Mapping Health Professions Education: Using Complexity Science to Make Sense of Learning Through Electronic Consultations.

Phenomena studied within health professions education are often complex and multifaceted. This article describes a complexity science-informed theoretical framework that was developed for exploring how electronic consultations support learning among primary care providers, as well as within the larger organizations or systems in which they practice. This framework enables researchers to investigate learning occurring simultaneously at multiple levels (including individuals and social groups), without simplistically conflating levels or theories. The various levels of learning and associated theories are illustrated using examples from electronic consultations. This complexity science-inspired framework can be used for studying learning in complex, multilayered systems.

Defining Short-Term Accommodation for Animals.

The terms short-term, temporary, and transitional are related but can have different contexts and meanings for animal husbandry. The definitions and use of these terms can be pivotal to animal housing and welfare. We conducted three separate literature searches using Google Scholar for relevant reports regarding short-term, temporary, or transitional animal husbandry, and analysed key publications that stipulate relevant periods of accommodation. English Government guidance regarding acceptable short-term, temporary, or transitional accommodation for animals varies widely from <1 day to 3 months; whereas independent scientific criteria and guidance use typical periods of hours to several days. Stipulations regarding acceptable short-term, temporary, or transitional accommodation, notably among English Government guidance, which we focused on in this study, were highly inconsistent and lacked scientific rationale. The definitions and use of terms for both formal and other guidance should be limited to precautionary time frames within one circadian cycle, i.e., periods of <24 h. At ≥24 h, all animals at all facilities should be accommodated in conditions that are consistent with long-term housing, husbandry, and best practices.

Development of eConsult reflective learning tools for healthcare providers: a pragmatic mixed methods approach.

BACKGROUND: Electronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults. METHODS: We performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users. RESULTS: The RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development. CONCLUSION: PCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.

Mobile Zoos and Other Itinerant Animal Handling Events: Current Status and Recommendations for Future Policies.

Mobile zoos are events in which non-domesticated (exotic) and domesticated species are transported to venues such as schools, hospitals, parties, and community centres, for the purposes of education, entertainment, or social and therapeutic assistance. We conducted literature searches and surveyed related government agencies regarding existing provisions within laws and policies, number of mobile zoos, and formal guidance issued concerning operation of such events in 74 countries or regions. We also examined governmental and non-governmental guidance standards for mobile zoos, as well as websites for mobile zoo operations, assessed promotional or educational materials for scientific accuracy, and recorded the diversity of species in use. We used the EMODE (Easy, Moderate, Difficult, or Extreme) algorithm, to evaluate identified species associated with mobile zoos for their suitability for keeping. We recorded 14 areas of concern regarding animal biology and public health and safety, and 8 areas of false and misleading content in promotional or educational materials. We identified at least 341 species used for mobile zoos. Mobile zoos are largely unregulated, unmonitored, and uncontrolled, and appear to be increasing. Issues regarding poor animal welfare, public health and safety, and education raise several serious concerns. Using the precautionary principle when empirical evidence was not available, we advise that exotic species should not be used for mobile zoos and similar itinerant events.

Lessons learned from using whiteboard videos and YouTube for deprescribing guidelines knowledge mobilization.

OBJECTIVES: Deprescribing is the planned and supervised process of dose reduction or stopping medication. Few clinical guidelines exist to help health care professionals in making decisions about deprescribing. The Bruyère Deprescribing Guidelines Team developed a series of evidence-based medication-class specific deprescribing guidelines and, to extend reach and uptake, disseminated them as whiteboard videos published on YouTube. This paper reports on the creation, sharing and evaluation of videos on proton pump inhibitor (PPI), antihyperglycemic (AHG), antipsychotic (AP) and benzodiazepine receptor agonist (BZRA) deprescribing guidelines. METHODS: Whiteboard videos depict an animator drawing on a whiteboard, while the narrator reads the script. In each video, the deprescribing algorithm is applied to mock patient cases. The videos were shared on YouTube and promoted via Twitter and other web-based tools. Evaluation methods included YouTube analytics and the validated Information Assessment Method (IAM) questionnaire. KEY FINDINGS: The four videos have a combined total of 26 387 views over the approximately 50 months since publishing, with viewers watching 34-40% of the videos' runtimes on average. The PPI and AHG deprescribing videos were viewed 4318 times in 97 countries during the first year. IAM respondents perceived the PPI, AHG and AP video content to be relevant, useful to learning and applicable to patient care. CONCLUSIONS: Using whiteboard videos on YouTube to explain deprescribing guidelines was a successful approach to knowledge mobilization. The evaluation approach is innovative as it combines typical success factors for online learning videos (e.g. views, estimated minutes watched) with responses to a validated information assessment tool.

