Showing papers by "Sunnybrook Health Sciences Centre published in 2022"

Virtual and in-person visits by Ontario physicians in the COVID-19 era

Abstract: We examined the coronavirus disease 2019 (COVID-19) pandemic impact on weekly trends in the billing of virtual and in-person physician visits in Ontario, Canada.In this retrospective cohort study, physician billing records from Ontario were aggregated on a weekly basis for in-person and virtual visits from 3 January 2016 to 27 March 2021. For each type of visit, a segmented negative binomial regression analysis was performed to estimate the weekly pre-pandemic trend in billing volume per thousand adults (3 January 2016 to 14 March 2020), the immediate change in mean volume at the start of the pandemic, and additional change in weekly volume in the pandemic era (15 March 2020 to 27 March 2021).Before the start of the pandemic, the weekly volume of virtual visits per thousand adults was low with a 0.5% increase per week (rate ratio [RR]: 1.0053, 95% confidence interval [CI]: 1.0050-1.0056). A dramatic 65% reduction in in-person visits (RR: 0.35, 95% CI: 0.32-0.39) occurred at the start of the pandemic while virtual visits grew by 21-fold (RR: 21.3, 95% CI: 19.6-23.0). In the pandemic era, in-person visits rose by 1.4% per week (RR: 1.014, 95% CI: 1.011-1.017) but no change was observed for virtual visits (p-value = 0.31). Overall, we noted a 57.6% increase in total weekly physician visits volume after the start of the pandemic.These results are meaningful for virtual care reimbursement models. Future study needs to assess the quality of care and whether the increase in virtual care volume is cost-effective to society.

COVID-rate: an automated framework for segmentation of COVID-19 lesions from chest CT images

Abstract: Novel Coronavirus disease (COVID-19) is a highly contagious respiratory infection that has had devastating effects on the world. Recently, new COVID-19 variants are emerging making the situation more challenging and threatening. Evaluation and quantification of COVID-19 lung abnormalities based on chest Computed Tomography (CT) images can help determining the disease stage, efficiently allocating limited healthcare resources, and making informed treatment decisions. During pandemic era, however, visual assessment and quantification of COVID-19 lung lesions by expert radiologists become expensive and prone to error, which raises an urgent quest to develop practical autonomous solutions. In this context, first, the paper introduces an open-access COVID-19 CT segmentation dataset containing 433 CT images from 82 patients that have been annotated by an expert radiologist. Second, a Deep Neural Network (DNN)-based framework is proposed, referred to as the [Formula: see text], that autonomously segments lung abnormalities associated with COVID-19 from chest CT images. Performance of the proposed [Formula: see text] framework is evaluated through several experiments based on the introduced and external datasets. Third, an unsupervised enhancement approach is introduced that can reduce the gap between the training set and test set and improve the model generalization. The enhanced results show a dice score of 0.8069 and specificity and sensitivity of 0.9969 and 0.8354, respectively. Furthermore, the results indicate that the [Formula: see text] model can efficiently segment COVID-19 lesions in both 2D CT images and whole lung volumes. Results on the external dataset illustrate generalization capabilities of the [Formula: see text] model to CT images obtained from a different scanner.

Sensitivity of <scp> <i>Meloidogyne enterolobii</i> </scp> and <scp> <i>M. incognita</i> </scp> to fluorinated nematicides

Abstract: Meloidogyne enterolobii (Yang and Eisenback) was recently introduced into Louisiana on contaminated sweetpotato planting material. Given the known variation in sensitivity to nematicides within the genus Meloidogyne, there is question as to whether fluorinated nematicides will be as efficacious toward M. enterolobii as they are with M. incognita (Chitwood). Using a series of in vitro and growth cabinet experiments, this study compared the sensitivity of M. enterolobii and M. incognita to four synthetic non-fumigant nematicides (fluopyram, fluensulfone, fluazaindolizine, and oxamyl).Meloidogyne enterolobii had lower sensitivity to nematicides than M. incognita in the majority of the in vitro exposure assays. Similar levels of reduction in root infectivity were observed after nematicide exposure among both nematode species. Fluopyram showed high hatching inhibition for both Meloidogyne species at low concentrations [median effective concentration (EC50 ) values of 0.273 to 0.018 mg L-1 ], whereas fluensulfone showed high root penetration inhibition at low concentrations (EC50 values of 0.151 to 0.065 mg L-1 ) relative to that of other evaluated nematicides. For both Meloidogyne species, each of the four non-fumigant nematicides reduced root galling (58-96% reduction for M. enterolobii, 71-100% reduction for M. incognita) and egg production (63-99% reduction for M. enterolobii, 58-96% reduction for M. incognita) on sweetpotato when applied at the label recommended rate.Fluorinated nematicides and oxamyl show capacity to suppress M. enterolobii on sweetpotato. © 2021 Society of Chemical Industry.

Variability in the psychological impact of four waves of COVID-19: a time-series study of 60 000 text-based counseling sessions

Abstract: Abstract Background Continuous exposure to stressors can lead to vulnerability and, in some cases, resilience. This study examined the variation in its psychological impact across the first four waves of COVID-19 in Hong Kong. Methods Transcripts from Open Up, an online text-based counseling service, between January 2019 and January 2021 were analyzed ( N = 60 775). We identified COVID-19 mentioned sessions using keywords and further categorized them into those that also mentioned symptoms of common mental disorders (CMDs) and those that did not. Autoregressive integrated moving average models were used to analyze the associations between the severity of the outbreak and the mention of COVID-19 and CMDs. Results Results revealed that the pandemic led to increased psychological distress. Compared to prior to its advent, more people sought help in the initial months of the outbreak. Furthermore, associations were found between the severity of the outbreak and the number of help-seeker mentioning the pandemic, as well as between the outbreak severity and the number of help-seekers disclosing psychological distress. However, these relationships were not uniform across the four waves of outbreaks; a dissociation between outbreak severity and help-seekers' concern was found in the fourth wave. Conclusion As the pandemic waxes and wanes, people may become habituated to its psychological toll. This may be interpreted as a form of resilience. Instead of worsening with time, the psychological impact of COVID-19 may reduce with repeated exposure.

