neurological outcome were also significantly and independently different across centers. This study shows that it is possible to collect data prospectively describing the structure, process and outcome associated with cardiac arrest in multiple international sites via the internet. Therefore, it is feasible to conduct adequately powered randomized trials of resuscitation therapies in international settings.