Correlates of Myopathy in Diabetic Patients Taking Statins.

Diabetes is one of the most common chronic ailments; its incidence has reached epidemic proportions in the 21st century. Diabetes significantly increases micro and macrovascular complications, which are effectively managed with statins. Therefore, statins' pharmacokinetics, pharmacodynamics, and pharmacogenetics have been extensively studied. Although statins act as a keystone in preventing cardiovascular complications, at the same time, they pose a threat to the quality of life of diabetics due to the resulting muscular side effects. This article summarizes the prevalence, clinical manifestations, pathophysiology, and risk factors of statin-induced myopathy in diabetic patients. Among the diverse predisposing risk factors, the primary variables identified for causing myopathy in diabetic patients include age, gender, ethnicity, duration and severity of illness, comorbid conditions, level of physical activity, alcohol use, cholecalciferol (vitamin D3) levels, type and dose of statins, and anti-diabetic drugs or other drugs used concomitantly. In addition, cardiovascular risk quotients also potentially impact diabetic patients making them more vulnerable to developing myopathy from statins. Therefore, this study highlights the importance of managing statin-associated myopathic side effects by providing consensus guidelines on diagnostic, monitoring, and treatment strategies. We also discussed statins' prognostic value in reducing cardiovascular events in diabetic individuals.

Chronic Obstructive Pulmonary Disease and Its Effect on Red Blood Cell Indices.

Chronic obstructive pulmonary disease (COPD) constitutes a set of heterogeneous symptoms affecting millions of people worldwide. The associated comorbidities developing in COPD involve dysregulation in physiological pathways resulting from systemic inflammation in respiratory airways. In addition to mentioning the pathophysiology, stages, and consequences of COPD, this paper also defines red blood cell (RBC) indices such as hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, red blood cell distribution width, and RBC count. It explains the role of RBC indices and RBC structural abnormalities with disease severity and exacerbations in COPD patients. Although many factors have been studied as a marker of morbidity and mortality for COPD patients, RBC indices have emerged as revolutionary evidence. Therefore, the effectiveness of evaluating RBC indices in COPD patients and their importance as a negative predictor of survival, mortality, and clinical outcomes have been debated through rigorous literature reviews. Furthermore, the prevalence, mechanisms of development, and prognosis of underlying anemia and polycythemia in COPD have also been evaluated, with anemia most significantly associated with COPD. Therefore, more studies should be conducted to address underlying anemia in COPD patients to lessen the severity and disease burden. Correcting the RBC indices in COPD patients remarkably impacts the quality of life and reduces in-patient admissions, healthcare resource utilization, and costs. Hence, it is noteworthy to understand the significance of considering RBC indices while dealing with COPD patients.

A gold nanoparticles coated unclad single mode fiber-optic sensor based on localized surface plasmon resonance.

In the last few decays, the fiber-optic was employed in the field of sensing because of its benefits in contrast to other types of sensors such as small size, easy to fabricate, high response, and flexibility. In this study, unclad single mode fiber-optic sensor is proposed to operate at 650 nm wavelength. COMSOL Multiphysics 5.1 finite element method (FEM) is used to design the sensor and tested it theoretically. The middle portion of the fiber cladding is removed and replaced by gold nanoparticles (Au NPs) of 50 nm thickness. Analytic layer of 3 µm thickness was immersed in different liquids in range of refractive index (RI) from 1.000281 to 1.39. These liquids are NaCl Deionized (DI) water solution, sucrose-Deionized (DI) water solution, and glycerol solution Deionized (DI) water. It was found that the highest obtained sensitivity and resolution are for glycerol-DI water solution with value of 3157.98 (nm/RIU) and 3.16 × 10-5 (RIU), respectively. Furthermore, it is easy to fabricate and of low cost. In experiments, pulsed laser ablation (PLA) was used to prepare Au NPs. X-ray diffraction (XRD) shown that the peak of the intensity grew as the ablated energy increased as well as the structure crystallization. Transmission electron microscopy (TEM) revealed an average diameter of 30 nm at the three ablated energies, while X-ray spectroscopy (EDX) spectrum has indicated the presence of Au NPs in the prepared solution. The photoluminescence (PL) and ultraviolet-visible UV-Vis transmission were used to study the optical properties of the prepared Au NPs. An optical spectrum analyzer was used to obtain the sensor's output results. It has shown that best intensity was obtained for sucrose which confined with theoretical results.

Revisiting Feed Forward: Promoting a Student-Centered Approach to Education Handoffs, Remediation, and Clerkship Success.

Issue: Throughout medical school, and especially during clerkships, students experience changing work and learning environments and are exposed to new academic, interpersonal, and professional challenges unique to clinical learning. Given the siloed nature of clinical rotations, students often "fall through the cracks" and may repeatedly struggle through clerkships without support and coaching from which they would otherwise benefit. Many institutions have grappled with creating feed forward processes, that is, educational handoffs in which information is shared among faculty about struggling students with the intention of providing longitudinal support to ensure their success, while protecting students from negative bias that may follow them throughout the remainder of their medical school tenure. Evidence: Here, the authors describe the feed forward processes of four medical schools. Each school's process relies on close collaboration between course directors and deans to identify students and develop intervention plans. Course leadership and administration are typically the primary drivers for long-term follow-up with students. The number of participants in the process varies, with only one school directly involving students. Two schools hold larger, regularly scheduled meetings with up to 12 faculty present in their institution's feed forward process. Across these institutions, students can "graduate" from the feed forward process once they achieve competency in the areas of concern. Implications: The authors believe the most important outcome achieved is the formalization and adherence to a feed forward process. Thus, risk to students in the form of negative bias is mitigated by the flow of information, the extent to which information is available, and permitting students to be part of the process. These exemplars give insight into variable approaches to feed forward systems adopted by medical schools and demonstrate highly visible methodologies by which educational leadership empower students and educators toward a shared goal of student progress and achievement.