Competency-Based Medical Training in Anesthesiology: Has It Delivered on the Promise of Better Education?

Abstract: See Article, page 220 It has been >40 years since the term “competency-based medical education” (CBME) first appeared in a forward-thinking report prepared for the World Health Organization.1 This landmark report described a curriculum that was organized around defined clinical competencies that were acquired through a mastery learning approach. The goal of this new curriculum was to produce a better health professional who could practice proficiently across the breadth of medicine and contextualize care to meet local patient needs.1 CBME was described as an outcome-based approach, in contrast to the traditional time-based medical training approach. The competency-focused outcomes were designed to prepare physicians with all the expected competencies, beyond medical knowledge only, to better serve society.2 As we celebrate the centenary edition of Anesthesia & Analgesia, it should be recognized that CBME represents only a small portion of the advances in graduate medical education. The time-based training with which most anesthesiologists are familiar dates back to the Flexner report,3 released a decade before the first issue of this journal. Flexner’s survey of the state of medical education at the turn of the 20th century led to a standardization of medical school curricula. Out of that report also arose the concept of clerkships and the necessity for innovations in medical education to support the advancements in medicine. CBME may represent the evolution in medical education of the 21st century. The goal of a postgraduate CBME curriculum in anesthesiology is to explicitly outline, teach, assess, and provide feedback to residents so they can graduate with the competencies to ensure safe and effective anesthesiology practices.4 Today, the national standards of postgraduate anesthesiology training have embraced a CBME model in Canada, the United States, Australia, New Zealand, the United Kingdom, and Ireland.5–9 With this expanding global experience with CMBE, have the theoretical advantages to this approach translated into practice? Moreover, are there any unintended consequences to this paradigm shift in medical education? In this article, we highlight the progress that has been made toward the integration of CBME curricula into the postgraduate training of anesthesiologists. This article outlines several of the benefits of a transition to CBME and explores its challenges to programs, faculty, and residents. We also discuss important areas for the future development of medical education, including innovations in resident assessments and considerations to ensure training programs remain relevant and well positioned to prepare anesthesiologists to meet future health care needs. WHERE IS CBME NOW? Several countries have concurrently developed requirements and standards for CBME anesthesiology training. A recent comparison of the competency frameworks of CBME programs in Europe, the United States, and Canada demonstrated that >90% of the clinical competencies that were identified as necessary skills were common to all 3 regions.10 Core anesthesia competencies, for example, perioperative anesthesia care, managing critically ill patients in acute care settings and airway management, demonstrated a high degree of overlap and importance between regions. Conversely, specific competencies, such as navigating health care systems and incorporating practice-based learning, varied between countries, with particular emphasis in the United States, and were contextualized to culture and practice.10 The commonalities articulated by CBME training programs that are located in different countries provide an opportunity to explore international competency standards for anesthesiology postgraduate training. In addition, a universal consensus regarding the necessary core clinical competencies could facilitate potential reciprocity of postgraduate training between jurisdictions and portability to practice. Entrustable professional activities (EPAs) have supported CBME by organizing trainee assessments around specific and tangible clinical encounters. These clinical activities can be observed and fully entrusted to trainees to perform unsupervised after all the required knowledge, skills, and behaviors of the encounter are achieved. EPAs can enable assessment in CBME by mapping to all the desired competencies.11 Furthermore, they can be scaffolded for demonstrable progression of increased resident autonomy and responsibility in patient care on the path to independent practice.12 The Royal College of Physicians and Surgeons of Canada Competence by Design framework for anesthesiology training was implemented nationally in 2017. Currently, the curriculum includes 49 EPAs that are distributed through the 4 stages of residency training (Table 1).13 Most of these EPAs are designed as observable clinical encounters. The Accreditation Council for Graduate Medical Education (ACGME) Milestones Project described the anesthesiology competencies to provide a nationally shared framework. However, the project did not describe the methods to assess milestones in practice, nor how to determine whether the milestones have been achieved. More recently, 20 EPAs that map to the ACGME anesthesiology milestones have been rigorously developed to facilitate resident assessment by anesthesiology training programs in the United States.11 Table 1. - Four Stages of Postgraduate Training in Competence by Design and Associated Number of Anesthesiology EPAs, Mapped to Traditional Training Competency by design stages Mapping to traditional PGY in training Number of anesthesiology EPAs Transition to discipline PGY 1 3 EPAs Foundations of discipline PGY 1–2 16 EPAs Core of discipline PGY 3–5 25 EPAs Transition to practice PGY 5 5 EPAs Abbreviations: EPA, entrusted professional activity; PGY, postgraduate year.Adapted from the Royal College of Physicians and Surgeons of Canada.13 One critical enabler to CBME is the workplace-based assessment (WBA). By observing residents in the complex and authentic clinical practice environment, WBA tools serve as an important measure to monitor their training and document their achievement of competencies. WBAs have incorporated entrustment scales, which focus an assessor’s judgment on progression toward independent practice by asking whether a resident is capable of completing a task at a defined level of supervision. By anchoring a faculty member’s observation of a resident’s performance to a required level of supervision, the reliability between assessors is improved.14 Several entrustment-based WBA scales, with robust validity data for anesthesia training, have been developed to assess the perioperative care competencies of residents and monitor their progress during training.15–17 Ideally, CBME is delivered with numerous WBAs, including detailed and constructive narratives. These formative assessments (assessments for learning) serve to provide frequent targeted feedback and tailored coaching to residents, which guide their development of competencies and support mastery learning.18 Individual assessments, with quantitative performance ratings and qualitative narratives, are also collected over time for summative purposes (assessments of learning).19 Competence committees require sufficient aggregated data to make summative judgments of the residents of their program, such as promotion through a training program and documenting progress toward readiness for independent practice. Early reports suggest that CBME trainees are receiving more constructive feedback and that CBME assessment systems are also providing training programs with more information to make summative decisions about their residents.20 WHAT APPEARS TO BE WORKING WITH CBME? Given these early days of CBME adoption, there is limited information available regarding the experiences and perceptions of residents and faculty supervisors. A survey from 2016 indicated that anesthesiology residents in the United States were satisfied with their CBME training programs and were confident that they would master the ACGME competencies.21 CBME residents from several