Student Performance During a Simulated Patient Encounter Has No Impact on Debriefer Adherence to PEARLS Debriefing Model

Purpose Debriefing is necessary for effective simulation education. The PEARLS (Promoting Excellence and Reflective Learning in Simulations) is a scripted debriefing model that incorporates debriefing best practices. It was hypothesized that student simulation performance might impact facilitator adherence to the PEARLS debriefing model. There are no published findings on the effect of student performance on debriefer behavior. Methods Third-year medical students participated in a video-recorded, formative simulation to treat a high-fidelity mannequin for an asthma exacerbation. A faculty debriefer trained in the PEARLS model evaluated student performance with a standardized rubric and conducted a recorded debriefing. Debriefing recordings were analyzed for debriefer adherence to the PEARLS model. Debriefers were assigned a debriefing score (DS) from 0 to 13; 13 was perfect adherence to the model. Definitive intervention (DI) for asthma exacerbation was defined as bronchodilator therapy. Critical actions were as follows: a focused history, heart/lung exam, giving oxygen, and giving a bronchodilator. Results Mean DS for the debriefers of students who provided DI was 8.57; 9.14 for those students who did not (P = 0.25). Mean DS for debriefers of students who completed all critical actions was 8.68; 8.52 for those students who did not (P = 0.62). Analysis of elapsed time to DI showed no relationship between the time DI was provided and DS. Conclusions Student performance had no impact on debriefer performance, suggesting the PEARLS model is an effective aid for debriefers, regardless of learner performance. These findings suggest student performance may not bias facilitators’ ability to conduct quality debriefings.

The role of Science Literacy, Trust, and Impulsivity on Adherence to COVID-19 Recommendations: Cross-sectional Study (Preprint)

BACKGROUND To slow down transmission and prevent deaths in the face of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, the public needs to adhere to recommendations to limit exposure and the spread of the disease. There is emerging evidence that television viewership choices and partisanship are associated to adherence to COVID-19 -related preventive recommendations. On the other hand, some suggest that believing fake news may be due to impulsivity or a lack of thinking rather than partisanship. OBJECTIVE To test whether 1) individuals with high levels of impulsivity will be less likely to adhere to COVID-19 recommendations; and 2) if the odds of adhering to the recommendations will be higher for those with positive attitudes toward science, higher levels of science literacy, and COVID-19 knowledge, who get their news from scientific/reliable sources. METHODS We conducted a cross-sectional online survey administered via Qualtrics (Provo, UT). COVID-related survey items were extracted from recent COVID-19 studies. Respondents completed assessments on impulsiveness, perception of scientists and science literacy. selected their common sources of information including conservative and liberal media (e.g., Fox News or One America News Network – OANN and MSNBC or CNN). The sample was recruited from Amazon’s Mechanical Turk (MTurk) and from the student population of a large university in the southwestern U.S. After removing incomplete responses, the final sample included 1223 cases. RESULTS Consistent with previous reports, compared to respondents who got their News from sources other than Fox News or OANN, those who reported Fox News or OANN as their main source of information had significantly lower scores of COVID-19 knowledge. Consistent with our hypotheses, we found that impulsivity was associated with adherence: high scores was associated to adherence failure while low scores were associated to perfect adherence. COVID-19 knowledge and trust in scientists showed the same significant associations: high knowledge scores were associated to perfect adherence and low to failure. Contrary to our hypothesis, Science Literacy did not predict adherence. Finally, race was also significantly associated with adherence: being white was associated to adherence failure while being non-white predicted perfect adherence. CONCLUSIONS To increase voluntary adherence to COVID-19 measures, it is critical to implement public health campaigns that foster trust in authorities –Republican and Democrat-- and leverage trustworthy individuals in the community to disseminate information. For individuals with high levels of impulsivity, environmental restructuring, and/or nudging may be necessary to increase adherence to preventive recommendations.