Genetic studies of human-chimpanzee divergence using stem cell fusions.

Complete genome sequencing has identified millions of DNA changes that differ between humans and chimpanzees. Although a subset of these changes likely underlies important phenotypic differences between humans and chimpanzees, it is currently difficult to distinguish causal from incidental changes and to map specific phenotypes to particular genome locations. To facilitate further genetic study of human-chimpanzee divergence, we have generated human and chimpanzee autotetraploids and allotetraploids by fusing induced pluripotent stem cells (iPSCs) of each species. The resulting tetraploid iPSCs can be stably maintained and retain the ability to differentiate along ectoderm, mesoderm, and endoderm lineages. RNA sequencing identifies thousands of genes whose expression differs between humans and chimpanzees when assessed in single-species diploid or autotetraploid iPSCs. Analysis of gene expression patterns in interspecific allotetraploid iPSCs shows that human-chimpanzee expression differences arise from substantial contributions of both cis-acting changes linked to the genes themselves and trans-acting changes elsewhere in the genome. To enable further genetic mapping of species differences, we tested chemical treatments for stimulating genome-wide mitotic recombination between human and chimpanzee chromosomes, and CRISPR methods for inducing species-specific changes on particular chromosomes in allotetraploid cells. We successfully generated derivative cells with nested deletions or interspecific recombination on the X chromosome. These studies confirm an important role for the X chromosome in trans regulation of expression differences between species and illustrate the potential of this system for more detailed cis and trans mapping of the molecular basis of human and chimpanzee evolution.

Getting It Straight: Accommodating Rectilinear Behavior in Captive Snakes-A Review of Recommendations and Their Evidence Base.

Snakes are sentient animals and should be subject to the accepted general welfare principles of other species. However, they are also the only vertebrates commonly housed in conditions that prevent them from adopting rectilinear behavior (ability to fully stretch out). To assess the evidence bases for historical and current guidance on snake spatial considerations, we conducted a literature search and review regarding recommendations consistent with or specifying ≥1 × and <1 × snake length enclosure size. We identified 65 publications referring to snake enclosure sizes, which were separated into three categories: peer-reviewed literature (article or chapter appearing in a peer-reviewed journal or book, n = 31), grey literature (government or other report or scientific letter, n = 18), and opaque literature (non-scientifically indexed reports, care sheets, articles, husbandry books, website or other information for which originating source is not based on scientific evidence or where scientific evidence was not provided, n = 16). We found that recommendations suggesting enclosure sizes shorter than the snakes were based entirely on decades-old 'rule of thumb' practices that were unsupported by scientific evidence. In contrast, recommendations suggesting enclosure sizes that allowed snakes to fully stretch utilized scientific evidence and considerations of animal welfare. Providing snakes with enclosures that enable them to fully stretch does not suggest that so doing allows adequate space for all necessary normal and important considerations. However, such enclosures are vital to allow for a limited number of essential welfare-associated behaviors, of which rectilinear posturing is one, making them absolute minimum facilities even for short-term housing.

Burden Associated With Selecting and Using Health Insurance to Manage Care Costs: Results of a Qualitative Study of Nonelderly Cancer Survivors.

This qualitative study explored cancer survivors' experiences selecting and using health insurance and anticipating out-of-pocket care costs. Thirty individuals participated in semistructured interviews. On average, participants were 54 years (SD ± 8.85, range 34-80) and diagnosed with cancer about 5 years prior (range 0.5-10 years). About 57% were female, 77% were non-Hispanic White, and 53% had less than a college education. Participants struggled to access information about health insurance and costs. Lack of cost transparency made it difficult to anticipate expenses and increased anxiety. Many participants were surprised that after cancer, care that was once preventive with no out-of-pocket costs became diagnostic with associated fees. They discussed the cognitive burden of managing finances on top of treatment and overseeing communication between doctors and insurance. Interventions are needed to clearly communicate information about insurance coverage and care costs to improve cancer survivors' confidence in selecting health insurance and anticipating out-of-pocket expenses.