Canadian programs, including anesthesia, identified that they valued frequent meaningful feedback from supervisors through formative assessments, as this information helped to modify their behaviors.22 Interestingly, anesthesiology residents prefer specific supervisor feedback comments over a rating of their performance on an entrustment scale. They explained that the qualitative feedback shifted their orientation from a focus on achievement to one of self-improvement.23 This result is encouraging, as it suggests that residents are embracing a growth-oriented mindset,18 which is a driving goal of CBME. One year after the implementation of CBME, a report from a single Canadian anesthesiology program suggested that faculty had a favorable view, perceiving that the curriculum improved the performance of junior residents and clarified expectations.24 Faculty also appreciated the resident-directed and centered-learning process, as they noticed residents seemed motivated, “taking their learning in their own hands and presenting it to staff.”24 WHAT AREAS IN CBME NEED MORE WORK? A competency-based assessment of a trainee is complex and requires multiple approaches to ensure a valid reflection of their performance. The exponential increase in the number of assessments required to support CBME has created challenges for residents, faculty, and programs. The duality in the purpose of assessments (formative versus summative) can foster tensions, as stakeholders may view the purposes and stakes of the “point in time” WBA observations differently. Residents can perceive any, or all, formative assessments, which provide input into competence committee decisions as summative and are therefore high stakes.23 This viewpoint can make them reluctant to engage with the assessment results as a learning opportunity. One unintended consequence of this perception is that trainees might seek out lenient assessors or seek to perform simpler cases to demonstrate their competencies. Such an approach can interfere with the intended effect of supporting a resident’s learning and growth.25 Furthermore, EPAs may not be perceived as low stakes when they result in low ratings or when a minimum number of assessments are required to ensure advancement through the training program. Anesthesiology residents in Canada have expressed concerns that EPAs and the associated entrustment scales contribute to a “tick box exercise,” in which they are simply attempting to acquire assessments.23 In addition, anesthesiology residents reported that the quantitative entrustment scales failed to provide them with meaningful information about how they were progressing during training.23 Regrettably, some residents find it onerous to obtain feedback or an explanation for performance ratings.22 Finally, the burden of WBAs has been described to increase workloads, disrupt clinical workflow, and foster assessment fatigue in learners and their faculty.22,23,26,27 All of these challenges threaten the intended growth mindset of CBME. Faculty, who likely trained in programs that used a time-based paradigm, have expressed concerns about the lack of evidence to support the shift to CBME.24 In surveys, faculty have acknowledged an apprehension about the considerable amount of resources that are necessary to successfully implement and manage CBME.24 Furthermore, they recognized a mismatch in the perception of the goals and responsibilities in a CBME model compared to residents.24 CBME represents a culture change for both faculty and learners, with both groups benefiting from a growth-oriented mindset and a partnership approach to assessments.28 Faculty development is critical to appreciate that the assessment and coaching that concomitantly occur during WBAs are not discrete and independent events. Rather, they should be seen as overlapping and interdependent processes to support resident growth. As mentioned above, entrustment scales are anchored to the required level of supervision. They aim to reduce assessor bias and may require less faculty training than a subjective scale that asks raters to make assessments against “meeting expectations” for postgraduate years.14 Nevertheless, a recent study suggests that faculty continue to align their assessments to preexisting cognitive benchmarks, such as a resident’s year of training, rather than the observed clinical performance.29 Even when assessments are viewed as having no consequence for a resident’s progression in training, anesthesia faculty are often unwilling to identify competency deficits, despite patient safety having been demonstrably compromised.30 Moreover, >25% of anesthesiology residents received the same rating across the ACGME milestones, a phenomenon described as “straightlining,” compared to <10% straightlined response among other specialties, providing better discrimination between their trainees.31 Analysis of longitudinal anesthesiology milestones data in 5 US programs demonstrated that the frequency of straightlining varied significantly by program, from 9% to 57%.32 While this could represent a true lack in variation in resident competence, straightlining conflicts with the CBME concept that trainees progress at different stages for various competencies. Rather, straightlining may suggest that individualized resident assessments are not occurring or that programs lack a reliable method for assessing specific milestones. It could also indicate that Clinical Competency Committees are influenced by the halo effect and applying an overall impression, or that milestone level is still being assessed based on the year of training. Programs should be exploring their assessment and competence rating culture to examine overall rating patterns, thereby searching for root causes to identify contextualized local solutions. Rater errors and biases can have serious implications for the validity and defensibility of the eventual high-stakes summative judgments made using these assessments. Thus, training programs and competence committees should attempt to identify their outlier faculty with leniency or stringency biases. CBME resident assessment data can also be reconsidered as a measure of faculty performance. Auditing the quality and quantity of the assessments provided to residents can provide context and feedback for faculty.12,20 Training of faculty assessors may be a way to reduce rater bias and encourage more meaningful learner assessments. After a short educational intervention for academic anesthesiologists, the quality of their feedback provided to a simulated anesthesiology resident significantly improved, and professionalism lapses were better addressed.33 Disappointingly, studies in nonanesthesia programs have reported an inconsistent impact of rater training, unable to inform evidence and best practices for optimal format or duration of an intervention.34 The shift to CBME was partly driven by a movement for public accountability in medicine. Accordingly, the high-stakes decision of confirming an anesthesiology resident’s readiness for independent clinical practice requires robust evidence.19 To allow competency committees to make summative decisions, a resident’s education portfolio should include workplace assessments completed by a variety of faculty across a wide breadth of clinical contexts.12 Unfortunately, programs are struggling to use the assessment data received for these purposes.20 In the absence of platforms to manage and interpret the realms of data, programs can be challenged to support the growth of their residents and to make confident valid decisions on readiness for practice. A central goal of competency-based, time-variable medical education is graded increases in clinical and professional responsibility by entrusting trainees to provide patient care without supervision. Regrettably, the realization of a fully competency-based, time-variable system is constrained by current licensing and certification requirements and program accreditation systems that rely on fixed durations of training. Consequently, we still primarily rely on high-stakes, standardized, summative examinations for anesthesiology certification. Modernization of this approach could permit that evidence of a resident’s