Can an Online Educational Module Improve Medical Trainee Confidence and Knowledge of Coagulation?

Background: Coagulation has notoriously been a topic that medical trainees find challenging to learn. A lack of understanding around coagulation has led to widespread inappropriate ordering of commonly used coagulation tests, including the prothrombin time (PT) and the activated partial thromboplastin time (aPTT). Despite these tests being validated for specific clinical indications, they are frequently ordered as screening tests in unselected patients, and often ordered together, suggesting a gap in physician understanding of coagulation and appropriate testing. To explore this further, we conducted a root-cause-analysis survey of 10 medical trainees. 70% of the surveyed trainees did not feel comfortable with their knowledge regarding coagulation and the appropriate use of coagulation tests. Trainees attributed their suboptimal knowledge to the manner in which coagulation is taught in training programs. Furthermore, they identified a scarcity of practical resources on coagulation and expressed interest in a web-accessible resource. Methods: We created an educational module on coagulation testing for trainees, available online at www.coagtesting.com. This module was created with the intent of simplifying the teaching of coagulation, with a focus on emphasizing clinically-relevant concepts. The module was evaluated at the University of Toronto with 50 participating medical trainees (11 medical students, 39 internal medicine residents [14 PGY1, 15 PGY2, 10 PGY3 residents]). Participation in our study included completing a validated knowledge pre-quiz on coagulation, completion of the educational module, and then the post-quiz following the module. To assess longer term knowledge retention, participants were asked to repeat the knowledge quiz three months following their initial participation. Our educational intervention was evaluated according to the Kirkpatrick Model, a framework for learning evaluation, with educational outcomes organized into four ranked levels (level 1, reaction; level 2, learning; level 3, behaviour; level 4, results). The primary objective of this study was to determine if the module improves trainee knowledge of coagulation, as indicated by their quiz results (level 2, learning). The secondary objective was to evaluate if the module has an influence on trainee ordering practices as assessed by a follow-up survey (level 3, behaviour). Results: The median pre-module quiz score was 67% (range 24% - 86%) with an increase of 24% to a median post-module quiz score of 91% (range 64% - 100%). Notably, in the pre-module quiz, 94% of trainees overestimated the sensitivity and specificity of the PT and aPTT in detecting a bleeding disorder, and 44% of trainees underestimated the cost of a PT test. 80% of trainees described increased confidence regarding their knowledge of coagulation and the use of coagulation tests following completion of the module. In addition, we have demonstrated sustained knowledge acquisition with a 3-month post-quiz median score of 89% (n=15, range 67%-100%). 100% of trainees who completed the 3-month follow-up survey (n=15) felt that the educational module had a positive influence on their practice and 87% of trainees were more likely to consider the sensitivity, specificity, and cost of a lab test prior to ordering it. In the seven months since the module was launched, it has been completed by over 2,000 unique visitors worldwide, with use in Canada, the United States, the United Kingdom, Australia, France, and Saudi Arabia according to data from our website host. Furthermore, several visitors to the website have re-visited the module multiple times. Conclusion: We have successfully demonstrated a significant increase in trainee knowledge and confidence regarding coagulation and appropriate use of coagulation tests with our educational intervention. Using the expertise of medical educators and incorporating feedback from trainees, we have employed a novel approach to the teaching of coagulation to maximize its approachability and clinical relevance. Our module also incorporates education on the cost of coagulation testing and appropriate use of these tests thus in line with the tenets of Choosing Wisely. The degree to which trainees have been utilizing and re-referring to our educational module worldwide emphasizes the need for this resource and its importance in bridging a large gap in medical training. Disclosures Sholzberg: Novartis: Honoraria; Amgen: Honoraria, Research Funding.

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Association between neoangiogenesis after first and second indirect bypass in moyamoya disease

10.21203/rs.2.20214/v1 ◽

2020 ◽

Author(s):

Peicong Ge ◽

Qian Zhang ◽

Xun Ye ◽

Xingju Liu ◽

Xiaofeng Deng ◽

...

