Foreign bodies: Is it feasible to develop tolerance for ambiguity among medical students through Equine-Facilitated learning?

Intolerance of ambiguity among medical students is associated with negative attitudes towards psychosocially complex patients. In this paper, the authors evaluated the feasibility of a 3.5-hour workshop aimed at fostering tolerance for ambiguity in medical students through semi-structured interactions with horses that functioned as experiential surrogates for ambiguity. Among 26 first-year medical students who participated in the feasibility assessment, an overwhelming majority rated the workshop as academically valuable and recommended that it be offered again in the future. After feasibility was established, an additional group of 7 first-year medical students and 5 fourth-year students completed Budner's Tolerance of Ambiguity scale before and after the workshop to provide preliminary data on its effectiveness. The post-workshop mean scores on the Budner scale were lower than pre-workshop mean scores, suggesting that students developed greater tolerance for ambiguity following the workshop. This difference was statistically significant among the first-year students, but not among the fourth-year students. Our findings demonstrate that the equine-facilitated workshop is feasible and can potentially help medical students develop greater tolerance for ambiguity.

Where's My Doctor? The Impact of the Primary Oncologist's Visit with Their Hospitalized Patients.

BACKGROUND: Continuity of care is a cornerstone of the patient-practitioner relationship. Previously, patient satisfaction has been related to perceived provider communication skills and competence. Our study assessed the relationship between the inpatient continuity visit (ICV), a face-to-face patient-provider interaction with the primary oncologist, and patient satisfaction. METHODS: Subjects were adult inpatients on the oncology unit at The Miriam Hospital who had an oncologist at the hospital-based cancer center. A survey, given at discharge, included a 5-point Likert scale ranging from greatly worsened to greatly improved satisfaction to assess the impact of the ICV on patient satisfaction. RESULTS: Of 75 participants, 43 (57.3%) reported a visit by their outpatient oncologist. Of these, 39 (90.7%) reported that this visit either greatly or somewhat improved satisfaction with their hospital stay. Of subjects who had a single ICV, 93.7% reported either greatly or somewhat improved satisfaction compared to 88.9% who had more than one visit. Of 32 (43.3%) subjects who did not receive a visit, 15.6% reported that the lack of visit either greatly or somewhat worsened their satisfaction during their hospital stay, while 84.4% reported no impact. CONCLUSIONS: Our study suggests that an ICV improves satisfaction of care in cancer patients on a hospitalist service, and a lack of ICV negatively impacted satisfaction. There was no improvement in satisfaction for multiple versus single ICVs. While the practicality of this intervention should be reassessed with the emergence of more accessible telehealth modalities, the efficacy of a single visit to improve satisfaction is informative.

Improving the online presence of residency programs to ameliorate COVID-19's impact on residency applications.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has created several challenges for residency programs and prospective interns alike during the upcoming application cycle, including the cancellation of away sub-internships and in-person interviews. Given prior research documenting that applicants' application and ranking decisions are significantly influenced by residency webpages, a potential solution to the loss of in-person experiences during the pandemic is the expansion of residency programs' online presence through their program websites, provision of virtual grand rounds and pseudo-away rotations, and enhancement of virtual interviews. This study seeks to summarize the existing literature on these areas and provide concrete suggestions for improving programs' virtual presence.Methods: The authors summarize earlier literature querying the content of program websites across 14 medical specialties, which documented significant gaps in the content of interest to applicants.Results: Among 14 analyzed specialties, the majority of programs had a functional website (>90%), with the exception of interventional radiology (73.9%). However, significant gaps in content were documented, with the percentage of content variables contained on websites ranging from 33.3% to 70.5% (median = 47.0%, interquartile range = 37.8-52.6%). Program websites were also limited by underrepresentation of content most valued by applicants as well as potential areas of inaccurate or outdated information.Conclusions: There are several interventions programs can undertake to address existing gaps in online presence. During an application cycle facing unprecedented resource strain, bolstering the online presence of programs may facilitate an improved fit between programs and future residents.