achievement of certain competencies be used to grant a graduated license or microcertification to allow them to take on greater clinical autonomy.35,36 Logistically, this would require close collaboration and innovation between programs and various regulatory bodies. WHAT WORK NEEDS TO BE DONE FOR CBME? Entrustment decisions are of particular importance in anesthesiology, in which patient care often occurs in high-stakes environments. In these dynamic, complex, acute, and rapidly changing situations, WBAs may not always be possible or appropriate. Thus, there are advantages to increasing the diversity of CBME assessment modalities. Simulation can be used to provide additional assessment data of technical and nontechnical skills.37 Simulation can also be beneficial when certain clinical events are critical but rare, and when it is not appropriate or safe to delegate responsibilities to a trainee solely for the purpose of undertaking an assessment.38 In anesthesiology and emergency medicine training, in which patient care is also acute and dynamic, simulation-based milestone assessments have been shown to be valid measures of resident competency and correlate with clinical evaluations.39–41 Relatedly, the performance on a regular objective structured clinical examination (OSCE)-based milestone assessment can also provide evidence of longitudinal growth in competence in anesthesiology residents.42 In Canada, the national CBME curriculum includes 5 mandatory, standardized mannequin-based simulation scenarios.43 Although the impact of simulated performance outcomes on certification decisions has yet to be determined, every Canadian anesthesiology resident must undertake these simulation scenarios before completing their training. Similarly, artificial intelligence is now being explored to enhance resident assessment through testing knowledge and observing workplace performance. For example, by training machines to understand speech patterns such as time spent talking or interruptions, a resident could receive specific feedback about their interpersonal communication directly after seeing a patient.44 Machine learning is also being explored to provide learning analytics to aggregated CBME assessment data to analyze and predict a trainee’s EPA progress to support residents and programs.45 As our experience deepens with CBME, more work is needed to demonstrate that the shift to CBME improves trainee performance and patient outcomes. Since operating room metrics are often used to assess the quality of patient care, one anesthesiology program in the United States examined perioperative databases to assess the efficiency of resident performance. This demonstrated that patient emergence time decreased by 28 seconds for each year of training.46 While this difference was statistically but not likely clinically significant, it serves as an example of exploring patient outcomes as a measure of competency. Patients are also increasingly involved in competency-based resident assessments, most often in the form of multisource feedback.47 Compared to physicians, who focus on medical expertise, patients provide greater comments on resident professional behaviors and communication skills in their assessments.47 Given the required investment by all stakeholders for successful CBME implementation, meaningful patient-focused outcomes still need to be identified to ensure a demonstrable return on that investment. In view of the exponential growth in medical knowledge and evolving patient needs, CBME must be agile and responsive. Nearly a decade after the original Milestones Project, the ACGME framework was recently revised to resolve some mismatch between the competencies and expectations for current and future graduates. The Anesthesiology Milestones now include previously absent critical skills and also reflect advances in clinical practice, such as point-of-care ultrasound (POCUS) and electronic medical records (Table 2).48 Table 2. - Six Domains of Competency in Anesthesiology Milestones 2.0, and Associated Subcompetencies Patient care PC 1: Preanesthetic evaluation PC 2: Perioperative care and management PC 3: Application and interpretation of monitors PC 4: Intraoperative care PC 5: Airway management PC 6: Point-of-care ultrasound PC 7: Situational awareness and crisis management PC 8: Postoperative care PC 9: Critical care PC 10: Regional (peripheral and neuraxial) anesthesia Medical knowledge MK 1: Foundational knowledge MK 2: Clinical reasoning Systems-based practice SBP 1: Patient safety and quality improvement SBP 2: System navigation for patient-centered care SBP 3: Physician role in health care systems Practice-based learning and improvement PBLI 1: Evidence-based and informed practice PBLI 2: Reflective practice and commitment to personal growth Professionalism PROF 1: Professional behavior and ethical principles PROF 2: Accountability/conscientiousness PROF 3: Well-being Interpersonal and communication skills ICS 1: Patient- and family-centered communication ICS 2: Interprofessional and team communication ICS 3: Communication within health care systems Abbreviations: ICS, interpersonal and communication skills; MK, medical knowledge; PBLI, practice-based learning and improvement; PC, patient care; PROF, professionalism; SBP, system-based practice.Adapted from the Accreditation Council for Graduate Medical Education.9 More nuanced, but perhaps more important to all specialties, is the increasing evidence of racial disparities that exist across the spectrum of health care. Black, Indigenous and people of color (BIPOC) encounter barriers to access surgical procedures, while also having higher rates of maternal mortality and worse surgical outcomes.49,50 As we continue to examine and face the legacy and persistence of structural racism in health care, it is clear that medical education institutions have an important role to play. Programs must be invested in training anesthesiologists with the competencies to provide effective and equitable care to BIPOC and other marginalized populations. It behooves us to iteratively revise CBME curriculum to reflect advances in practice (eg, POCUS). Analogous curriculum updates are also required to address social determinants of health (eg, health inequities in perioperative and maternal care for racialized persons) and to support antiracism in medical education.51,52 Finally, no discussion of CBME is complete without considering the abandonment of time as the framework of postgraduate training. If nothing else, the disruption caused by the global pandemic has served to clarify the need to innovate and utilize the opportunity of CBME for flexibility in training time and individualized curricula based on competence. Programs and accrediting and licensing bodies may need to consider the suppleness of time offered by CBME. This would allow them to capitalize on adding competent anesthesiologists to the workforce when they are ready for independent practice as opposed to a time-based certification date.53 CONCLUSIONS Twenty years ago, CBME was going to dramatically improve medical education to address unsafe, inefficient, and poor-quality health care, all while reforming training systems to ensure that physicians have the skills needed for complex modern practice. The medical education system has since undergone an accelerated transformation. No one will dispute that implementing CBME in anesthesiology programs has proven to be been challenging. Nevertheless, it has provided an explicit and transparent educational framework for residents, faculty, and programs. More work is needed to iteratively build on our early successes and to determine whether CBME produces more competent anesthesiologists to benefit patients and society. DISCLOSURES Name: Alayne Kealey, MD, FRCPC. Contribution: This author helped with the literature search and design, draft, and revisions of the manuscript. Conflicts of Interest: None. Name: Viren N. Naik, MD, MEd, MBA, FRCPC. Contribution: This author helped with design and revisions of the manuscript. Conflicts of Interest: V. N. Naik is an employee of the Royal College of Physicians and Surgeons of Canada. This manuscript was handled by: Thomas R. Vetter, MD, MPH.

