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

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

Intergenerational Transmission of Well Being–Genetic and Epigenetic Mechanisms

Introduction

Maternal mental well being influences offspring development. Research suggests that an interplay between genetic and environmental factors underlies this familial transmission of mental disorders.

Objectives

To explore an interaction between genetic and environmental factors to predict trajectories of maternal mental well being, and to examine whether these trajectories are associated with epigenetic modifications in mothers and their offspring.

Method

We assessed maternal childhood trauma and rearing experiences, prenatal and postnatal symptoms of depression and stress experience from 6 to 72 months postpartum, and genetic and epigenetic variation in a longitudinal birth-cohort study (n = 262) (Maternal adversity, vulnerability and neurodevelopment project). We used latent class modeling to describe trajectories in maternal depressive symptoms, parenting stress, marital stress and general stress, taking polygenetic risk for major depressive disorder (MDD), a composite score for maternal early life adversities, and prenatal depressive symptoms into account.

Results

Genetic risk for MDD associated with trajectories of maternal well being in the postpartum, conditional on the experience of early life adversities and prenatal symptoms of depression. We will explore whether these trajectories are also linked to DNA methylation patterns in mothers and their offspring. Preliminary analyses suggest that maternal early life adversities associate with offspring DNA methylation age estimates, which is mediated through maternal mental well being and maternal DNA methylation age estimates.

Conclusion

We found relevant gene-environment interactions associated with trajectories of maternal well being. Our findings inform research on mechanisms underlying familial transmission of vulnerability for psychopathology and might thus be relevant to prevention and early intervention programs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Mineral and organic matrix interaction in normally calcifying tendon visualized in three dimensions by high-voltage electron microscopic tomography and graphic image reconstruction

To define the ultrastructural accommodation of mineral crystals by collagen fibrils and other organic matrix components during vertebrate calcification, electron microscopic 3-D reconstructions were generated from the normally mineralizing leg tendons from the domestic turkey, Meleagris gallopavo. Embedded specimens containing initial collagen mineralizing sites were cut into 0.5-micron-thick sections and viewed and photographed at 1.0 MV in the Albany AEI-EM7 high-voltage electron microscope. Tomographic 3-D reconstructions were computed from a 2 degree tilt series of micrographs taken over a minimum angular range of +/- 60 degrees. Reconstructions of longitudinal tendon profiles confirm the presence of irregularly shaped mineral platelets, whose crystallographic c-axes are oriented generally parallel to one another and directed along the collagen long axes. The reconstructions also corroborate observations of a variable crystal length (up to 170 nm measured along crystallographic c-axes), the presence of crystals initially in either the hole or overlap zones of collagen, and crystal growth in the c-axis direction beyond these zones into adjacent overlap and other hole regions. Tomography shows for the first time that crystal width varies (30-45 nm) but crystal thickness is uniform (approximately 4-6 nm at the resolution limit of tomography); more crystals are located in the collagen hole zones than in the overlap regions at the earliest stages of tendon mineralization; the crystallographic c-axes of the platelets lie within +/- 15-20 degrees of one another rather than being perfectly parallel; adjacent platelets are spatially separated by a minimum of 4.2 +/- 1.0 nm; crystals apparently fuse in coplanar alignment to form larger platelets; development of crystals in width occurs to dimensions beyond single collagen hole zones; and a thin envelope of organic origin may be present along or just beneath the surfaces of individual mineral platelets. Implicit in the results is that the formation of crystals occurs at different sites and times by independent nucleation events in local regions of collagen. These data provide the first direct visual evidence from 3-D imaging describing the size, shape, orientation, and growth of mineral crystals in association with collagen of a normally mineralizing vertebrate tissue. They support concepts that c-axial crystal growth is unhindered by collage hole zone dimensions, that crystals are organized in the tendon in a series of generally parallel platelets, and that crystal growth in width across collagen fibrils may follow channels or grooves formed by adjacent hole zones in register.