Carol Gonsalves

Baseline imaging after therapy for unprovoked venous thromboembolism: a randomized controlled comparison of baseline imaging for diagnosis of suspected recurrence

Summary.  Background: After a first unprovoked venous thromboembolism (VTE), many patients have residual pulmonary and/or lower limb vascular obstruction following completion of short‐term anticoagulation. Residual vascular obstruction may complicate the diagnosis of recurrent VTE. Whether baseline imaging, conducted after completion of anticoagulation, helps in interpreting diagnostic testing in patients who subsequently have suspected recurrent VTE is unknown. Study design: The REVERSE study is a cohort study whose primary aim was to derive a clinical decision rule to guide the duration of anticoagulation after a first unprovoked VTE. All patients underwent baseline imaging after completing 5–7 months of anticoagulant therapy. We performed a post hoc randomized controlled comparison among 121 patients investigated for a suspected recurrent VTE during follow‐up: the decision on recurrent VTE with or without baseline imaging was made available to two independent adjudicators. Results: The proportion of patients not classifiable for recurrent VTE was statistically significantly higher in the group with no baseline imaging than in the group with baseline imaging: one in five as compared with one in 25. The interobserver agreement between the two adjudicators was better in the group with baseline imaging than in the group with no baseline imaging: κ‐values were 0.78 and 0.54, respectively. Conclusions: In patients with a first unprovoked VTE, baseline imaging at completion of anticoagulant therapy helps in interpreting diagnostic tests performed in cases of suspected recurrent VTE.

Using consensus group methods such as Delphi and Nominal Group in medical education research

Abstract Consensus group methods are widely used in research to identify and measure areas where incomplete evidence exists for decision-making. Despite their widespread use, these methods are often inconsistently used and reported. Using examples from the three most commonly used methods, the Delphi, Nominal Group and RAND/UCLA; this paper and associated Guide aim to describe these methods and to highlight common weaknesses in methodology and reporting. The paper outlines a series of recommendations to assist researchers using consensus group methods in providing a comprehensive description and justification of the steps taken in their study.

A novel approach to needs assessment in curriculum development: Going beyond consensus methods

Abstract Background: Needs assessment should be the starting point for curriculum development. In medical education, expert opinion and consensus methods are commonly employed. Aim: This paper showcases a more practice-grounded needs assessment approach. Methods: A mixed-methods approach, incorporating a national survey, practice audit, and expert consensus, was developed and piloted in thrombosis medicine; Phase 1: National survey of practicing consultants, Phase 2: Practice audit of consult service at a large academic centre and Phase 3: Focus group and modified Delphi techniques vetting Phase 1 and 2 findings. Results: Phase 1 provided information on active curricula, training and practice patterns of consultants, and volume and variety of thrombosis consults. Phase 2’s practice audit provided empirical data on the characteristics of thrombosis consults and their associated learning issues. Phase 3 generated consensus on a final curricular topic list and explored issues regarding curriculum delivery and accreditation. Conclusions: This approach offered a means of validating expert and consensus derived curricular content by incorporating a novel practice audit. By using this approach we were able to identify gaps in training programs and barriers to curriculum development. This approach to curriculum development can be applied to other postgraduate programs.

Trilineage myelodysplasia and hemophagocytosis associated with systemic lupus erythematosus

Marked trilineage myelodysplasia and hemophagocytosis was noted in the marrow of a 28-year old male of Filipino decent. Six days prior he had been admitted to the hospital for work-up of renal failure, proteinuria, hematuria, and pancytopenia. Past medical history was noteworthy for a 2-year history of a psoriatic like skin rash. The patient also had an emergency room visit for chest pain 1 week prior. He was diagnosed with likely pericarditis and discharged with indomethacin. At admission the patient’s initial laboratory investigation was significant for a creatinine of 270 lmol/L (normal 62–106), potassium of 5.9 mmol/L (normal 3.5–5.1), hemoglobin 104 g/L (normal 130–170), mean corpuscular volume (MCV) of 79.7 fL (normal 80–100), reticulocytopenia of 19.3 3 10/L (normal 25–100), neutrophil count of 2.0 3 10/L (normal 2–7.5), and a platelet count of 105 3 10/L (normal Image 1. Top two rows, left and middle: Evidence of dysplastic erythropoiesis: karyorrhexis (A), cytoplasmic nuclear dysynchrony predominantly in the late normoblasts (B), multinucleation (A,C), and nuclear blebbing (D). 31000 on oil. Top two rows, right: Micromegakaryocyte. 31000 on oil (above). Hemophagocytosis. 31000 on oil (below). Bottom two rows: Normocellular bone marrow with a few strikingly pyknotic megakaryocytes at 3200 and 3400, respectively (A,B), abnormal clustering of megakaryocytes at 3200 (C), mild gelatinous transformation occupying 10% of the core biopsy at3200 (D).

International Society on Thrombosis and Haemostasis core curriculum project: core competencies in clinical thrombosis and hemostasis: comment.