Aging in Place in Social Housing: A Scoping Review of Social Housing for Older Adults

Abstract: Access to affordable housing is a rising concern, and social housing is one approach to support low-income, older renters. A scoping review was undertaken to understand the characteristics of older tenants and social housing services to identify strategies to promote aging in place. Seven peer review databases were searched to identify relevant articles. A total of 146 articles were included. Almost all examined socio-demographic and health characteristics of older tenants, while 72 per cent examined social housing services, including eligibility policies, staffing, and access to on-site services. This review points to a high vulnerability among older tenants and highlights the importance of co-locating services on-site with a tenant-facing support staff to identify vulnerable tenants and link them to services. More research on tenancy issues (e.g., unit condition, rental management) is needed to identify new opportunities for social housing landlords to help older tenants age in place.

Clinical Validation of a Plasma Donor-derived Cell-free DNA Assay to Detect Allograft Rejection and Injury in Lung Transplant

Abstract: Lung transplant patients are vulnerable to various forms of allograft injury, whether from acute rejection (AR) (encompassing acute cellular rejection [ACR] and antibody-mediated rejection [AMR]), chronic lung allograft dysfunction (CLAD), or infection (INFXN). Previous research indicates that donor-derived cell-free DNA (dd-cfDNA) is a promising noninvasive biomarker for the detection of AR and allograft injury. Our aim was to validate a clinical plasma dd-cfDNA assay for detection of AR and other allograft injury and to confirm and expand on dd-cfDNA and allograft injury associations observed in previous studies.We measured dd-cfDNA fraction using a novel single-nucleotide polymorphism-based assay in prospectively collected plasma samples paired with clinical-pathologic diagnoses. dd-cfDNA fraction was compared across clinical-pathologic cohorts: stable, ACR, AMR, isolated lymphocytic bronchiolitis, CLAD/neutrophilic-responsive allograft dysfunction (NRAD), and INFXN. Performance characteristics were calculated for AR and combined allograft injury (AR + CLAD/NRAD + INFXN) versus the stable cohort.The study included 195 samples from 103 patients. Median dd-cfDNA fraction was significantly higher for ACR (1.43%, interquartile range [IQR]: 0.67%-2.32%, P = 5 × 10-6), AMR (2.50%, IQR: 2.06%-3.79%, P = 2 × 10-5), INFXN (0.74%, IQR: 0.46%-1.38%, P = 0.02), and CLAD/NRAD (1.60%, IQR: 0.57%-2.60%, P = 1.4 × 10-4) versus the stable cohort. Area under the receiver operator characteristic curve for AR versus stable was 0.91 (95% confidence interval [CI]: 0.83-0.98). Using a ≥1% dd-cfDNA fraction threshold, sensitivity for AR was 89.1% (95% CI: 76.2%-100.0%), specificity 82.9% (95% CI: 73.3%-92.4%), positive predictive value, 51.9% (95% CI: 37.5%-66.3%), and negative predictive value, 97.3% (95% CI: 94.3%-100%). For combined allograft injury area under the receiver operator characteristic curve was 0.76 (95% CI: 0.66-0.85), sensitivity 59.9% (95% CI: 46.0%-73.9%), specificity 83.9% (95% CI: 74.1%-93.7%), positive predictive value, 43.6% (95% CI: 27.6%-59.6%), and negative predictive value, 91.0% (95% CI: 87.9%-94.0%).These results indicate that our dd-cfDNA assay detects AR and other allograft injury. dd-cfDNA monitoring, accompanied by standard clinical assessments, represents a valuable precision tool to support lung transplant health and is appropriate for further assessment in a prospective randomized-controlled study.