Keyword(s):

Digital Subtraction Angiography ◽

Moyamoya Disease ◽

Digital Subtraction ◽

Study Objective ◽

Second Surgery ◽

Level 3 ◽

Level 1 ◽

Medical University ◽

Level 2

Abstract Background The research on neoangiogenesis after indirect bypass for moyamoya disease (MMD) evaluated by using digital subtraction angiography (DSA) is limited. Our study objective was to investigate association between neoangiogenesis after first indirect bypass and second indirect bypass in MMD.Methods All consecutive inpatients with MMD who received indirect bypass at Beijing Tiantan Hospital, Capital Medical University from January 2011 through December 2017 were screened. Bilateral neoangiogenesis was evaluated on lateral views and anteroposterior views by using DSA .Results Twenty-two patients (44 hemispheres) were included in this study. After a median 7.5 months DSA follow-up, On lateral views, 9 (40.9%) hemispheres had grade A, 8 (36.4%) hemispheres had grade B, and 5 (22.7%) hemispheres had grade C after the first procedures; 11 (50.0%) hemispheres had grade A, 7 (31.8%) hemispheres had grade B, and 4 (18.2%) hemispheres had grade C after the second surgery. On anteroposterior views of ECA, 2 (9.1%) hemispheres had level 0, 3 (13.6%) had level 1, 6 (27.3%) had level 2, and 11 (50.0%) had level 3 after the first procedures; 2 (9.1%) hemispheres had level 0, 2 (9.1%) had level 1, 6 (27.3%) had level 2, and 12 (54.6%) had level 3 after second operation. Neovascularization after second operation was strongly associated with the neovascularization after first operation on lateral views (r s =0.770; p=0.000) and the anteroposterior views (r s =0.548; p=0.008).Conclusion Neovascularization after second indirect bypass was strongly associated with neovascularization of first indirect bypass.

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RADIAL NERVE LACERATIONS — THE OUTCOME OF END-TO-END REPAIRS IN PENETRATING TRAUMA

Hand Surgery ◽

10.1142/s0218810415500094 ◽

2015 ◽

Vol 20 (01) ◽

pp. 67-72 ◽

Cited By ~ 3

Author(s):

M. Laubscher ◽

M. Held ◽

M. Maree ◽

M. Solomons

Keyword(s):

Radial Nerve ◽

Medical Research Council ◽

Penetrating Trauma ◽

Finger Extension ◽

British Medical Research Council ◽

Level 3 ◽

End To End ◽

Stab Injuries ◽

Level 2

Due to its mostly motor content, repair of the radial nerve is considered to yield favourable results. This is despite the fact that there are limited studies looking at the outcomes of end-to-end repair secondary to sharp penetrating trauma. We retrospectively reviewed the outcome of a series of repaired level 2 and level 3 radial nerves following penetrating stab injuries. Twenty-seven cases with adequate follow-up were included. All the patients underwent direct end-to-end repair. We evaluated the motor recovery of the target muscles using the British Medical Research Council (MRC) grading system. Wrist extension recovered in 93% of cases at a mean of six months. Finger extension recovered in 74% and thumb extension in 52% of cases within the follow-up period. We conclude that end-to-end repair is possible in the majority of level 2 and level 3 radial nerve lacerations secondary to penetrating stab injuries. Acceptable results can be expected.

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Historical text archives and prosopography: the COEL database system

History and Computing ◽

10.3366/hac.1998.10.1-3.57 ◽

1998 ◽

Vol 10 (1-3) ◽

pp. 57-72 ◽

Cited By ~ 4

Author(s):

K. S. B. Keats-Rohan

Keyword(s):