Critical Analysis of Hematology and Oncology Fellowship Web Sites in the United States.

PURPOSE: Prospective hematology-oncology fellowship applicants use program Web sites as a critical source of information. The purpose of this study was to evaluate the current content and comprehensiveness of hematology-oncology fellowship Web sites and to identify specific areas for improvement. METHODS: This study assessed the presence of 27 commonly evaluated program and application and curriculum and training informational items for Web sites of all accredited hematology-oncology fellowship programs in 2018. The comprehensiveness score was calculated as the number of items present on a fellowship Web site out of 27 and was compared by program region and size using analysis of variance and two-tailed t tests. RESULTS: Of the 143 fellowship Web sites evaluated, the mean comprehensiveness score was 39.3% (10.6 ± 3.8 out of 27). Programs contained a mean of 42.1% (5.9 ± 2.3 out of 14) of program and application and 36.2% (4.7 ± 2.1 out of 13) of curriculum and training items. The program and application items most common among Web sites were program coordinator contact and faculty listing (83.2% and 74.1% of Web sites, respectively), whereas social events and salary and benefits were less common (31.5% and 20.3% of Web sites, respectively). Prevalent curriculum and training items were research publications and activity and rotation scheduling (86.0% and 81.1% of Web sites, respectively), whereas board examination pass rates and fellow call duties were uncommon (4.2% and 15.4% of Web sites, respectively). Large programs were associated with greater overall Web site items compared with small programs (43.0% [11.6 ± 4.1 out of 27] v 35.9% [9.7 ± 3.3 out of 27]; P = .003). CONCLUSION: Hematology-oncology fellowship Web sites vary considerably in the level and nature of content they contain. Because applicants rely on online information for decision making, more comprehensive online content may promote a better fit between program and applicant. There is room for improvement in hematology-oncology fellowship Web sites, and programs may consider directing resources toward enhancing these Web sites.

Type B lactic acidosis as a severe metabolic complication in lymphoma and leukemia: a case series from a single institution and literature review.

Type B lactic acidosis is a rare complication of hematologic malignancies. The exact mechanism of this process is not well understood. Because caregivers may not be aware of the association of type B lactic acidosis with hematologic malignancies, it may go unrecognized as a cause of acidosis in these patients. We report the cases of 7 patients with type B lactic acidosis who were cared for by members of the Brown Medical School Hematology/Oncology Division. Of the 7 patients reported, 5 had lymphomas and 2 had chronic lymphocytic leukemia. One of the lymphomas was a T-cell lymphoma. Of the patients we were able to evaluate, there did not seem to be a unique cluster of differentiation marker in association with type B lactic acidosis. We also review 14 additional cases, most reported since 2001. From our review of the literature, we suggest that a deficiency of thiamine or riboflavin may play a more pivotal role than previously recognized in the development of type B lactic acidosis associated with malignancy. Further investigation should be undertaken to learn if thiamine or riboflavin replacement might be useful in treating this disorder.

HHV-8+, EBV+ multicentric plasmablastic microlymphoma in an HIV+ Man: the spectrum of HHV-8+ lymphoproliferative disorders expands.

Human herpesvirus-8 (HHV-8) is associated with several distinct lymphoproliferative disorders: primary effusion lymphoma, multicentric Castleman disease (MCD), MCD-associated plasmablastic lymphoma and HHV-8+, Epstein-Barr virus (EBV)+ germinotropic lymphoproliferative disorder. We report the case of a human immunodeficiency virus (HIV)+ male with fever, generalized lymphadenopathy, and splenomegaly. Two peripheral lymph nodes were excised and showed features of MCD and a prominent proliferation of HHV-8+, EBV+, CD20, CD138, MUM1+, lambda dim+, Ig heavy chain plasmablasts and immunoblasts replacing some follicles. Subsequently, a splenectomy and biopsy of retroperitoneal lymph nodes were performed; the retroperitoneal and splenic hilar lymph nodes showed changes similar to those in the peripheral lymph nodes while the markedly enlarged spleen showed replacement of occasional white pulp by the HHV-8+, EBV+ large cells. The histologic features and coinfection by EBV and HHV-8 suggested a diagnosis of HHV-8+ germinotropic lymphoproliferative disorder. However, the occurrence in an HIV+ individual, the background of MCD, the widespread anatomic distribution and the aggressive clinical course tended to exclude germinotropic lymphoproliferative disorder, and to favor multifocal plasmablastic microlymphoma. The patient died shortly after surgery; postmortem examination showed progression to overt lymphoma. The marrow showed extensive hemophagocytosis, consistent with development of a hemophagocytic syndrome. This unique case has clinical features compatible with a MCD-associated plasmablastic lymphoproliferative disorder, with pathologic features intermediate between HHV-8+ plasmablastic microlymphoma, and HHV-8+ germinotropic lymphoproliferative disorder, although in contrast to both of these, in our case, light chain expression was dim and heavy chain was not detected.