Validity evidence for the Anesthesia Clinical Encounter Assessment (ACEA) tool to support competency-based medical education

Abstract: Workplace-based assessment (WBA) is key to a competency-based assessment strategy. Concomitantly with our programme's launch of competency-based medical education, we developed an entrustment-based WBA, the Anesthesia Clinical Encounter Assessment (ACEA), to assess readiness for independent practice of competencies essential to perioperative patient care. This study aimed to examine validity evidence of the ACEA during postgraduate anaesthesiology training.The ACEA comprises an eight-item global rating scale (GRS), an overall independence rating, an eight-item checklist, and case details. ACEA data were extracted for University of Toronto anaesthesia residents from July 2017 to January 2020 from the programme's online assessment portal. Validity evidence was generated following Messick's validity framework, including response process, internal structure, relations with other variables, and consequences.We analysed 8664 assessments for 137 residents completed by 342 assessors. From generalisability analysis, 10 independent observations (two assessments each from five assessors) were sufficient to achieve a reliability threshold of ≥0.70 for in-training assessments. A composite GRS score of 3.65/5 provided optimal sensitivity (93.6%) and specificity (90.8%) for determining entrustment on receiver operator characteristic curve analysis. Test-retest reliability was high (intraclass correlation coefficient [ICC2,1]=0.81) for matched assessments within 14 days of each other. Composite GRS scores differed significantly between residents based on their training level (P<0.0001) and correlated highly with overall independence (0.91, P<0.001). The internal consistency of the GRS (α=0.96) was excellent.This study supports the validity of the ACEA for assessing the competence of residents performing perioperative care and supports its use in competency-based anaesthesiology training.

The IDentif.AI-x pandemic readiness platform: Rapid prioritization of optimized COVID-19 combination therapy regimens

Abstract: IDentif.AI-x, a clinically actionable artificial intelligence platform, was used to rapidly pinpoint and prioritize optimal combination therapies against COVID-19 by pairing a prospective, experimental validation of multi-drug efficacy on a SARS-CoV-2 live virus and Vero E6 assay with a quadratic optimization workflow. A starting pool of 12 candidate drugs developed in collaboration with a community of infectious disease clinicians was first narrowed down to a six-drug pool and then interrogated in 50 combination regimens at three dosing levels per drug, representing 729 possible combinations. IDentif.AI-x revealed EIDD-1931 to be a strong candidate upon which multiple drug combinations can be derived, and pinpointed a number of clinically actionable drug interactions, which were further reconfirmed in SARS-CoV-2 variants B.1.351 (Beta) and B.1.617.2 (Delta). IDentif.AI-x prioritized promising drug combinations for clinical translation and can be immediately adjusted and re-executed with a new pool of promising therapies in an actionable path towards rapidly optimizing combination therapy following pandemic emergence.

The 852/3 CE Mount Churchill eruption: examining the potential climatic and societal impacts and the timing of the Medieval Climate Anomaly in the North Atlantic region

Abstract: Abstract. The 852/3 CE eruption of Mount Churchill, Alaska, was one of the largest first-millennium volcanic events, with a magnitude of 6.7 (VEI 6) and a tephra volume of 39.4–61.9 km3 (95 % confidence). The spatial extent of the ash fallout from this event is considerable and the cryptotephra (White River Ash east; WRAe) extends as far as Finland and Poland. Proximal ecosystem and societal disturbances have been linked with this eruption; however, wider eruption impacts on climate and society are unknown. Greenland ice core records show that the eruption occurred in winter 852/3 ± 1 CE and that the eruption is associated with a relatively moderate sulfate aerosol loading but large abundances of volcanic ash and chlorine. Here we assess the potential broader impact of this eruption using palaeoenvironmental reconstructions, historical records and climate model simulations. We also use the fortuitous timing of the 852/3 CE Churchill eruption and its extensively widespread tephra deposition of the White River Ash (east) (WRAe) to examine the climatic expression of the warm Medieval Climate Anomaly period (MCA; ca. 950–1250 CE) from precisely linked peatlands in the North Atlantic region. The reconstructed climate forcing potential of the 852/3 CE Churchill eruption is moderate compared with the eruption magnitude, but tree-ring-inferred temperatures report a significant atmospheric cooling of 0.8 ∘C in summer 853 CE. Modelled climate scenarios also show a cooling in 853 CE, although the average magnitude of cooling is smaller (0.3 ∘C). The simulated spatial patterns of cooling are generally similar to those generated using the tree-ring-inferred temperature reconstructions. Tree-ring-inferred cooling begins prior to the date of the eruption suggesting that natural internal climate variability may have increased the climate system's susceptibility to further cooling. The magnitude of the reconstructed cooling could also suggest that the climate forcing potential of this eruption may be underestimated, thereby highlighting the need for greater insight into, and consideration of, the role of halogens and volcanic ash when estimating eruption climate forcing potential. Precise comparisons of palaeoenvironmental records from peatlands across North America and Europe, facilitated by the presence of the WRAe isochron, reveal no consistent MCA signal. These findings contribute to the growing body of evidence that characterises the MCA hydroclimate as time-transgressive and heterogeneous rather than a well-defined climatic period. The presence of the WRAe isochron also demonstrates that no long-term (multidecadal) climatic or societal impacts from the 852/3 CE Churchill eruption were identified beyond areas proximal to the eruption. Historical evidence in Europe for subsistence crises demonstrate a degree of temporal correspondence on interannual timescales, but similar events were reported outside of the eruption period and were common in the 9th century. The 852/3 CE Churchill eruption exemplifies the difficulties of identifying and confirming volcanic impacts for a single eruption, even when the eruption has a small age uncertainty.

