Bringing Needed Change to Medical Student Well-Being: A Call to Expand Accreditation Requirements.

Issue: Noting high rates of burnout, depression, and suicidality among medical students, academic medical communities are trying to identify preventive and curricular measures that protect and promote student well-being. To date, the effectiveness of these efforts is unclear. In addition, evidence increasingly suggests that the major drivers of distress appear to be factors within the social, learning, and work environments. Specific to medical schools in the United States, neither the Liaison Committee on Medical Education nor the Commission on Osteopathic College Accreditation include accreditation standards regarding well-being curricula and, as such, these curricula are not well-integrated into students' medical school experience. Current accreditation standards also do not specifically require institutions to assess or address systemic factors of the learning environment that negatively affect student well-being. Evidence: This paper proposes expanding current Liaison Committee on Medical Education and Commission on Osteopathic College Accreditation standards on professionalism to incorporate well-being as a core component of professional identity formation by requiring individual and institutional-level actions. Proposed changes to accreditation standards include (1) institutional assessment of the impact of the learning environment on student well-being; (2) continuous quality improvement efforts to address structural factors associated with student well-being and modification of practices that impair student well-being; and (3) integrated curriculum with related assessment to educate students on empirically-supported strategies for well-being. Implications: Refining undergraduate medical education accreditation standards in the United States to include language specific to student well-being will facilitate long overdue changes to the learning environment. In the end, the goal is not just to improve medical student well-being, but to provide a workforce better equipped for a sustainable and meaningful career.

Using the Practical Robust Implementation and Sustainability Model (PRISM) to Identify and Address Provider-Perceived Barriers to Optimal Statin Prescribing and Use in Community Health Centers.

Statins are an important but underutilized therapy to prevent cardiovascular events, particularly in high-risk patients. To increase use of statin therapy in high-risk patients, the Centers for Disease Control and Prevention funded a project led by the National Association of Community Health Centers to discover reasons for statin underuse in health centers and identify possible leverage points, particularly among vulnerable and underserved patients. The project further sought to develop training and educational materials to improve statin prescribing for and acceptance in eligible high-risk patients. As a first step, investigators implemented a questionnaire to clinical providers (n = 45) at health centers participating in the project to obtain their perspective on barriers to optimal statin use. We used the practical robust implementation and sustainability model (PRISM) domains to frame the overall project and guide the development of our questionnaire. This paper summarizes top perceived barriers to patient and health system/provider statin initiation and sustainment, as well as facilitators to prescribing, using PRISM as an organizing framework. Our questionnaire yielded important suggestions related to public awareness, education materials, health information technology (HIT)/data solutions, and clinical guidelines as key factors in optimizing statin use. It also informed the design of patient education resources and provider training tools. Future directions include using the full application of the PRISM implementation science model to assess how well our educational and training resources help overcome barriers to statin use in high-risk patients, including evaluating how key contextual factors influence successful implementation.

Medical School Strategies to Address Student Well-Being: A National Survey.

PURPOSE: To describe the breadth of strategies U.S. medical schools use to promote medical student well-being. METHOD: In October 2016, 32 U.S. medical schools were surveyed about their student well-being initiatives, resources, and infrastructure; grading in preclinical courses; and learning communities. RESULTS: Twenty-seven schools (84%) responded. Sixteen (59%) had a student well-being curriculum, with content scheduled during regular curricular hours at most (13/16; 81%). These sessions were held at least monthly (12/16; 75%), and there was a combination of optional and mandatory attendance (9/16; 56%). Most responding schools offered a variety of emotional/spiritual, physical, financial, and social well-being activities. Nearly one-quarter had a specific well-being competency (6/27; 22%). Most schools relied on participation rates (26/27; 96%) and student satisfaction (22/27; 81%) to evaluate effectiveness. Sixteen (59%) assessed student well-being from survey data, and 7 (26%) offered students access to self-assessment tools. Other common elements included an individual dedicated to overseeing student well-being (22/27; 82%), a student well-being committee (22/27; 82%), pass/fail grading in preclinical courses (20/27; 74%), and the presence of learning communities (22/27; 81%). CONCLUSIONS: Schools have implemented a broad range of well-being curricula and activities intended to promote self-care, reduce stress, and build social support for medical students, with variable resources, infrastructure, and evaluation. Implementing dedicated well-being competencies and rigorously evaluating their impact would help ensure appropriate allocation of time and resources and determine if well-being strategies are making a difference. Strengthening evaluation is an important next step in alleviating learner distress and ultimately improving student well-being.