Research Tool ◽

Direct Access ◽

Specific Situation ◽

Core Data ◽

Secondary Sources ◽

The Core ◽

Level 3 ◽

Full Discussion ◽

Available Information ◽

Level 2

The COEL database and database software, a combined reference and research tool created by historians for historians, is presented here through Screenshots illustrating the underlying theoretical model and the specific situation to which that has been applied. The key emphases are upon data integrity, and the historian's role in interpreting and manipulating what is often contentious data. From a corpus of sources (Level 1) certain core data are extracted for separate treatment at an interpretive level (Level 3), based upon a master list of the core data (Level 2). The core data are interdependent: each record in Level 2 is of interest in itself; and it either could or should be associated with an(other) record(s) as a specific entity. Sometimes the sources are ambiguous and the association is contentious, necessitating a probabilty-coding approach. The entities created by the association process can then be treated at a commentary level, introducing material external to the database, whether primary or secondary sources. A full discussion of the difficulties is provided within a synthesis of available information on the core data. Direct access to the source texts is only ever a mouse click away. Fully query able, COEL is formidable look-up and research tool for users of all levels, who remain free to exercise an alternative judgement on the associations of the core data. In principle, there is no limit on the type of text or core data that could be handled in such a system.

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EVALUASI PELATIHAN DI PT. PUPUK KUJANG CIKAMPEK

PSYCHOPEDIA : Jurnal Psikologi Universitas Buana Perjuangan Karawang ◽

10.36805/psikologi.v3i2.714 ◽

2018 ◽

Vol 3 (2) ◽

Author(s):

Lania Muharsih ◽

Ratih Saraswati

Keyword(s):

Training Evaluation ◽

Work Productivity ◽

Learning Behavior ◽

Level 3 ◽

Level 1 ◽

Four Levels ◽

A Company ◽

Level 2 ◽

Evaluation Sheet ◽

Assessment Factor

This study aims to determine the training evaluation at PT. Kujang Fertilizer. PT. Pupuk Kujang is a company engaged in the field of petrochemicals. Evaluation sheet of PT. Fertilizer Kujang is made based on Kirkpatrick's theory which consists of four levels of evaluation, namely reaction, learning, behavior, and results. At level 1, namely reaction, in the evaluation sheet is in accordance with the theory of Kirkpatrick, at level 2 that is learning should be held pretest and posttest but only made scale. At level 3, behavior, according to theory, but on assessment factor number 3, quantity and work productivity should not need to be included because they are included in level 4. At level 4, that is the result, here is still lacking to get a picture of the results of the training that has been carried out because only based on answers from superiors without evidence of any documents. Keywords: Training Evaluation, Kirkpatrick Theory. Penelitian ini bertujuan mengetahui evaluasi training di PT. Pupuk Kujang. PT. Pupuk Kujang merupakan perusahaan yang bergerak di bidang petrokimia. Lembar evaluasi PT. Pupuk Kujang dibuat berdasarkan teori Kirkpatrick yang terdiri dari empat level evaluasi, yaitu reaksi, learning, behavior, dan hasil. Pada level 1 yaitu reaksi, di lembar evaluasi tersebut sudah sesuai dengan teori dari Kirkpatrick, pada level 2 yaitu learning seharusnya diadakan pretest dan posttest namun hanya dibuatkan skala. Pada level 3 yaitu behavior, sudah sesuai teori namun pada faktor penilaian nomor 3 kuantitas dan produktivitas kerja semestinya tidak perlu dimasukkan karena sudah termasuk ke dalam level 4. Pada level 4 yaitu hasil, disini masih sangat kurang untuk mendapatkan gambaran hasil dari pelatihan yang sudah dilaksanakan karena hanya berdasarkan dari jawaban atasan tanpa bukti dokumen apapun. Kata kunci: Evaluasi Pelatihan, Teori Kirkpatrick.

