X + Y = Time for QI: Meaningful Engagement of Residents in Quality Improvement During the Ambulatory Block.

BACKGROUND: Meaningful resident engagement in quality improvement (QI) remains challenging. Barriers include a lack of time and of faculty with QI expertise. We leveraged our internal medicine (IM) residency program's adoption of an "X" (inpatient rotations) plus "Y" (ambulatory block) schedule to implement a QI curriculum for all residents during their ambulatory block. OBJECTIVE: We sought to engage residents in interprofessional QI, improve residents' QI confidence and knowledge and application to practice, and create opportunities for QI scholarship. METHODS: In July 2015, the program provided dedicated time for QI in the ambulatory block. All categorical IM residents and 11 voluntary faculty mentors were divided into 10 teams based on clinic site and "Y" block schedule. Teams participated in resident-led, interprofessional ambulatory QI projects. Resident QI knowledge and confidence were assessed before the curriculum and 11 months after using the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and surveys. QI project implementation and scholarship were tracked. RESULTS: All categorical residents (N = 81) participated. Residents reported increased confidence in all QI skills, and they demonstrated increased knowledge, with mean QIKAT-R paired scores improving from 15.8 ± 4.6 to 19.1 ± 5.9 (n = 45 pairs, P < .001). A total of 9 of 10 teams implemented process changes, and 6 team project improvements have been sustained. CONCLUSIONS: This ongoing curriculum engaged IM and IM-psychiatry residents in QI during their ambulatory block using volunteer clinic faculty mentors. Residents demonstrated improved QI confidence and knowledge. The majority of resident projects were sustained and generated scholarship.

USL255 extended-release topiramate: dose-proportional pharmacokinetics and tolerability in healthy volunteers.

OBJECTIVE: Evaluate the pharmacokinetics (PK), safety, and tolerability of single doses of once-daily USL255, Qudexy XR (topiramate) extended-release capsules, over a wide dosing range. METHODS: Two single-dose, phase I studies in healthy adults were used to evaluate the PK profile and maximum tolerated dose (MTD) of USL255 from 25-1,400 mg. Standard PK parameters assessed included area under the plasma concentration-time curve (AUC) and maximum plasma concentration (Cmax ). Dose proportionality, linearity, and intersubject and intrasubject variability (coefficient of variation [%CV]) of AUC and Cmax were evaluated. Investigator-reported adverse events (AEs) were obtained throughout the studies. RESULTS: After the initial increase in plasma concentration levels immediately following administration of USL255 25-1,400 mg, plasma topiramate concentration-time profiles were flat up to 24 h after dosing. AUC was dose proportional from 25-1,400 mg, and Cmax was dose proportional from 50-1,400 mg; both AUC and Cmax were linear across the entire dose range. Low intersubject and intrasubject %CV values were observed for AUC0-t , AUC0-∞ , and Cmax (intersubject %CV: 20.2, 19.6, and 22.4%, respectively; intrasubject %CV of dose-normalized mean values: 10.8, 8.2, and 13.2%, respectively). USL255 was generally safe and well tolerated with MTD established at 1,200 mg. SIGNIFICANCE: These results demonstrate that USL255 provides consistent plasma topiramate exposure across an extended-dosing interval and predictable plasma topiramate concentrations over a wide dosing range. Overall, the favorable safety profile and consistency of exposure suggest once-daily USL255 can be a useful treatment option for patients with epilepsy.

Increased impulsive choice for saccharin during PCP withdrawal in female monkeys: influence of menstrual cycle phase.

BACKGROUND: In previous studies with male and female rhesus monkeys, withdrawal of access to oral phencyclidine (PCP) self-administration reduced responding for food under a high fixed-ratio (FR) schedule more in males than females, and with a delay discounting (DD) task with saccharin (SACC) as the reinforcer impulsive choice for SACC increased during PCP withdrawal more in males than females. OBJECTIVES: The goal of the present study was to examine the effect of PCP (0.25 or 0.5 mg/ml) withdrawal on impulsive choice for SACC in females during the follicular and luteal phases of the menstrual cycle. MATERIALS AND METHODS: In component 1, PCP and water were available from two drinking spouts for 1.5 h sessions under concurrent FR 16 schedules. In component 2, a SACC solution was available for 45 min under a DD schedule. Monkeys had a choice of one immediate SACC delivery (0.6 ml) or six delayed SACC deliveries, and the delay was increased by 1 s after a response on the delayed lever and decreased by 1 s after a response on the immediate lever. There was then a 10-day water substitution phase, or PCP withdrawal, that occurred during the mid-follicular phase (days 7-11) or the late luteal phase (days 24-28) of the menstrual cycle. Access to PCP and concurrent water was then restored, and the PCP withdrawal procedure was repeated over several follicular and luteal menstrual phases. RESULTS: PCP deliveries were higher during the luteal (vs follicular) phase. Impulsive choice was greater during the luteal (vs follicular) phase during withdrawal of the higher PCP concentration. CONCLUSIONS: PCP withdrawal was associated with elevated impulsive choice for SACC, especially in the luteal (vs follicular) phase of the menstrual cycle in female monkeys.

Between two worlds: a multi-institutional qualitative analysis of students' reflections on joining the medical profession.

BACKGROUND: Recent changes in healthcare system and training mandates have altered the clinical learning environment. We incorporated reflective writing into Internal Medicine clerkships (IMcs) in multiple institutions so students could consider the impact of clerkship experiences on their personal and professional development. We analyzed student reflections to inform curricula and support learning. METHODS: We qualitatively analyzed the reflections of students at 3 US medical schools during IMcs (N = 292) to identify themes, tone, and reflective quality using an iterative approach. Chi-square tests assessed differences between these factors and across institutions. FINDINGS: Students openly described powerful experiences. Major themes focused on 4 categories: personal issues (PI), professional development (PD), relational issues (RI), and medical care (MC). Each major theme was represented at each institution, although with significant variability between institutions in many of the subcategories including student role (PI), development-as-a-physician (PD), professionalism (PD) (p < 0.001). Students used positive tones to describe student role, development-as-a-physician and physician-patient relationship (PD) (p < 0.01-0.001), and negative tones for quality and safety (MC) (p < 0.05). Only 4% of writings coded as professionalism had a positive tone. Students employed a "reporting" voice in writing about clinical problem-solving, healthcare systems, and quality/safety (MC). DISCUSSION: Reflection is considered important to professional development. Our analysis suggests that students at 3 institutions reflect on similar experiences. Theme variability across institutions implies curricula should be tailored to local culture. Reflective quality analysis suggests students are better equipped to reflect on certain experiences over others, which may impact learning. Student reflections can function as a mirror for our organizations, offer institutional feedback for support and improvement, and inform curricula for learners and faculty.