Evaluating medical student engagement during virtual patient simulations: a sequential, mixed methods study.

BACKGROUND: Student engagement is an important domain for medical education, however, it is difficult to quantify. The goal of this study was to investigate the utility of virtual patient simulations (VPS) for increasing medical student engagement. Our aims were specifically to investigate how and to what extent the VPS foster student engagement. This study took place at A.T. Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA), in the USA. METHODS: First year medical students (n = 108) worked in teams to complete a series of four in-class virtual patient case studies. Student engagement was measured, defined as flow, interest, and relevance. These dimensions were measured using four data collection instruments: researcher observations, classroom photographs, tutor feedback, and an electronic exit survey. Qualitative data were analyzed using a grounded theory approach. RESULTS: Triangulation of findings between the four data sources indicate that VPS foster engagement in three facets: 1) Flow. In general, students enjoyed the activities, and were absorbed in the task at hand. 2) Interest. Students demonstrated interest in the activities, as evidenced by enjoyment, active discussion, and humor. Students remarked upon elements that caused cognitive dissonance: excessive text and classroom noise generated by multi-media and peer conversations. 3) Relevance. VPS were relevant, in terms of situational clinical practice, exam preparation, and obtaining concrete feedback on clinical decisions. CONCLUSIONS: Researchers successfully introduced a new learning platform into the medical school curriculum. The data collected during this study were also used to improve new learning modules and techniques associated with implementing them in the classroom. Results of this study assert that virtual patient simulations foster engagement in terms of flow, relevance, and interest.

Phosphoinositide3-kinase regulates actin polymerization during delayed phagocytosis of Helicobacter pylori.

We have shown previously that ulcerogenic (type I) strains of Helicobacter pylori (Hp) retard their entry into macrophages. However, the signaling pathways that regulate Hp phagocytosis are largely undefined. We show here that Hp strongly activated class IA phosphoinositide3-kinases (PI3Ks) in macrophages, coincident with phagocytosis, and endogenous p85 and active protein kinase Balpha accumulated on forming phagosomes. PI3K inhibitors, wortmannin and LY294002, inhibited phagocytosis of Hp in a dose-dependent manner, and blockade of engulfment correlated directly with loss of 3'-phosphoinositides in the membrane subjacent to attached bacteria. During uptake of large immunoglobulin G (IgG)-coated particles, PI3Ks regulate pseudopod extension and phagosome closure. In marked contrast, we show here that 3'-phosphoinositides regulated actin polymerization at sites of Hp uptake. Moreover, Hp and IgG beads activated distinct PI3K isoforms. Phagosomes containing IgG-coated particles accumulated 3'-phosphatase and tensin homologue deleted on chromosome 10 and Src homology 2 domain-containing inositol 5'-phosphatase, yet Hp phagosomes did not. Finally, rapid uptake of IgG-opsonized Hp or a less-virulent type II Hp was PI3K-independent. We conclude that Hp and IgG beads are ingested by distinct mechanisms and that PI3Ks regulate the actin cytoskeleton during slow phagocytosis of ulcerogenic Hp.

Atypical protein kinase C-zeta is essential for delayed phagocytosis of Helicobacter pylori.