Model-based effectiveness and cost-effectiveness of risk-based selection strategies for adjuvant chemotherapy in Dutch stage II colon cancer patients

Background: We aimed to evaluate the cost-effectiveness of risk-based strategies to improve the selection of surgically treated stage II colon cancer (CC) patients for adjuvant chemotherapy. Methods: Using the ‘Personalized Adjuvant TreaTment in EaRly stage coloN cancer’ (PATTERN) model, we evaluated five selection strategies: (1) no chemotherapy, (2) Dutch guideline recommendations assuming observed adherence, (3) Dutch guideline recommendations assuming perfect adherence, (4) biomarker mutation OR pT4 stage strategy in which patients with MSS status combined with a pT4 stage or a mutation in BRAF and/or KRAS receive chemotherapy assuming perfect adherence and (5) biomarker mutation AND pT4 stage strategy in which patients with MSS status combined with a pT4 stage tumor and a BRAF and/or KRAS mutation receive chemotherapy assuming perfect adherence. Outcomes were number of CC deaths per 1000 patients and total discounted costs and quality-adjusted life-years (QALYs) per patient (pp). Analyses were conducted from a societal perspective. The robustness of model predictions was assessed in sensitivity analyses. Results: The reference strategy, that is, no adjuvant chemotherapy, resulted in 139 CC deaths in a cohort of 1000 patients, 8.077 QALYs pp and total costs of €22,032 pp. Strategies 2–5 were more effective (range 8.094–8.217 QALYs pp and range 118–136 CC deaths per 1000 patients) and more costly (range €22,404–€25,102 pp). Given a threshold of €50,000/QALY, the optimal use of resources would be to treat patients with either the full adherence strategy and biomarker mutation OR pT4 stage strategy. Conclusion: Selection of stage II CC patients for chemotherapy can be improved by either including biomarker status in the selection strategy or by improving adherence to the Dutch guideline recommendations.

Winning as American Women

This chapter explores how black women athletes began to emerge as accepted exemplars of American identity after their performance at the inaugural US–Soviet Union dual track and field meet in Moscow in 1958. An almost perfect adherence to normative, white-defined gender expectations allowed black American track women to assume this symbolic status. These young women athletes, especially the sprinters and jumpers of Tennessee State University, now protected, rather than contested, the relationship between race, gender, and Americanness. The celebrated emergence of Wilma Rudolph ahead of and during the 1960 Olympic Games highlights the central role of heteronormativity in determining the boundaries of belonging in modern America.

1448. Forgiveness of BIC/FTC/TAF: In Vitro Simulations of Intermittent Poor Adherence Find Limited HIV-1 Breakthrough and High Barrier to Resistance

Background Short lapses in adherence to ARVs can lead to virologic failure and emergence of resistance. Previous in vitro studies of regimen “forgiveness” simulated drug exposures of perfect adherence or short-term suboptimal adherence with bictegravir+emtricitabine+tenofovir alafenamide (BIC+FTC+TAF) and with dolutegravir and lamivudine (DTG+3TC). Here, viral breakthrough (VB) and resistance development were evaluated under alternating high and low drug exposures simulating variable adherence levels. Methods Wild-type HIV-1 (IIIb)-infected MT-2 cells were exposed to drug combinations and monitored for VB. Experiments alternated between high and low drug concentrations of either BIC+FTC+TAF or DTG+3TC (Table 1). Drug concentrations for each regimen were determined using human plasma-free adjusted clinical trough concentrations (Cmin), at simulated Cmin after missing 2 or 4 consecutive doses (Cmin-2 and Cmin-4) based on drug half-lives. Emergent HIV-1 were genotyped by deep sequencing and a 2% threshold. Results In these experiments, constant drug concentrations corresponding to full adherence (Cmin) did not lead to VB. Using Cmin concentrations for one week followed by constant Cmin-2 exposures for 4 weeks, DTG+3TC had VB and emergence of M184V/I in reverse transcriptase (RT) but there was no VB for BIC+FTC+TAF. Using alternating drug exposures of Cmin (weeks 1 and 3) and Cmin-2 or Cmin -4 (weeks 2, 4, and 5), VB was not observed with BIC+FTC+TAF, and VB was decreased or delayed with DTG+3TC compared to DTG+3TC held at Cmin-2 or Cmin-4. Resistance development was observed in some cultures with VB: 1 culture with BIC+FTC+TAF had G163R in IN and 19 cultures with DTG+3TC had INSTI and RT resistance including 10 with M184V/I. Table 1. Summary of Breakthrough Frequency and Resistance Development Conclusion BIC+FTC+TAF has high in vitro forgiveness and consistent protection against emergence of drug resistance during simulations of short lapses in adherence. Higher DTG+3TC exposure, whether constant or intermittent, was better at preventing or delaying VB than lower DTG+3TC exposures, but DTG+3TC was less forgiving than BIC+FTC+TAF. Prevention of viral replication and resistance development is necessary to maintain lifelong viral suppression, particularly in the real world where drug adherence is often imperfect. Disclosures Andrew Mulato, BS, MBA, Gilead Sciences, Inc. (Employee, Shareholder) Rima K. Acosta, BS, Gilead Sciences, Inc. (Employee, Shareholder) Stephen R. Yant, PhD, Gilead Sciences, Inc. (Employee, Shareholder) Tomas Cihlar, PhD, Gilead Sciences, Inc. (Employee, Shareholder) Kirsten L. White, PhD, Gilead Sciences, Inc. (Employee, Shareholder)