Multicentric Castleman disease, Kaposi sarcoma, hemophagocytic syndrome, and a novel HHV8-lymphoproliferative disorder.

The case of a 45-year-old man with HIV disease with bulky lymphadenopathy, fevers, and weight loss is presented. Immune reconstitution inflammatory syndrome was initially believed to be the cause, but the patient was found to suffer from Kaposi sarcoma, multicentric Castleman disease, hemophagocytic syndrome, and a newly described lymphoproliferative disorder. The diagnostic reasoning related to the causes of the fulminant illness is discussed as well as the roles of Epstein-Barr virus, human herpesvirus 8, and hepatitis C virus in the patient's clinical presentation and the therapeutic choices.

Playing in the "Gutter": Cultivating Creativity in Medical Education and Practice.

In comics, "gutters" are the empty spaces between panels that readers must navigate to weave disjointed visual sequences into coherent narratives. A gutter, however, is more than a blank space--it represents a creative zone for making connections and for constructing meaning from disparate ideas, values, and experiences. Over the course of medical training, learners encounter various "gutters" created by the disconnected subject blocks and learning experiences within the curriculum, the ambiguity and uncertainty of medical practice, and the conflicts and tensions within clinical encounters. Navigating these gutters requires not only medical knowledge and skills but also creativity, defined as the ability to make connections between disparate fragments to create meaningful, new configurations. To cultivate medical students' creative capacity, the authors developed the Integrated Clinical Arts (ICA) program, a required component of the first-year curriculum at the Warren Alpert Medical School of Brown University. ICA workshops are designed to place students in a metaphorical gutter, wherein they can practice making connections between medicine and arts-based disciplines. By playing in the gutter, students have opportunities to broaden their perspectives, gain new insights into both medical practice and themselves, and explore different ways of making meaning. Student feedback on the ICA program highlights an important role for creativity and the arts in medicine: to transform gutters from potential learning barriers into opportunities for discovery, self-reflection, and personal growth.

Splenosis and sepsis: The born-again spleen provides poor protection.

Splenosis describes ectopic splenic tissue found in patients after rupture of the spleen. These implants are commonly located on the omentum but can be scattered throughout the body in varying number and size. Although splenosis was first documented over a century ago, the precise mechanism for its development remains unknown. The degree of immunoprotection offered by this tissue remains unclear. Much of the human data is in the form of case reports documenting failure of splenotic tissue to protect against septicemia. Even accessory spleens may not offer complete protection once the primary spleen is removed. This review of the literature demonstrates that no amount of splenosis should be considered protective against overwhelming post-splenectomy infection.

Phase I trial examining addition of gemcitabine to CHOP in intermediate grade NHL.

