The effect of a medical student on community preceptor productivity.

BACKGROUND: Medical students are increasingly being taught in community-based hospitals and clinics in addition to university-based health systems, and there is sustained interest in the question of whether medical schools should pay healthcare organizations to allow students to precept to compensate for loss of productivity by preceptors. This study aimed to inform this subject by investigating the effect of medical students on preceptor productivity. METHODS: The authors analysed retrospective data on preceptor productivity and time efficiency from 17 outpatient primary care physicians over 7 months and 38,205 patient visits. Then, the authors surveyed these same physicians to assess how they believe precepting medical students affected their productivity. RESULTS: The retrospective data analysis found that physicians see slightly more patients per half-day when accompanied by a student. In surveys, these physicians reported the same number of patients seen per half-day with or without a medical student, but more time spent in clinic with a medical student. They also reported that allowing students to document in the medical record often helped reduce/offset the lengthened workday. CONCLUSIONS: Medical students either increase or do not change the number of patients seen per half-day but can increase preceptor time spent in clinic per day. Generally, physicians accept this increased time for the sake of promoting education and the joy of teaching. These findings can inform medical schools and healthcare organizations when negotiating financial arrangements for preceptorships in community based primary care clinics. Specifically, these findings suggest that medical students precepting do not cost the hospital organization in terms of preceptor productivity.

A cytoskeletal protein complex is essential for division of intracellular amastigotes of Leishmania mexicana.

Previous studies in Leishmania mexicana have identified the cytoskeletal protein KHARON as being important for both flagellar trafficking of the glucose transporter GT1 and for successful cytokinesis and survival of infectious amastigote forms inside mammalian macrophages. KHARON is located in three distinct regions of the cytoskeleton: the base of the flagellum, the subpellicular microtubules, and the mitotic spindle. To deconvolve the different functions for KHARON, we have identified two partner proteins, KHAP1 and KHAP2, which associate with KHARON. KHAP1 is located only in the subpellicular microtubules, whereas KHAP2 is located at the subpellicular microtubules and the base of the flagellum. Both KHAP1 and KHAP2 null mutants are unable to execute cytokinesis but are able to traffic GT1 to the flagellum. These results confirm that KHARON assembles into distinct functional complexes and that the subpellicular complex is essential for cytokinesis and viability of disease-causing amastigotes but not for flagellar membrane trafficking.

Extent of resection and role of adjuvant treatment in resected localized breast angiosarcoma.

BACKGROUND: Localized breast angiosarcoma (LBA) is a rare condition with no prospective clinical trials guiding the management of afflicted patients. Management of LBA and the resulting outcomes on a nationwide scale has not been previously examined. METHODS: The National Cancer Data Base (NCDB) from 2004 to 2014 identified resected LBA patients. Treatment patterns were compared between three time periods (2004-2007, 2008-2011, and 2012-2014). Demographic and tumor characteristics, as well as treatments received-extent of surgery and adjuvant therapies-were analyzed for association with overall survival after adjustment for covariates. RESULTS: 826 resected localized breast angiosarcoma patients were identified. Mastectomy was the most common surgical approach (86%); over 60% of patients did not receive adjuvant therapies after surgery. On multivariate analysis, tumor grade, tumor size, and surgical margins were associated with worse survival. Extent of surgery (mastectomy versus lumpectomy) and radiation therapy use were not associated with improved survival. Adjuvant chemotherapy was associated with improved survival in patients with primary tumors 5 cm and greater. CONCLUSIONS: The extent of surgery is not associated with improved survival in women with LBA, and patients may consider breast-conservation surgery. Adjuvant therapies are not associated with improved survival, with the exception of possible role of adjuvant chemotherapy in large primary tumors (5 cm or greater). Further clinical studies are needed to determine the impact of these treatments on local control, progression-free survival, and patients' quality of life. Until then, the findings of our analysis will form basis for the multi-disciplinary discussion of management of women with LBA.

The use of cannabinoids in palliating cancer-related symptoms: a narrative review.

Despite uncertain efficacy, cannabinoids and derived products are becoming increasingly used in the field of palliative care for oncologic patients. Cannabinoids chiefly include psychoactive tetrahydrocannabinol (THC) and nonpsychoactive cannabidiol (CBD). Use of and research interest in THC, CBD, and combination THC/CBD products have increased in recent years, particularly after the Agriculture Improvement Act of 2018 made cannabis plants with <0.3% THC no longer controlled substances, and many states recently legalized THC use altogether. To provide an updated review of this topic, we reviewed randomized controlled trials with >50 patients studying cannabinoid use in cancer patients. We found that THC products, including THC and THC/CBD combination products, are helpful for treating chemotherapy-induced nausea/vomiting. CBD products were not helpful for this indication. For most other studied indications (anorexia/cachexia, mood, general global symptoms), there was no convincing evidence to support widespread cannabinoid use in cancer symptom management. The evidence for treating cancer-related pain with THC/CBD products is somewhat conflicting. We conclude that, apart from using THC products to treat chemotherapy-induced nausea/vomiting, cannabinoid products should not be routinely recommended for cancer supportive care. Further research in the form of large randomized controlled trials is warranted in this area.