Adherence to the EAT-Lancet Recommendations in a Sample of Mexican Health Workers

Objectives To evaluate the adherence to the EAT-Lancet recommendations in a sample of Mexican health workers. Methods We used data on 1908 men and women aged 19 to 59 who participated in the third wave of the Health Workers Cohort Study (HWCS), carried out in 2016. Dietary intake was estimated by using a 116-item semi-quantitative food frequency questionnaire. To evaluate the adherence to EAT, we adapted the EAT-Lancet score proposed by Knuppel et al. We used 13 out of 14 EAT-Lancet score components: 1) whole grains, 2) tubers and starchy vegetables, 3) vegetables, 4) fruits, 5) whole milk or derivative equivalents (dairy) , 6) beef, lamb and pork, 7) chicken and other poultry, 8) eggs, 9) fish, 10) dry beans, lentils and peas (legumes), 11) peanuts and tree nuts, and 12) added fats. We additionally created the component of processed meats, where the recommendation is zero consumption. Participants were assigned a point for meeting each of the recommendations, resulting in a range of scores from 0 (nonadherence) to 13 (perfect adherence). We calculated the median and interquartile range (IQR) for the total adapted EAT-Lancet score. Also, we estimated the percentage of participants achieving each one of the EAT-Lancet recommendations. Results More than 90% of participants met the recommendations for fruits [95.1%, 95% confidence interval (CI): 93.6–96.2%], fish (97.5%, 95% CI: 96.4–98.3%), dairy(95.4%, 95% CI: 93.9–96.4%) and legumes (96.3%, 95% CI: 95.1–97.3%). The lowest adherences were observed for whole grains (9.38%, 95% CI: 7.8–11.2%), process meat (4.1%, 95% CI: 3.1–5.5%) and, the peanuts or tree nuts group (6.9%, 95% CI: 5.6–8.6%). As a result, the median of total adapted EAT-Lancet score was 8.0 (IQR: 8.0–9.0) and only 9.18% of individuals had an adherence > = 10 to the EAT-Lancet recommendations. Conclusions Mexican workers achieved the recommendations for fruits, eggs, fish, whole milk, dry beans, and fats, suggesting that only a subset of recommendations may fit the Mexican diet. Important diet changes should be promoted in Mexico in order to improve the adherence to the EAT-Lancet recommendations. Funding Sources This project was partially funded by CONACYT (grants nos. M-7876, etc, etc), the Instituto Mexicano del Seguro Social (grants nos. 2005–785-012), and Bloomberg Philanthropy.

Estimating the Potential for Conservation and Farming in the Amazon and Cerrado under Four Policy Scenarios