L . SKE ITH ,*† M. A. RODGER ,*†‡§ A. Y . LEE , ¶ S . R . KAHN,**†† S . M. BATES‡‡ and C . GONSALVES*† *Division of Hematology; †Department of Medicine; ‡Department of Obstetrics and Gynecology, University of Ottawa and The Ottawa Hospital; §Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON; ¶Department of Medicine, Thrombosis Program, University of British Columbia and Vancouver Coastal Health Authority, Vancouver, BC; **Department of Medicine and Center for Clinical Epidemiology, Jewish General Hospital; ††Department of Medicine, McGill University, Montreal, QC; and ‡‡Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada

The Use of the Delphi and Other Consensus Group Methods in Medical Education Research: A Review.

Purpose Consensus group methods, such as the Delphi method and nominal group technique (NGT), are used to synthesize expert opinions when evidence is lacking. Despite their extensive use, these methods are inconsistently applied. Their use in medical education research has not been well studied. The authors set out to describe the use of consensus methods in medical education research and to assess the reporting quality of these methods and results. Method Using scoping review methods, the authors searched the Medline, Embase, PsycInfo, PubMed, Scopus, and ERIC databases for 2009–2016. Full-text articles that focused on medical education and the keywords Delphi, RAND, NGT, or other consensus group methods were included. A standardized extraction form was used to collect article demographic data and features reflecting methodological rigor. Results Of the articles reviewed, 257 met the inclusion criteria. The Modified Delphi (105/257; 40.8%), Delphi (91/257; 35.4%), and NGT (23/257; 8.9%) methods were most often used. The most common study purpose was curriculum development or reform (68/257; 26.5%), assessment tool development (55/257; 21.4%), and defining competencies (43/257; 16.7%). The reporting quality varied, with 70.0% (180/257) of articles reporting a literature review, 27.2% (70/257) reporting what background information was provided to participants, 66.1% (170/257) describing the number of participants, 40.1% (103/257) reporting if private decisions were collected, 37.7% (97/257) reporting if formal feedback of group ratings was shared, and 43.2% (111/257) defining consensus a priori. Conclusions Consensus methods are poorly standardized and inconsistently used in medical education research. Improved criteria for reporting are needed.

Identifying the factors influencing practice variation in thrombosis medicine: A qualitative content analysis of published practice-pattern surveys

Practice variation, the differences in clinical management between physicians, is one reason why patient outcomes may differ. Identifying factors that contribute to practice variation in areas of clinical uncertainty or equipoise may have implications for understanding and improving patient care. To discern what factors may influence practice variation, we completed a qualitative content analysis of all practice-pattern surveys in thrombosis medicine in the last 10years. Out of 2117 articles screened using a systematic search strategy, 33 practice-pattern surveys met eligibility criteria. Themes were identified using constant comparative analysis of qualitative data. Practice variation was noted in all 33 practice-pattern surveys. Contributing factors to variation included lack of available evidence, lack of clear and specific guideline recommendations, past experience, patient context, institutional culture and the perceived risk and benefit of a particular treatment. Additional themes highlight the value placed on expertise in challenging clinical scenarios, the complexity of practice variation and the value placed on minimizing practice variation.

Capsule Commentary on Rocha et al., Opinions of Students from a Brazilian Medical School on Online Professionalism

S ocial media is the communication medium of choice for many. While users of online forums and networking sites may make the distinction between personal and professional posts, posts intended as ‘personal’ can have negative professional ramifications. Rocha et al. surveyed 350 Brazilian Medical Students on the frequency with which they had observed ten categorized unprofessional online behaviours. These ranged from 14 % (patient privacy) to 85 % (photos of alcohol consumption). Lapses in patient privacy were universally condemned. Other unprofessional behaviors, such as posing in bathing suits, were judged neutrally. Some differences in professional expectations as they apply to social media will be influenced by cultural differences, However, given the nature of the physician– patient relationship and similar codes of ethics for medical professionals in most countries, cultural differences should account for a minority of the variance expected for these standards in the online world. In most countries, professionalism is a central competency in the training of physicians. However, the challenge to educators involved in medical education has been the steadily increased use of social media by students and physicians alike. Less than 15 % of the Brazilian students in this study report receiving any structured learning in this area. While the potential consequences of online behaviour may seem intuitive, the fact that these students condemned violation of patient privacy, yet did not find the case vignette depicting the posting of pictures of pediatric patients inappropriate is telling of incongruent judgment in this area. That students judged certain online behaviours more unacceptable from faculty also indicates a potential lack of awareness of the ‘permanent’ and public nature of the online world and how inappropriate posts may impact a student’s career long after they have left the classroom. Reports from several US medical schools have identified a significant amount of inappropriate online posts by students, with damaging professional consequences. It is our duty to adjust our academic curricula to include online behavior and to evaluate the impact of such programs, so as to avoid harm, embarrassment, and penalties for individual careers, institutions, the medical profession itself and the patients and communities that are served.