Improving Cancer Patients' Insurance Choices (I Can PIC): A Randomized Trial of a Personalized Health Insurance Decision Aid.

BACKGROUND: Many cancer survivors struggle to choose a health insurance plan that meets their needs because of high costs, limited health insurance literacy, and lack of decision support. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. MATERIALS AND METHODS: Eligible individuals (18-64 years, diagnosed with cancer for ≤5 years, English-speaking, not Medicaid or Medicare eligible) were randomized to I Can PIC or an attention control health insurance worksheet. Primary outcomes included health insurance knowledge, decisional conflict, and decision self-efficacy after completing I Can PIC or the control. Secondary outcomes included knowledge, decisional conflict, decision self-efficacy, health insurance literacy, financial toxicity, and delayed care at a 3-6-month follow-up. RESULTS: A total of 263 of 335 eligible participants (79%) consented and were randomized; 206 (73%) completed the initial survey (106 in I Can PIC; 100 in the control), and 180 (87%) completed a 3-6 month follow-up. After viewing I Can PIC or the control, health insurance knowledge and a health insurance literacy item assessing confidence understanding health insurance were higher in the I Can PIC group. At follow-up, the I Can PIC group retained higher knowledge than the control; confidence understanding health insurance was not reassessed. There were no significant differences between groups in other outcomes. Results did not change when controlling for health literacy and employment. Both groups reported having limited health insurance options. CONCLUSION: I Can PIC can improve cancer survivors' health insurance knowledge and confidence using health insurance. System-level interventions are needed to lower financial toxicity and help patients manage care costs. IMPLICATIONS FOR PRACTICE: Inadequate health insurance compromises cancer treatment and impacts overall and cancer-specific mortality. Uninsured or underinsured survivors report fewer recommended cancer screenings and may delay or avoid needed follow-up cancer care because of costs. Even those with adequate insurance report difficulty managing care costs. Health insurance decision support and resources to help manage care costs are thus paramount to cancer survivors' health and care management. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. I Can PIC provides health insurance information, supports patients through managing care costs, offers a list of financial and emotional support resources, and provides a personalized cost estimate of annual health care expenses across plan types.

Decisional conflict associated with clinicians discouraging particular contraceptive methods.

RATIONALE, AIMS, AND OBJECTIVES: Approximately 45% of pregnancies in the United States are unintended. The use of contraception reduces the risk of unintended pregnancy. The initiation of several contraceptive methods requires seeing a clinician. This study explored how clinicians' expressed preferences against particular contraceptive methods impacted participants' confidence in their method choice and perception of shared contraceptive decision making. METHODS: Eligible individuals were 18 to 45 years of age, assigned female sex at birth, English speaking, and either using or had previously used contraception. Participants completed an anonymous survey via web link on Amazon Mechanical Turk. Primary self-reported outcomes were (a) proportion of participants being discouraged from a particular contraceptive method, (b) decisional conflict, and (c) extent of shared decision making. Secondary self-reported outcomes were (a) importance of contraceptive attributes and (b) self-reported quality of care. RESULTS: Six hundred sixty-nine participants completed the survey. Most were white (74.0%), non-Hispanic (84.5%), married or cohabitating (69.4%), and nulliparous (47.2%). A total of 33.8% reported that a clinician had discouraged them from using a particular contraceptive method, most commonly because of side effects, usability, and/or method effectiveness. Effectiveness, affordability, and side effects were the self-reported most important contraceptive features. Those who were discouraged from using a method (versus those who were not) were more likely to report decisional conflict (41.2% vs 30.0%, P = .004), yet reported a higher extent of shared decision making (median: 76 vs 71; P = .03). Adjusting for age and nulliparity did not impact results, except nulliparity made the relationship between being discouraged from using a method and shared decision making no longer significant (P = .06). CONCLUSIONS: Decisional conflict might arise when clinicians discourage individuals using particular contraceptive methods. Clinicians' reasons for discouraging methods might not always align with patients' preferences. More research is needed to examine how to reduce decisional conflict and support contraceptive method selection.

Electronic Consultation Services Worldwide: Environmental Scan.