Since 2013, clearing rates have rapidly increased in the Amazon and Cerrado biomes. This acceleration has raised questions about the efficacy of current regional public and private conservation policies that seek to promote agricultural production while conserving remnants of natural vegetation. In this study, we assessed conservation and agricultural outcomes of four potential policy scenarios that represent perfect adherence to private sector, zero-deforestation commitments (i.e., the Amazon soy moratorium—ASM and the Amazon cattle agreements—CA) and to varying levels of implementation of the Brazilian Forest Code (FC). Under a zero-clearing scenario, we find that the extent of croplands as of 2017 within the two biomes (31 MHa) could double without further clearing if agriculture were to expand on all previously cleared land that is suitable for crops. Moreover, at least 47 MHa of land that is already cleared but unsuitable for crops would remain available for pasture. Under scenarios in which only legal clearing under the FC could occur, 51 MHa of additional natural vegetation could be cleared. This includes as many as 1 MHa of nonforest vegetation that could be cleared in the Amazon biome without triggering the ASM and CA monitoring systems. Two-thirds of the total vegetation vulnerable to legal clearing is located within the Cerrado biome, and 19 MHa of this land is suitable for cropland expansion. Legal clearing of all of these areas could reduce biodiversity persistence by 4% within the two biomes, when compared with the zero-clearing scenario, and release up to 9 PgCO2e, with the majority (75%) coming from the Cerrado biome. However, when we considered the potential outcomes of full implementation of the FC, we found that 22% (11 MHa) of the 51 MHa of vegetation subject to legal clearing could be protected through the environmental quotas market, while an additional 1 MHa should be replanted across the two biomes, predominantly in the Amazon biome (73% of the area subject to replanting). Together, quotas and replanting could prevent the release of 2 PgCO2e that would otherwise be emitted if all legal clearing occurred. Based on our results, we conclude that ongoing legal clearing could create additional space for cropland and cattle production beyond the substantial existing stocks of cleared areas but would significantly impair local carbon and biodiversity stocks.

A Noninferiority Randomized Clinical Trial of the Use of the Smartphone-Based Health Applications IBDsmart and IBDoc in the Care of Inflammatory Bowel Disease Patients

Background Providing timely follow-up care for patients with inflammatory bowel disease in remission is important but often difficult because of resource limitations. Using smartphones to communicate symptoms and biomarkers is a potential alternative. We aimed to compare outpatient management using 2 smartphone apps (IBDsmart for symptoms and IBDoc for fecal calprotectin monitoring) vs standard face-to-face care. We hypothesized noninferiority of quality of life and symptoms at 12 months plus a reduction in face-to-face appointments in the smartphone app group. Methods Inflammatory bowel disease outpatients (previously seen more often than annually) were randomized to smartphone app or standard face-to-face care over 12 months. Quality of life and symptoms were measured quarterly for 12 months. Acceptability was measured for gastroenterologists and patients at 12 months. Results One hundred people (73 Crohn’s disease, 49 male, average age 35 years) consented and completed baseline questionnaires (50 in each group). Intention-to-treat and per-protocol analyses revealed noninferiority of quality of life and symptom scores at 12 months. Outpatient appointment numbers were reduced in smartphone app care (P < 0.001). There was no difference in number of surgical outpatient appointments or number of disease-related hospitalizations between groups. Adherence to IBDsmart (50% perfect adherence) was slightly better than adherence to IBDoc (30% perfect adherence). Good acceptability was reported among most gastroenterologists and patients. Conclusions Remote symptom and fecal calprotectin monitoring is effective and acceptable. It also reduces the need for face-to-face outpatient appointments. Patients with mild-to-moderate disease who are not new diagnoses are ideal for this system. Clinical Trial Registration Number ACTRN12615000342516.

Treatment of relapsed, residual and neglected clubfoot: adjunctive surgery

Over the past two decades, the Ponseti ‘conservative’ (non-surgical) method of clubfoot treatment has been almost universally adopted worldwide. As a result, the need for operative treatment for clubfoot has decreased dramatically. However, even Ponseti himself routinely used surgery for certain patients: at least 90% of feet need percutaneous tenotomy, and 15% to 40% may require tibialis anterior tendon transfer. Additionally, relapses are common, sometimes necessitating further surgical intervention. Relapses are recurrent deformities in previously well corrected feet. Residual deformities may be defined as persistent deformities in incompletely corrected feet. In addition, in many parts of the developing world, neglected clubfoot is still a major challenge. Many neglected feet can be treated with Ponseti principles, particularly in younger children. However, in older children and adults, surgical approaches are more likely to be needed. Major reasons for relapsed/residual clubfoot include incomplete application of the Ponseti principles, inability to adhere to the foot abduction brace protocol, failure to recommend a complete course of bracing and inadequate follow-up. Sometimes, despite excellent treatment, and perfect adherence to the bracing protocols, there are still relapses, related to intrinsic muscle imbalance. We describe several solutions that include reinstitution of Ponseti casting and ‘á la carte’ operative treatment. As an alternative for particularly stubborn cases, application of a hexapod external fixator can be a powerful tool. In order to be a full-service clubfoot specialist, and not only a Ponseti practitioner, one must have in their toolbox the full gamut of adjunctive surgical options. Level of Evidence: V