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Variation in antibiotic use across intensive care units (ICU): A population-based cohort study in Ontario, Canada

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.217 ◽

2020 ◽

Vol 41 (9) ◽

pp. 1035-1041

Author(s):

Erika Y. Lee ◽

Michael E. Detsky ◽

Jin Ma ◽

Chaim M. Bell ◽

Andrew M. Morris

Keyword(s):

Cohort Study ◽

Intensive Care ◽

Intensive Care Units ◽

Ventilatory Support ◽

Severity Of Illness ◽

Antibiotic Use ◽

Patient Factors ◽

Days Of Therapy ◽

Level 3 ◽

Level 2

AbstractObjectives:Antibiotics are commonly used in intensive care units (ICUs), yet differences in antibiotic use across ICUs are unknown. Herein, we studied antibiotic use across ICUs and examined factors that contributed to variation.Methods:We conducted a retrospective cohort study using data from Ontario’s Critical Care Information System (CCIS), which included 201 adult ICUs and 2,013,397 patient days from January 2012 to June 2016. Antibiotic use was measured in days of therapy (DOT) per 1,000 patient days. ICU factors included ability to provide ventilator support (level 3) or not (level 2), ICU type (medical-surgical or other), and academic status. Patient factors included severity of illness using multiple-organ dysfunction score (MODS), ventilatory support, and central venous catheter (CVC) use. We analyzed the effect of these factors on variation in antibiotic use.Results:Overall, 269,351 patients (56%) received antibiotics during their ICU stay. The mean antibiotic use was 624 (range 3–1460) DOT per 1,000 patient days. Antibiotic use was significantly higher in medical-surgical ICUs compared to other ICUs (697 vs 410 DOT per 1,000 patient days; P < .0001) and in level 3 ICUs compared to level 2 ICUs (751 vs 513 DOT per 1,000 patient days; P < .0001). Higher antibiotic use was associated with higher severity of illness and intensity of treatment. ICU and patient factors explained 47% of the variation in antibiotic use across ICUs.Conclusions:Antibiotic use varies widely across ICUs, which is partially associated with ICUs and patient characteristics. These differences highlight the importance of antimicrobial stewardship to ensure appropriate use of antibiotics in ICU patients.

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More for less: predicting and maximizing genomic variant discovery via Bayesian nonparametrics

Biometrika ◽

10.1093/biomet/asab012 ◽

2021 ◽

Author(s):

Lorenzo Masoero ◽

Federico Camerlenghi ◽

Stefano Favaro ◽

Tamara Broderick

Keyword(s):

Optimal Allocation ◽

Bayesian Nonparametrics ◽

Allocation Of Resources ◽

Experimental Conditions ◽

Follow Up Study ◽

Variant Discovery ◽

Fixed Budget ◽

The Cost ◽

Genomic Variant

Abstract While the cost of sequencing genomes has decreased dramatically in recent years, this expense often remains non-trivial. Under a fixed budget, scientists face a natural trade-off between quantity and quality: spending resources to sequence a greater number of genomes or spending resources to sequence genomes with increased accuracy. Our goal is to find the optimal allocation of resources between quantity and quality. Optimizing resource allocation promises to reveal as many new variations in the genome as possible. In this paper, we introduce a Bayesian nonparametric methodology to predict the number of new variants in a follow-up study based on a pilot study. When experimental conditions are kept constant between the pilot and follow-up, we find that our prediction is competitive with the best existing methods. Unlike current methods, though, our new method allows practitioners to change experimental conditions between the pilot and the follow-up. We demonstrate how this distinction allows our method to be used for more realistic predictions and for optimal allocation of a fixed budget between quality and quantity.

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447 Cost-Effectiveness of a 3-Year Tele-OSA Intervention

SLEEP ◽

10.1093/sleep/zsab072.446 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A177-A177

Author(s):

Jaejin An ◽

Dennis Hwang ◽

Jiaxiao Shi ◽

Amy Sawyer ◽

Aiyu Chen ◽

...