BACKGROUND: Excessive wait times for specialist care pose a serious concern for many patients, leading to duplication of tests, patient anxiety, and poorer health outcomes. In response to this issue, many health care systems have begun implementing technological innovations designed to improve the referral-consultation process. Among these services is electronic consultation (eConsult), which connects primary care providers and specialists through a secure platform to facilitate discussion of patients' care. OBJECTIVE: This study aims to examine different eConsult services available worldwide and compare the strategies, barriers, and successes of their implementation in different health care contexts. METHODS: We conducted an environmental scan comprising 3 stages as follows: literature review; gray literature search; and targeted, semistructured key informant interviews. We searched MEDLINE and EMBASE (literature review) and Google (gray literature search). Upon completing the search, we generated a list of potential interview candidates from among the stakeholders identified. Potential participants included researchers, physicians, and decision makers. The maximum variation sampling was used to ensure sufficient breadth of participant experience. In addition, we conducted semistructured interviews by telephone using an interview guide based on the RE-AIM framework. Analyses of transcripts were conducted using a thematic synthesis approach. RESULTS: A total of 53 services emerged from the published and gray literature. Respondents from 10 services participated in telephonic interviews. The following 4 major themes emerged from the analysis: service structure; benefits of eConsult; implementation challenges; and implementation enablers. CONCLUSIONS: eConsult services have emerged in a variety of countries and health system contexts worldwide. Despite differences in structure, platform, and delivery of their services, respondents described similar barriers and enablers to the implementation and growth and reported improved access and high levels of satisfaction.

MLL1 is essential for retinal neurogenesis and horizontal inner neuron integrity.

Development of retinal structure and function is controlled by cell type-specific transcription factors and widely expressed co-regulators. The latter includes the mixed-lineage leukemia (MLL) family of histone methyltransferases that catalyze histone H3 lysine 4 di- and tri-methylation associated with gene activation. One such member, MLL1, is widely expressed in the central nervous system including the retina. However, its role in retinal development is unknown. To address this question, we knocked out Mll1 in mouse retinal progenitors, and discovered that MLL1 plays multiple roles in retinal development by regulating progenitor cell proliferation, cell type composition and neuron-glia balance, maintenance of horizontal neurons, and formation of functional synapses between neuronal layers required for visual signal transmission and processing. Altogether, our results suggest that MLL1 is indispensable for retinal neurogenesis and function development, providing a new paradigm for cell type-specific roles of known histone modifying enzymes during CNS tissue development.

Evaluation of an electronic consultation service in psychiatry for primary care providers.

BACKGROUND: This study explores the effectiveness of an electronic consultation (eConsult) service between primary care providers and psychiatry, and the types and content of the clinical questions that were asked. METHODS: This is a retrospective eConsult review study. All eConsults directed to Psychiatry from July 2011 to January 2015 by Primary care providers were reviewed. Response time and the amount of time reported by the specialist to answer each eConsult was analyzed. Each eConsult was also categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults. RESULTS: Of the 5597 eConsults, 169 psychiatry eConsults were completed during the study period. The average response time for a specialist to a primary care provider was 2.3 days. Eighty-seven percent of clinical responses were completed by the psychiatrist in less than 15 min. The primary care providers most commonly asked clinical questions were about depressive and anxiety disorders. 88.7% of PCPs rated the eConsult service a 5 (excellent value) or 4. CONCLUSIONS: This study indicates that an eConsult psychiatry service has tremendous potential to improve access to psychiatric advice and expand the capacity to treat mental illness in primary care. Future research may include follow-up with PCPs regarding the implementation of specialist advice.

Looking beyond the checklist: An ethnography of interprofessional operating room safety cultures.

The Surgical Safety Checklist (SSC) has been adopted in operating rooms (OR) worldwide to reduce medical errors, increase patient safety and improve interprofessional communication. Despite often high compliance rates, recent studies suggested the SSC has not been associated with significant reductions in operative mortality or complications. This ethnographic study sought to understand this disconnection through approximately 50 hours of observation in the OR and 10 in-depth semi-structured interviews with surgeons, nurses, and anaesthesiologists in orthopaedic surgery. Inductive thematic analysis was used to analyse the data. By spending time in the OR and listening to the staff, this study was able to look beyond what "ought" to be happening in the OR and garner a deep understanding of the realities of OR work that acknowledges the complexities of surgical culture in which the SSC is being implemented. This study found SSC compliance was influenced by the perceived (un)importance of individual checklist items within the orthopaedic setting. Additionally, there remains a need to further explore patients' involvement in their operative experience.