Clinical Practice Guideline: Early Mobilization and Rehabilitation of Critically Ill Burn Patients

Abstract: Abstract This Clinical Practice Guideline addresses early mobilization and rehabilitation (EMR) of critically ill adult burn patients in an intensive care unit (ICU) setting. We defined EMR as any systematic or protocolized intervention that could include muscle activation, active exercises in bed, active resistance exercises, active side-to-side turning, or mobilization to sitting at the bedside, standing, or walking, including mobilization using assistance with hoists or tilt tables, which was initiated within at least 14 days of injury, while the patient was still in an ICU setting. After developing relevant PICO (Population, Intervention, Comparator, Outcomes) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations were formulated through the consensus of a multidisciplinary committee, which included burn nurses, physicians, and rehabilitation therapists, based on the available scientific evidence. No recommendation could be formed on the use of EMR to reduce the duration of mechanical ventilation in the burn ICU, but we conditionally recommend the use of EMR to reduce ICU-acquired weakness in critically ill burn patients. No recommendation could be made regarding EMR’s effects on the development of hospital-acquired pressure injuries or disruption or damage to the skin grafts and skin substitutes. We conditionally recommend the use of EMR to reduce delirium in critically ill burn patients in the ICU.

The adverse cardiovascular risk factor profile of women with pre‐eclampsia develops over time in the years before pregnancy

Abstract: Women with a history of pre-eclampsia have an elevated lifetime risk of cardiovascular disease that may be partly attributed to an adverse cardiovascular risk factor profile, the etiology of which is unclear. Hypothesising that this adverse risk profile may begin to arise over time in the years before pregnancy, we sought to evaluate the pregravid changes over time in cardiovascular risk factors in women who go on to develop pre-eclampsia and those who do not.Retrospective cohort study using population-based administrative databases.Ontario, Canada.All nulliparous women who had singleton pregnancies between January 2011 and December 2018.All results for the following analytes between January 2008 and the start of pregnancy were identified: A1c, glucose, lipids, and transaminases. Mean values were compared between those with and without preeclampsia. The annual change for each analyte in the years before pregnancy was estimated using generalized estimating equations.Preeclampsia.The 156 278 women (of whom 3827 developed preeclampsia) had mean 4.0 ± 3.3 pregravid tests overall. The two most recent pregravid tests were performed at median 0.6 and 1.9 years before pregnancy, respectively. Women who developed pre-eclampsia had higher pregravid A1c, fasting glucose, random glucose, LDL-cholesterol, triglycerides, and ALT, and lower HDL-cholesterol, than their peers (all P < 0.0001). In the years before pregnancy, women who went on to develop pre-eclampsia had higher annual increases than their peers in triglycerides (13.8-fold higher; P = 0.0004) and random glucose (1.55-fold higher; P = 0.001), coupled with a greater annual decrease in HDL-cholesterol (9.7-fold higher; P = 0.002). During this time, fasting glucose increased in women who developed pre-eclampsia but decreased in their peers (P = 0.01).In women who develop pre-eclampsia, an adverse cardiovascular risk factor profile evolves over time in the years before pregnancy.In women who develop pre-eclampsia, an adverse CV risk factor profile evolves in the years before pregnancy.

The Impact of Inflammation and General Anesthesia on Memory and Executive Function in Mice

Abstract: Perioperative neurocognitive disorders (PNDs) are complex, multifactorial conditions that are associated with poor long-term outcomes. Inflammation and exposure to general anesthetic drugs are likely contributing factors; however, the relative impact of each factor alone versus the combination of these factors remains poorly understood. The goal of this study was to compare the relative impact of inflammation, general anesthesia, and the combination of both factors on memory and executive function.To induce neuroinflammation at the time of exposure to an anesthetic drug, adult male mice were treated with lipopolysaccharide (LPS) or vehicle. One day later, they were anesthetized with etomidate (or vehicle). Levels of proinflammatory cytokines were measured in the hippocampus and cortex 24 hours after LPS treatment. Recognition memory and executive function were assessed starting 24 hours after anesthesia using the novel object recognition assay and the puzzle box, respectively. Data are expressed as mean (or median) differences (95% confidence interval).LPS induced neuroinflammation, as indicated by elevated levels of proinflammatory cytokines, including interleukin-1β (LPS versus control, hippocampus: 3.49 pg/mg [2.06-4.92], P < .001; cortex: 2.60 pg/mg [0.83-4.40], P = .010) and tumor necrosis factor-α (hippocampus: 3.50 pg/mg [0.83-11.82], P = .002; cortex: 2.38 pg/mg [0.44-4.31], P = .021). Recognition memory was impaired in mice treated with LPS, as evinced by a lack of preference for the novel object (novel versus familiar: 1.03 seconds [-1.25 to 3.30], P = .689), but not in mice treated with etomidate alone (novel versus familiar: 2.38 seconds [0.15-4.60], P = .031). Mice cotreated with both LPS and etomidate also exhibited memory deficits (novel versus familiar: 1.40 seconds [-0.83 to 3.62], P = .383). In the puzzle box, mice treated with either LPS or etomidate alone showed no deficits. However, the combination of LPS and etomidate caused deficits in problem-solving tasks (door open task: -0.21 seconds [-0.40 to -0.01], P = .037; plug task: -0.30 seconds [-0.50 to -0.10], P < .001; log values versus control), indicating impaired executive function.Impairments in recognition memory were driven by inflammation. Deficits in executive function were only observed in mice cotreated with LPS and etomidate. Thus, an interplay between inflammation and etomidate anesthesia led to cognitive deficits that were not observed with either factor alone. These findings suggest that inflammation and anesthetic drugs may interact synergistically, or their combination may unmask covert or latent deficits induced by each factor alone, leading to PNDs.

Association between time to therapeutic INR and length of stay following mechanical heart valve surgery.