Keyword(s):

Cost Effectiveness ◽

Willingness To Pay ◽

Incremental Cost ◽

Economic Benefits ◽

Small Sample ◽

Apnea Hypopnea Index ◽

Obstructive Sleep ◽

Group 2 ◽

The Cost

Abstract Introduction Trial-based tele-obstructive sleep apnea (OSA) cost-effectiveness analyses have often been inconclusive due to small sample sizes and short follow-up. In this study, we report the cost-effectiveness of Tele-OSA using a larger sample from a 3-month trial that was augmented with 2.75 additional years of epidemiologic follow-up. Methods The Tele-OSA study was a 3-month randomized trial conducted in Kaiser Permanente Southern California that demonstrated improved adherence in patients receiving automated feedback messaging regarding their positive airway pressure (PAP) use when compared to usual care. At the end of the 3 months, participants in the intervention group pseudo-randomly either stopped or continued receiving messaging. This analysis included those participants who had moderate-severe OSA (Apnea Hypopnea Index >=15) and compared the cost-effectiveness of 3 groups: 1) no messaging, 2) messaging for 3 months only, and 3) messaging for 3 years. Costs were derived by multiplying medical service use from electronic medical records times costs from Federal fee schedules. Effects were average nightly hours of PAP use. We report the incremental cost per incremental hour of PAP use as well as the fraction acceptable. Results We included 256 patients with moderate-severe OSA (Group 1, n=132; Group 2, n=79; Group 3, n=45). Group 2, which received the intervention for 3 months only, had the highest costs and fewest hours of use and was dominated by the other two groups. Average 1-year costs for groups 1 and 3 were $6035 (SE, $477) and $6154 (SE, $575), respectively; average nightly hours of PAP use were 3.07 (SE, 0.23) and 4.09 (SE, 0.42). Compared to no messaging, messaging for 3 years had an incremental cost ($119, p=0.86) per incremental hour of use (1.02, p=0.03) of $117. For a willingness-to-pay (WTP) of $500 per year ($1.37/night), 3-year messaging has a 70% chance of being acceptable. Conclusion Long-term Tele-OSA messaging was more effective than no messaging for PAP use outcomes but also highly likely cost-effective with an acceptable willingness-to-pay threshold. Epidemiologic evidence suggests that this greater use will yield both clinical and additional economic benefits. Support (if any) Tele-OSA study was supported by the AASM Foundation SRA Grant #: 104-SR-13

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Characterization and outcome of 11 children with non-diabetic ketoacidosis

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2020-0324 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Elsayed Abdelkreem ◽

Rofaida M. Magdy ◽

Abdelrahim A. Sadek

Keyword(s):

Diabetic Ketoacidosis ◽

Case Series ◽

Inborn Errors ◽

Laboratory Features ◽

Level 3 ◽

Conscious Level ◽

Neurodevelopmental Impairment ◽

Salicylate Intoxication ◽

Prompt Diagnosis

AbstractObjectivesTo study the clinical and laboratory features, management, and outcome of pediatric non-diabetic ketoacidosis (NDKA).MethodsBetween May 2018 and April 2020, we prospectively collected children under 18 years who presented with ketoacidosis, defined as ketosis (urinary ketones ≥++ and/or serum β-hydroxybutyrate level ≥3 mmol/L) and metabolic acidosis (pH <7.3 and HCO3− <15 mmol/L). Children with HbA1c level ≥6.5% at initial presentation and those meeting the diagnostic criteria for DM during follow-up were excluded. Data were collected on demographics, clinical and laboratory features, management, and outcome.ResultsEleven children with 19 episodes of NDKA were identified. The median age was 12 months (range from 5 months to 5 years). They manifested dehydration and disturbed conscious level (all cases), convulsions (n=6), hypoglycemia (n=6), hyperglycemia (n=2) and significant hyperammonemia (n=4). Most cases required intensive care management. Death or neurodevelopmental impairment occurred in six cases. Seven cases had inborn errors of metabolism (IEMs). Other cases were attributed to starvation, sepsis, and salicylate intoxication.ConclusionsThis is the largest case series of pediatric NDKA. Ketoacidosis, even with hyperglycemia, is not always secondary to diabetes mellitus. IEMs may constitute a significant portion of pediatric NDKA. Increased awareness of this unfamiliar condition is important for prompt diagnosis, timely management, and better outcome.

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Coagulation derangement and risk factors for valve thrombosis following transcatheter aortic valve implantation

Open Heart ◽

10.1136/openhrt-2020-001496 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001496

Author(s):

Tiffany Patterson ◽

Harriet Hurrell ◽

Jack Lee ◽

Giulia Esposito ◽

Utkarsh Dutta ◽

...