Regional wall motion abnormalities in transthoracic echocardiography in patients with significant coronary artery disease and coronary collateral circulation in adults.

BACKGROUND: Coronary collateral circulation is a common finding in patients with chronic total occlusions (CTOs) resulting from chronic coronary artery disease (CAD). Regional wall motion abnormalities (RWMA) on transthoracic echocardiography (TTE) can be used for the diagnosis of CAD. However, little work has been done to investigate the impact of collateral vessels on the diagnostic accuracy of resting TTE for CAD. METHODS: A retrospective chart review was conducted of adults who received a resting TTE and cardiac catheterization within 30 days over a 4-year period at the Temple Baylor Scott & White echocardiography laboratory. Exclusion criteria included catheterization without coronary angiography and prior history of CAD, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). We analyzed RWMA on TTE in patients with CAD and coronary collateral circulation on cardiac catheterization to assess for correlation. RESULTS: Of the 753 patients were included in this study, 453 had CAD, 272 had both CAD and RWMA, 111 had collateral circulation, and 73 had collateral circulation and RWMA. There was no significant difference in RWMA in patients with CAD with and without collateral circulation. There was no significant difference in the sensitivity (60.0 % vs 59.2 %) and specificity (78.4 % vs 73.9 %) after collateral-adjusted interpretation of RWMA and CAD (p = 0.3). DISCUSSION: Our results suggest the average coronary collateral system is of insufficient clinical significance to prevent the development of RWMA on resting TTE.

A solitary angiokeratoma on the toe of a teenaged girl.

An angiokeratoma is a benign vascular lesion that appears as one or more red to black papules with a verrucous surface. Histologically, it is defined by ectatic, thin-walled vessels in the papillary dermis, acanthosis with elongated rete ridges, and compact hyperkeratosis. Solitary angiokeratoma is one of five defined subtypes of angiokeratoma. We report the case of an 18-year-old woman with a "wart" that had been present for many years. After treatment with several over-the-counter wart therapies, several rounds of paring plus cryotherapy, and Candida antigen injections failed, a shave biopsy was taken to remove the lesion, and histopathologic examination was consistent with an angiokeratoma. This case demonstrates the importance of considering angiokeratoma in the differential diagnosis of a wart, particularly one recalcitrant to treatment.

Dietary supplements and bleeding.

An estimated one-third of US adults use herbal supplements, often without reporting that use to their physicians. These supplements can potentially alter bleeding and coagulation during surgery and when used concomitantly with anticoagulants. Our objective was to provide a comprehensive review of the evidence of bleeding risks of the most popular herbal and dietary supplements. A PubMed search and review of the literature was performed. We found that garlic and hawthorn supplementation is strongly associated with surgical bleeding independent of anticoagulants. Cordyceps sinensis, echinacea, and aloe vera are loosely associated with surgical bleeding independent of anticoagulants. In patients on anticoagulants, ginkgo biloba, chondroitin-glucosamine, melatonin, turmeric, bilberry, chamomile, fenugreek, milk thistle, and peppermint are associated with bleeding risk. No evidence was found for bleeding with these supplements independent of anticoagulants. Fish oil, ginseng, and saw palmetto are not associated with bleeding. Evidence for overall bleeding risk associated with St. John's wort, ginger, ginkgo biloba, or cranberry supplementation is conflicting. In conclusion, physicians must be aware of the potential anticoagulant effects of these supplements. It is imperative to report dietary and herbal supplement usage to physicians and is best to discontinue nonessential supplement use 2 weeks prior to surgery.

Management of Localized Breast Angiosarcoma by North American Radiation and Medical Oncologists.

INTRODUCTION: Primary breast angiosarcoma is a rare malignancy with no clinical trials to guide management. The current use of surgery, chemotherapy, and radiotherapy among North American oncologists is unknown. PATIENTS AND METHODS: An institutional review board-approved anonymous electronic survey was distributed to 9660 practicing North American radiation and medical oncologists. Questions pertained to treatment recommendations for localized nonmetastatic primary breast angiosarcoma, as well as knowledge/use of ß-blockers in angiosarcoma. The Fisher exact test was used to compare responses of medical and radiation oncologists. RESULTS: Surgery was recommended by 95% of all respondents. Chemotherapy was recommended by over half of medical and radiation oncologists. Radiotherapy was recommended by 92% of radiation and 56% of medical oncologists. The most common treatment recommendation was a trimodal treatment, with up-front surgery followed by adjuvant chemotherapy, then by adjuvant radiotherapy. Twenty-two percent of respondents were aware of clinical data pertaining to the use of ß-blockers in management of angiosarcoma, and among these respondents 69% were comfortable incorporating this treatment into standard practice. CONCLUSION: Trimodal management of primary localized breast angiosarcoma is supported by North American radiation and medical oncologists, with the majority recommending up-front surgery followed by adjuvant chemotherapy and radiation. The recently published reports of successful use of ß-blockers are not yet known among North American clinicians, but there is a great enthusiasm to incorporate these commonly prescribed medications into standard practice. These findings may greatly influence the standard of care for breast angiosarcoma treatment, particularly given the absence of Level I-supported evidence.