PURPOSE: Gemcitabine induces a 20% response as single-agent therapy in patients with relapsed or refractory NHL. We report phase I findings of gemcitabine in combination with standard CHOP chemotherapy with G-CSF support for intermediate grade NHL. The protocol was modified during enrollment to include rituximab in CD 20+ lymphomas. METHODS: Patients received CHOP plus gemcitabine at 500 mg/m(2) (Cohort 1) or 750 mg/m(2) (Cohort 2) on days 1 and 4 of each 21-day cycle. Accrual was suspended once each cohort was filled. Dose escalation occurred after all patients in the cohort were determined to not have a dose-limiting toxicity. RESULTS: Between April 2002 and May 2004, 10 patients were enrolled and completed the study treatment (6 in Cohort 1, 4 in Cohort 2). In Cohort 1, grade 3 toxicities included neutropenia, anemia, neuropathy, and constipation. Grade 4 toxicities were febrile neutropenia and thrombocytopenia. In Cohort 2, grade 3 toxicities included neutropenia, thrombocytopenia, mucositis, anemia, and intestinal obstruction. Grade 4 toxicities included febrile neutropenia, neutropenia, and thrombocytopenia. One patient developed MDS 36 months after chemotherapy. Three of four patients in Cohort 2 developed dose-limiting toxicities (mucositis and thrombocytopenia) requiring dose reduction in gemcitabine after cycle 1. Overall, the survival rate at 2.5 years was 71%. CONCLUSIONS: This Phase I trial concludes that gemcitabine 500 mg/m(2) on days 1 and 4 of each 21-day cycle is the maximum tolerated dose when combined with standard CHOP chemotherapy with G-CSF support for intermediate grade NHL.

Who's My Doctor? First-Year Residents and Patient Care: Hospitalized Patients' Perception of Their "Main Physician".

BACKGROUND: Studies have shown that a large portion of patient satisfaction is related to physician care, especially when the patient can identify the role of the physician on the team. Because patients encounter multiple physicians in teaching hospitals, it is often difficult to determine who the patient feels is his or her main caregiver. Surveys evaluating resident physicians would help to improve patient satisfaction but are not currently implemented at most medical institutions. INTERVENTION: We created a survey to judge patient satisfaction and to determine who patients believe is their "main physician" on the teaching service. METHODS: Patients on a medical teaching service at The Miriam Hospital during 20 days in March 2008 were asked to complete the survey. A physician involved in the research project administered the surveys. Surveys included 3 questions that judged patient's perception and identification of their primary physician and 7 questions regarding patient satisfaction. Completed surveys were analyzed using averages. RESULTS: Of the 126 patients identified for participation, 102 (81%) completed the survey. Most patients identified the intern (first-year resident) as their main physician. Overall, more than 90% of patients expressed satisfaction with their main physician. CONCLUSION: Most patients on the teaching service perceived the intern as their main physician and were satisfied with their physician's care. One likely reason is that interns spend the greatest amount of time with patients on the teaching service.

Venous thrombosis in patients with chronic liver disease.

Patients with chronic liver disease are susceptible to bleeding and thrombotic complications of their disease, but the incidence of thrombosis and what predisposes them to thrombotic disease is largely unknown. One hundred and eight patients with chronic liver disease admitted with a first episode of venous thromboembolism, matched with patients of similar age, sex, and cause of liver disease without thrombosis were compared in a retrospective, case-control study over a 4-year period at two academic hospitals in Rhode Island. Incidence was determined from all admissions of patients with chronic liver disease during the specified time. Minimum and maximum values of complete blood counts, liver and kidney function tests, and coagulation tests during admission were compared between cases and controls. Incidence of new venous thrombosis in patients admitted with chronic liver disease was 0.73%. Patients with thromboses were more likely to have a lower albumin (2.77 vs. 3.49; P < 0.01) and hematocrit (37.7 vs. 40.2; P < 0.01) and higher platelet counts (143 vs. 109; P = 0.03), bilirubin (1.71 vs. 1.11; P < 0.01) and activated partial thromboplastin time (87 vs. 60.3; P < 0.01) as compared with controls. Although the incidence of thrombosis in patients with chronic liver disease is lower than the general medical population, hypoalbuminemia, anemia, and hyperbilirubinemia may confer increased risk of thrombosis whereas thrombocytopenia may be protective. Elevation of traditional markers of coagulation such as the prothrombin time and partial thromboplastin time does not safeguard against thrombotic events.