Phagocytosis is a rapid actin-dependent endocytic process used by macrophages and neutrophils to ingest and kill microorganisms. Perturbation of phagocytosis is central to the ability of some pathogenic microbes to cause disease, and we demonstrated previously that the ulcerogenic bacterium Helicobacter pylori (Hp) actively retards its uptake by macrophages and subsequently persists inside novel vacuoles called megasomes. Neither the receptor that mediates Hp binding nor the signaling pathways that regulate bacterial engulfment have been defined. Nevertheless, the fact that other phagocytic stimuli do not exhibit delayed phagocytosis suggests that Hp may be ingested by a unique mechanism. We now show that Hp transiently activated protein kinase C (PKC) in macrophages and that atypical PKCzeta and novel PKC(epsilon), but not conventional PKC(alpha), accumulated on forming phagosomes. Pharmacologic agents, isoform-selective pseudosubstrate peptides, and antisense oligonucleotides demonstrated that PKC(zeta) regulated local actin polymerization and bacterial engulfment, whereas other PKC isoforms did not. In contrast, opsonization of Hp with immunoglobulin G (IgG) induced rapid PKC(zeta)-independent uptake and enhanced killing of ingested bacteria. A role for atypical PKCs in phagocytosis has not been described. We conclude that Hp defines a new phagocytic pathway in macrophages that is regulated by PKC(zeta).

Toxicity of fipronil and its degradation products to Procambarus sp.: field and laboratory studies.

Fipronil is a phenylpyrazole insecticide that is the active ingredient in the pesticide Icon 6.2 FS which is applied to rice seeds targeting the rice water weevil. An arthropod-selective insecticide, fipronil blocks the GABA-gated chloride channel and is unique in that several of its degradation products have been indicated to be equal or more potent than fipronil. After application of rice seeds (2-3 days postplant) to flooded rice fields, water is typically pumped from the rice fields and can be used for the culture of crayfish (Procambarus sp.). Because fipronil is selective for arthropods, is transported via organic sediment, and crayfish consume organic sediment, 96-h LC(50) experiments were conducted with fipronil and three of its environmental derivatives in crayfish under conditions without carrier solvents in water of similar pH, alkalinity, and hardness as observed in south Louisiana crayfish culture ponds. Measured LC(50)s for fipronil to red swamp (Procambarus clarkii) and white river (Procambarus zonangulus) crayfish were 14.3 (95% CI; 5.1-23.4) and 19.5 (95% CI; 11.1-27.9) microg/L, respectively. LC(50)s of fipronil sulfone (11.2; 9.2-13.2 microg/L), fipronil sulfide (15.5; 13-18 microg/L); and the photoproduct, desulfinyl fipronil (68.6; 46-95.2 microg/L) displayed very high toxicity in crayfish. In situ toxicity studies using caged crayfish in culturing ponds receiving effluent from drained rice fields indicated that effluent from rice fields planted with Icon-treated seed was significantly more toxic compared to untreated surface water (40% survival compared to 83% survival). Hazard quotient comparisons using measured water concentrations in the field and laboratory-based LC(50)s indicated that fipronil and its metabolites in water resulting from Icon-treated rice seed planting poses a significant risk to crayfish survival.

Determination of heavy metals and pesticides in ginseng products.

Medicinal plants may carry residuals of environmentally persistent pesticides or assimilate heavy metals in varying degrees. Several factors may influence contaminant accumulation, including species, level and duration of contaminant exposure, and topography. As part of a program for assessment of the quality of herbal medicines, we have analyzed 21 over-the-counter ginseng (Panax ginseng) products in various dosage forms. Chromium, mercury, and arsenic were undetectable above their limits of detection in both liquid and solid samples; while cadmium, lead, and nickel were present in the majority of samples. The chlorinated pesticide levels varied widely. In most samples, the total concentration of pesticides was below 100 ppb; while in 5 samples the total concentration exceeded 100 ppb.

Mercury in sediment and fish from North Mississippi Lakes.