Keyword(s):

Aortic Valve ◽

Reference Range ◽

Multivariable Analysis ◽

Single Centre ◽

Transcatheter Aortic Valve ◽

Coagulation Testing ◽

Valve Thrombosis ◽

Valve Implantation ◽

Transfemoral Tavi

AimsDurability of transcatheter aortic valve implantation (TAVI) is key to its expansion. We sought to identify incidence of valve thrombosis and predictors of valve thrombosis in our single centre with associated coagulation testing pre-TAVI and post-TAVI.Methods and resultsThis single-centre observational study comprised patients undergoing transfemoral TAVI discussed in the Heart Team meeting . Patients were followed up with echocardiography at 120 days to identify incidence of elevated transvalvular gradient and multivariable analysis was performed to identify factors associated with an increased odds of developing valve thrombosis. In addition, 11 patients underwent baseline, day 1 and day 120 post-TAVI coagulation testing. Between August 2017 and August 2019, 437 consecutive patients underwent transfemoral TAVI. Of these patients, 207/437 (47.4%) had 3-month follow-up echo data available and were analysed. Of these patients, 26/207 (12.6%) had elevated transvalvular gradients. These patients tended to be younger (80±14 vs 83±6 years; p=0.047) with a lower ejection fraction (49±13 vs 54%±11%; p=0.021), with a greater proportion of the population experiencing atrial fibrillation (14/21, 54% vs 68/181, 38%; p=0.067). Following multivariable analysis, there remained a trend towards higher eccentricity index associated with elevated gradients. Baseline (pre-TAVI) elevation of thrombin antithrombin levels (56±63; reference range 1.0–4.1 ng/L) and PF 1+2 (791±632; reference range 69–229 ng/mL) normalised at 120 days post-TAVIConclusionThis study demonstrated that in the cohort of patients undergoing transfemoral TAVI in our centre: younger age, poor ejection fraction, atrial fibrillation and increased baseline eccentricity of the aortic valve annulus were present to a greater extent in patients exhibiting elevated transvalvular gradients at 3-month follow-up. Further work is required to delineate the extent of coagulation derangement and confirm predictors of thrombosis.

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An Atmospheric Visibility Grading Method Based on Ensemble Learning and Stochastic Weight Average

Atmosphere ◽

10.3390/atmos12070869 ◽

2021 ◽

Vol 12 (7) ◽

pp. 869

Author(s):

Xiuguo Zou ◽

Jiahong Wu ◽

Zhibin Cao ◽

Yan Qian ◽

Shixiu Zhang ◽

...

Keyword(s):

Ensemble Learning ◽

Traffic Accidents ◽

Feature Sets ◽

Atmospheric Visibility ◽

Average Accuracy ◽

Level 3 ◽

Visual Characteristics ◽

Level 1 ◽

Grading Model ◽

Level 2

In order to adequately characterize the visual characteristics of atmospheric visibility and overcome the disadvantages of the traditional atmospheric visibility measurement method with significant dependence on preset reference objects, high cost, and complicated steps, this paper proposed an ensemble learning method for atmospheric visibility grading based on deep neural network and stochastic weight averaging. An experiment was conducted using the scene of an expressway, and three visibility levels were set, i.e., Level 1, Level 2, and Level 3. Firstly, the EfficientNet was transferred to extract the abstract features of the images. Then, training and grading were performed on the feature sets through the SoftMax regression model. Subsequently, the feature sets were ensembled using the method of stochastic weight averaging to obtain the atmospheric visibility grading model. The obtained datasets were input into the grading model and tested. The grading model classified the results into three categories, with the grading accuracy being 95.00%, 89.45%, and 90.91%, respectively, and the average accuracy of 91.79%. The results obtained by the proposed method were compared with those obtained by the existing methods, and the proposed method showed better performance than those of other methods. This method can be used to classify the atmospheric visibility of traffic and reduce the incidence of traffic accidents caused by atmospheric visibility.

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