Abstract: BACKGROUND Warfarin is the only oral anticoagulant approved for use following mechanical valve surgery (MeVS). Patients may experience prolonged hospital length of stay (LOS) following MeVS awaiting an appropriate warfarin effect. We aimed to determine whether an association exists between time to achieve the first therapeutic international normalized ratio (INR) and LOS following MeVS. MATERIALS AND METHODS Retrospective single center cohort study. We included consecutive adult patients undergoing elective MeVS from 2013 to 2018. Landmark analyses and multivariable regression with time-updated INR were used to estimate the association between time to therapeutic INR (TTI) and LOS. RESULTS Among 384 patients (median age: 51 years, interquartile range [IQR]: 41-57; 58.3% male), the median TTI was 4 days (IQR: 2-5). Thirty seven percent of patients were discharged with a subtherapeutic INR, many on bridging anticoagulation or with an INR close to target. Those achieving therapeutic INR had an increased rate of hospital discharge (adjusted hazard ratio: 2.17; 95% confidence interval: 1.71-2.76; p < .0001). Attainment of a therapeutic INR anytime between postoperative Days 4 and 13 was significantly associated with a shorter LOS. CONCLUSIONS Prolonged time to achieve a therapeutic INR was independently associated with prolonged LOS. Future strategies aimed at improving attainment of therapeutic INR following MeVS may reduce hospital LOS.

A review of the AURORA and BLISS trials: will it revolutionize the treatment of lupus nephritis?

Abstract: Renal involvement in patients with systemic lupus erythematosus can lead to significant complications including end-stage renal disease. Treatment of lupus nephritis has evolved over the last several decades, but despite this evolution, many patients fail to achieve remission and often progress to end-stage kidney disease or carry a burden of adverse side effects related to treatment.The recent findings from AURORA 1 and BLISS LN trials led the FDA to approve voclosporin and belimumab for the treatment of lupus nephritis. The AURORA 1 trial demonstrated that voclosporin, a second-generation calcineurin inhibitor, effectively lowers proteinuria in patients with lupus nephritis, when added to mycophenolate mofetil with a better safety profile, compared with other calcineurin inhibitors. The BLISS LN trial revealed better control of disease and lower risk of progression to end stage kidney disease (ESKD) and relapses in patients treated with belimumab in addition to standard therapy.Both voclosporin and belimumab are costly and have not shown any early evidence to revolutionize practice in the management of lupus nephritis. Until more data are made available with future studies or other cost-effective treatment options become available, the widespread adoption and utility of these novel agents remains limited.

Acute Pain Management for a Tibial Plateau Fracture Shortly After a Buprenorphine XR Depot Injection: A Case Report

Abstract: Acute pain management of patients on buprenorphine for opioid use disorder remains a challenge. The buprenorphine extended-release depot injection which lasts for 1 month and has a higher plasma concentration of buprenorphine compared to the sublingual formulation is increasingly being used in patients. Acute pain management of patients on buprenorphine depot remains a challenge because waiting for the washout of the medication is not feasible and discontinuation is challenging because it requires surgical excision. We describe here the pharmacokinetics of the buprenorphine depot formulation and the clinical implications of its long duration of action. A 39-year-old woman with a history of alcohol and opioid use disorder, on buprenorphine depot, was admitted to the hospital with a left tibial plateau fracture. Acute pain service managed her pain by utilizing a multimodal analgesia plan including femoral and popliteal nerve catheters, intravenous patient-controlled analgesia and oral opioid and nonopioid medications. The patient had a prolonged length of stay of 11 days but was successfully weaned off nerve catheters and intravenous medications and converted to an oral medication regiment such that she could be discharged from the acute care hospital.

Pattern of Recurrence of Glioblastoma Versus Grade 4 IDH-Mutant Astrocytoma Following Chemoradiation: A Retrospective Matched-Cohort Analysis

Abstract: Background and Purpose: To quantitatively compare the recurrence patterns of glioblastoma (isocitrate dehydrogenase-wild type) versus grade 4 isocitrate dehydrogenase-mutant astrocytoma (wild type isocitrate dehydrogenase and mutant isocitrate dehydrogenase, respectively) following primary chemoradiation. Materials and Methods: A retrospective matched cohort of 22 wild type isocitrate dehydrogenase and 22 mutant isocitrate dehydrogenase patients were matched by sex, extent of resection, and corpus callosum involvement. The recurrent gross tumor volume was compared to the original gross tumor volume and clinical target volume contours from radiotherapy planning. Failure patterns were quantified by the incidence and volume of the recurrent gross tumor volume outside the gross tumor volume and clinical target volume, and positional differences of the recurrent gross tumor volume centroid from the gross tumor volume and clinical target volume. Results: The gross tumor volume was smaller for wild type isocitrate dehydrogenase patients compared to the mutant isocitrate dehydrogenase cohort (mean ± SD: 46.5 ± 26.0 cm 3 vs 72.2 ± 45.4 cm 3 , P = .026). The recurrent gross tumor volume was 10.7 ± 26.9 cm 3 and 46.9 ± 55.0 cm 3 smaller than the gross tumor volume for the same groups ( P = .018). The recurrent gross tumor volume extended outside the gross tumor volume in 22 (100%) and 15 (68%) ( P= .009) of wild type isocitrate dehydrogenase and mutant isocitrate dehydrogenase patients, respectively; however, the volume of recurrent gross tumor volume outside the gross tumor volume was not significantly different (12.4 ± 16.1 cm 3 vs 8.4 ± 14.2 cm 3 , P = .443). The recurrent gross tumor volume centroid was within 5.7 mm of the closest gross tumor volume edge for 21 (95%) and 22 (100%) of wild type isocitrate dehydrogenase and mutant isocitrate dehydrogenase patients, respectively. Conclusion: The recurrent gross tumor volume extended beyond the gross tumor volume less often in mutant isocitrate dehydrogenase patients possibly implying a differential response to chemoradiotherapy and suggesting isocitrate dehydrogenase status might be used to personalize radiotherapy. The results require validation in prospective randomized trials.