Offshore Earthquakes Do Not Influence Marine Mammal Stranding Risk on the Washington and Oregon Coasts.

The causes of marine mammals stranding on coastal beaches are not well understood, but may relate to topography, currents, wind, water temperature, disease, toxic algal blooms, and anthropogenic activity. Offshore earthquakes are a source of intense sound and disturbance and could be a contributing factor to stranding probability. We tested the hypothesis that the probability of marine mammal stranding events on the coasts of Washington and Oregon, USA is increased by the occurrence of offshore earthquakes in the nearby Cascadia subduction zone. The analysis carried out here indicated that earthquakes are at most, a very minor predictor of either single, or large (six or more animals) stranding events, at least for the study period and location. We also tested whether earthquakes inhibit stranding and again, there was no link. Although we did not find a substantial association of earthquakes with strandings in this study, it is likely that there are many factors influencing stranding of marine mammals and a single cause is unlikely to be responsible. Analysis of a subset of data for which detailed descriptions were available showed that most live stranded animals were pups, calves, or juveniles, and in the case of dead stranded mammals, the commonest cause of death was trauma, disease, and emaciation.

What's in a name? Tensions between formal and informal communities of practice among regional subspecialty cancer surgeons.

In 2007 the Cancer Care Ontario Hepatobiliary-Pancreatic (HPB) Community of Practice was formed during the wake of provincial regionalization of HPB services in Ontario, Canada. Despite being conceptualized within the literature as an educational intervention, communities of practice (CoP) are increasingly being adopted in healthcare as quality improvement initiatives. A qualitative case study approach using in-depth interviews and document analysis was employed to gain insight into the perceptions and attitudes of the HPB surgeons in the CoP. This study demonstrates how an engineered formal or idealized structure of a CoP was created in tension with the natural CoPs that HPB surgeons identified with during and after their training. This tension contributed to the inactive and/or marginal participation by some of the surgeons in the CoP. The findings of this study represent a cautionary tale for such future engineering attempts in two distinct ways: (1) a CoP in surgery cannot simply be created by regulatory agencies, rather they need to be supported in a way to evolve naturally, and (2) when the concept of CoPs is co-opted by governing bodies, it does not necessarily capture the power and potential of situated learning. To ensure CoP sustainability and effectiveness, we suggest that both core and peripheral members need to be more directly involved at the inception of the COP in terms of design, organization, implementation and ongoing management.

Mind-Body Therapies in Cancer: What Is the Latest Evidence?

PURPOSE OF REVIEW: Many people living with cancer use complementary therapies, and some of the most popular are mind-body therapies (MBTs), including relaxation and imagery, hypnosis, yoga, meditation, tai chi and qigong, and art therapies. The efficacy of these modalities was reviewed by assessing recent findings in the context of cancer care. RECENT FINDINGS: These therapies show efficacy in treating common cancer-related side effects, including nausea and vomiting, pain, fatigue, anxiety, depressive symptoms and improving overall quality of life. Some also have effects on biomarkers such as immune function and stress hormones. Overall studies lack large sample sizes and active comparison groups. Common issues around clearly defining treatments including standardizing treatment components, dose, intensity, duration and training of providers make generalization across studies difficult. MBTs in cancer care show great promise and evidence of efficacy for treating many common symptoms. Future studies should investigate more diverse cancer populations using standardized treatment protocols and directly compare various MBTs to one another.

ExNOTic: Should We Be Keeping Exotic Pets?

There has been a recent trend towards keeping non-traditional companion animals, also known as exotic pets. These pets include parrots, reptiles, amphibians and rabbits, as well as small species of rodent such as degus and guinea pigs. Many of these exotic pet species are not domesticated, and often have special requirements in captivity, which many owners do not have the facilities or knowledge to provide. Keeping animals in settings to which they are poorly adapted is a threat to their welfare. Additionally, owner satisfaction with the animal may be poor due to a misalignment of expectations, which further impacts on welfare, as it may lead to repeated rehoming or neglect. We investigate a range of commonly kept exotic species in terms of their suitability as companion animals from the point of view of animal welfare and owner satisfaction, and make recommendations on the suitability of various species as pets.

The Relationship Between Specialty Certification of Individual Nurses and Outcomes: Developing a Standardized Taxonomy for Research.

Specialty certification is an important method to demonstrate that RNs possess advanced training, knowledge, and competencies required to provide safe, high-quality care for specific populations.