Sediments and/or fish were collected from Sardis, Enid and Grenada Lakes, which are located in three different watersheds in North Mississippi, in order to assess mercury contamination. The mean total mercury concentration in sediments from Enid Lake in 1997 was 0.154 mg Hg/kg, while 1998 sediment concentrations in Sardis, Enid and Grenada Lakes were 0.112, 0.088 and 0.133 mg Hg/kg, respectively. Sediment mercury concentrations in 1999 were similar in all three lakes but, generally lower than 1998. Mean total mercury concentrations in edible fillets of fish collected from Enid Lake in 1998 were above the human health FDA action level (> 1.0 mg Hg/kg) for bass (1.40), crappie (1.69) and gar (1.89); however, tissue concentrations were less than 1.0 mg Hg/kg in carp (0.63) and catfish (0.82). Human hazard indexes for each species was > or = 1 for both adults and children, indicating that there is a potential for toxic effects to occur. In addition, calculated consumption limits indicate that adults may consume 4-12 oz. of fish per month, depending on the species consumed. For children, 2 oz. per month may be consumed. Further studies are needed to determine the exact environmental consequences and human health impacts associated with mercury contamination in North Mississippi and the Southeastern United States.

Timing of concomitant boost irradiation affects incidence and severity of intestinal complications.

PURPOSE: In an effort to increase the therapeutic ratio of radiation therapy, so-called "nonstandard" irradiation regimens are being used more frequently. One such regimen, concomitant boost, entails giving a second daily fraction during part of the treatment course, thus reducing the total treatment time and decreasing the opportunity for tumor cell proliferation during treatment. The probability of tumor control is, therefore, increased for a given total dose. Timing of the boost, i.e., whether it is given early or late during the treatment course, affects both normal tissue and tumor response. This study assessed the influence of timing of a second daily boost on the development of intestinal radiation injury in a rat model. METHODS AND MATERIALS: A functionally intact segment of distal ileum was sutured to the inside of the scrotum in 52 orchiectomized, male Sprague-Dawley rats. After a 3-week postoperative recovery period, the intestine contained in the "scrotal hernia" was irradiated. All rats received a total dose of 50.4 Gy, given over a 12-day period as two different boost regimens, daily fractions of 2.8 Gy plus six concomitant boost doses of 2.8 Gy. The early boost group received the additional boost during the first 6 days and the late boost group received the additional boost during the last 6 days. The boost was given 6 h after the daily fraction. Groups of rats were sacrificed at 24 h (acute changes), 2 weeks (subacute changes), and 26 weeks (chronic changes) after the end of the irradiation schedule. Radiation injury was assessed by frequency of radiation-induced complications, histopathologic radiation injury score, collagen content, and epithelial cytokinetics. RESULTS: Radiation injury in the early boost group was significantly more severe than in the late boost group in terms of incidence of complication and histopathologic injury. Relative collagen content of irradiated intestine was significantly increased in the early boost group when compared to the late boost group at 2 weeks and at 26 weeks. Irradiated intestine in the early boost group exhibited decreased labeling index at 2 weeks, whereas irradiated intestine in the late boost group exhibited normal labeling index and increased total crypt cellularity at 2 weeks. CONCLUSION: When small intestine has to be included in the treatment field during radiation therapy, concomitant boost should be given towards the end of the radiation schedule, after the onset of compensatory proliferation, to minimized the risk of subsequent complications.

Modifications of B, I, i, and Lewisb antigens in a patient with DiGuglielmo's erythroleukemia.

Loss of red blood cell antigens has been documented in patients with acute myelocytic leukemia and includes loss of A, B, and H antigens in the ABO system as well as antigens of the Rh, MNSsU, Lewis and Ii systems. The following case represents partial loss of the B, I and Lewisb antigens in a patient with erythroleukemia. Also, the loss of the I antigen was associated with a concomitant increase in i antigen, a known but rare finding. These changes within the ABO, Ii, and Lewis systems do not appear to be coincidental, as these blood group systems share a common biochemical backbone.