Team-Based Learning Sessions Compared With Traditional Lecture in the Obstetrics and Gynecology Clerkship.

OBJECTIVE: To estimate the effects of team-based learning sessions as part of the curriculum for the obstetrics and gynecology clerkship. METHODS: This is a prospective cohort study of clinical clerkship curriculum undertaken in Kansas City and Wichita between 2013 and 2017. A team-based learning curriculum included the same topics as the traditional lecture-format lectures and was instituted in Kansas City. The primary outcome was the obstetrics and gynecology National Board of Medical Examiners examination given at the end of the clerkship, both before and after the implementation of the team-based learning curriculum in Kansas City. An online questionnaire issued by the University of Kansas School of Medicine assessed learner satisfaction. A voluntary multiple-choice examination taken by both Kansas City and Wichita students months after clerkship completion assessed knowledge retention. RESULTS: The post-team-based learning Kansas City cohort scored a mean of 78.6 (95% CI 77.8-79.4) on the National Board of Medical Examiners obstetrics and gynecology subject examination compared with the pre-team-based learning Kansas City cohort scoring a mean of 74.6 (95% CI 73.6-75.6, P<.001). Student surveys did not show significant differences in satisfaction between pre-team- and post-team-based learning cohorts in Kansas City. There was no significant difference in knowledge retention scores between Kansas City and Wichita cohorts. DISCUSSION: We found significant improvement in National Board of Medical Examiners subject examination scores, which is likely the result of multiple curriculum changes, including the shift from didactic sessions to the active learning strategy of team-based learning. Team-based learning has provided a beneficial and stimulating learning experience for students.

Regulation of human placental drug transporters in HCV infection and their influence on direct acting antiviral medications.

INTRODUCTION: The objectives of this study were to determine how HCV infection affects placental drug transporters, and to determine the role of drug transporters on the cellular accumulation of direct-acting antiviral drugs in human trophoblasts. METHODS: Eighty-four ABC and SLC transporter genes were first screened in normal and HCV infected pregnant women using PCR profiler array. The changes in expression were confirmed by qPCR and Western blot. The impact of selected drug transporters on the cellular accumulation of radiolabeled antiviral drugs sofosbuvir, entecavir, and tenofovir was measured in primary human trophoblasts (PHT) and BeWo b30 cells in the presence or absence of transporter-specific inhibitors. PHT were then treated with CL097, ssRNA40, and imquimod to determine the impact of Toll-like receptor (TLR) 7/8 activation on drug transporter expression. RESULTS: The expression of the ABC efflux transporters ABCB1/P-gp and ABCG2/BCRP was increased in placenta of women with HCV, while the nucleoside transporters SLC29A1/ENT1 and SLC29A2/ENT2 remained unchanged. The accumulation of sofosbuvir and tenofovir was unaffected by inhibition of these transporters in trophoblast cells. Entecavir accumulation was decreased by the inhibition of ENT2. P-gp and BCRP inhibition enhanced entecavir accumulation in BeWo b30, but not PHT. Overall, there was little effect of TLR7/8 activation on these drug transporters, and the accumulation of entecavir in PHT. DISCUSSION: The data suggest that expression of placental drug transporters and selection of antiviral drug may impact fetal drug exposure in pregnancies complicated by HCV infections.

Etanercept-Induced Hypoglycemia in a Patient With Psoriatic Arthritis and Diabetes.

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis and inflammation involving the axial skeleton and/or peripheral joints. It is more likely to be associated with metabolic syndrome and diabetes when compared with other inflammatory arthritides. Tumor necrosis factor-α (TNF-α) is one of several cytokines often elevated in rheumatologic disorders including PsA and has also been found to be elevated in patients with obesity, metabolic syndrome, diabetes, and/or atherosclerotic disease. We describe the case of a patient with PsA as well as poorly controlled type 2 diabetes mellitus who experienced not only improvement in his psoriasis and arthritis with the anti-TNF-α agent etanercept but also recurrent hypoglycemia and significant improvement in hemoglobin A1c despite discontinuation of all conventional therapy for diabetes.

Polymyalgia Rheumatica and its Association with Cancer.

OBJECTIVE: Polymyalgia rheumatica (PMR) is a common rheumatologic disease in the elderly population. Studies on the relationship between PMR and cancer have yielded mixed results and have been limited by multiple factors. This study examined the association between PMR and development of cancer in a community cohort. METHODS: A population-based cohort of 359 patients with PMR diagnosed between 1/1/1970 and 12/31/1999 and followed to 12/31/2013 was assembled along with a comparison cohort of 357 subjects. Records of the PMR and comparator subjects were reviewed for details concerning diagnosis of cancer. The cumulative incidence of malignancy in patients with and without PMR, adjusted for the competing risk of death, was estimated and compared using methods of Gray. Cox proportional hazards models were used to assess the trends in malignancy over time. RESULTS: There was no significant difference in the prevalence of malignancy prior to PMR incidence date/index date between the two groups with prior malignancies in 41 (11%) of patients with PMR, and 50 (14%) of non-PMR subjects (p-value=0.31). As well, there was no difference in the cumulative incidence of malignancy at 10 years following PMR incidence between patients with PMR and non-PMR subjects (cumulative incidence at 10 years ± SE: PMR 13.8 ± 2.0, control 13.1 ± 2.0; p-value=0.89). CONCLUSION: There is no increased risk of malignancy in patients who are diagnosed with PMR when compared to subjects without PMR in this population-based cohort.

The influence of early menopause on cardiovascular risk in women with rheumatoid arthritis.

OBJECTIVE: Early menopause is associated with an increased risk for developing rheumatoid arthritis (RA). The risk for cardiovascular disease (CVD) in women increases following menopause. Because RA is associated with an increased risk of CVD, this study was undertaken to determine whether early menopause affects the risk of developing CVD in women with RA. METHODS: A population-based inception cohort of 600 women with RA who fulfilled 1987 American College of Rheumatology criteria for RA between 1955 and 2007 and were age ≥ 45 years at diagnosis was assembled and followed. Age at menopause and duration of hormone replacement therapy, along with occurrence of CVD, was ascertained by review of medical records. Cox proportional hazard models compared women who underwent early menopause (natural or artificial menopause at age ≤ 45 yrs) to those within the cohort who did not undergo early menopause. RESULTS: Of 600 women, 79 experienced early menopause. Women who underwent early menopause were at significantly higher risk for developing CVD when compared to women who did not (HR 1.56; 95% CI 1.08-2.26). CONCLUSION: The risk of CVD in women with RA was higher in those who experienced early menopause, and like other known risk factors should increase clinician concern for development of CVD in these patients.