Design of an unclad single-mode fiber-optic biosensor based on localized surface plasmon resonance by using COMSOL Multiphysics 5.1 finite element method.

This study proposed an unclad optical fiber biosensor based on the localized surface plasmon resonance phenomenon and operating at 650 nm using COMSOL Multiphysics 5.1 finite element method (FEM). Gold nanoparticles (50 nm thickness) were coated on the middle portion of the unclad fiber. Air, water, blood plasma, liver tissue, colon tissue, and pentanol (C5H11OH) were used as analytical layers with 3 µm. The sensor serves as a theoretical foundation for experimental research. The blood plasma had the highest sensitivity with a sensitivity of 10,638.297 nm/RIU and a resolution of 9.410-6RIU. The proposed sensor is a promising candidate for a low-cost, simple-geometry biochemical sensing solution.

Update 2021: Management of Small Cell Lung Cancer.

BACKGROUND: Accounting for 14% of lung cancer, small cell lung cancer (SCLC) is a highly aggressive neuroendocrine malignancy with rapid proliferation, early spread, and poor survival. AIM AND METHODS: We provide an overview of recent advances regarding SCLC pathogenesis, subtypes, and treatment development through literature review of key trials. RESULTS: There are no validated biomarkers or approved targeted treatments for this overly heterogeneous disease, but recent analyses have identified some promising targets and four major subtypes which may carry unique therapeutic vulnerabilities in SCLC. Treatment wise, only a third of patients present with limited stage SCLC, which can be managed with a combined modality approach with curative intent (usually chemo-radiotherapy, but in some eligible patients, surgery followed by systemic treatment). For advanced or extensive stage SCLC, combined chemotherapy (platinum-etoposide) and immunotherapy (atezolizumab or durvalumab during and after chemotherapy) has become the new standard front-line treatment, with modest improvement in overall survival. In the second-line setting, for disease relapse ≤ 6 months, topotecan, lurbinectedin, and clinical trials are reasonable treatment options; for disease relapse > 6 months, original regimen, topotecan or lurbinectedin can be considered. Moreover, Trilaciclib, a CD4/CD6 inhibitor, was recently FDA-approved to decrease the incidence of chemotherapy-related myelosuppression in SCLC patients. CONCLUSIONS: While modest improvements in survival have been made especially in the metastatic setting with chemo-immunotherapy, further research in understanding the biology of SCLC is warranted to develop biomarker-driven therapeutic strategies and combinational approaches for this aggressive disease.

One Joint Aspirate: Three Diagnoses.

Gout is a frequently diagnosed condition. However, it is rarely diagnosed with concomitant pseudogout or reactive arthritis (ReA) from ​​​​​Chlamydophila pneumoniae (C. pneumoniae). This case report describes an interesting case of a 67-year-old man who presented with a two-week history of malaise, chills, and shortness of breath. He also reported a one-day history of polyarthritis, which limited his ambulation. The results of polarized microscopy revealed uric acid and calcium pyrophosphate crystals. The respiratory panel was positive for C. pneumoniae and rhinovirus. Therefore, he was diagnosed with gout, pseudogout, and ReA. Appropriate management led to a full clinical recovery. This is the first report documenting the simultaneous occurrence of ReA, gout, and pseudogout in a single patient. The association between these rheumatic diseases and a summary of similar cases in the literature are also discussed.

A Better Learning Community: Mixed-Methods Reveal Medical Student Preferences with Implications for Learning Community Design and Implementation.

BACKGROUND: Medical school learning communities benefit students. The College of Medicine (COM) at the University of Arkansas for Medical Sciences (UAMS) provides medical students with academic, professional, and personal support through a learning community (LC) made of 7 academic houses. OBJECTIVES: To evaluate the effectiveness of the academic house model at UAMS utilizing a mixed-methods survey. The aims were to: (1) assess student experience and satisfaction with academic houses, (2) describe the realms of advising and guidance, and (3) identify areas for improvement. METHOD: An online survey was assigned to 723 COM students (all students enrolled, first through fourth years) at UAMS in March 2019. The survey was comprised of 25 items (10 multiple-choice, 8 on the Likert scale, and 7 open-ended questions). Data was depicted using frequency and percentages and/or thematic review of free-form responses. RESULTS: The survey response rate was 31% (227 students). The majority of students responding (132, 58.1%) attended 2 or more face-to-face meetings with the faculty advisor within the preceding year. However, 27 (11.9%) students did not have any meetings. Approximately two-thirds of the respondents were satisfied or very satisfied with the guidance and direction provided by their advisors [very satisfied (n = 83; 36.6%); satisfied (n = 77; 33.9%)]. Themes that emerged from student generated areas for improvement include time constraints, advisor/advisee interest mismatch, and perceived inadequacy of advising content/connections. CONCLUSIONS: This study confirms the effectiveness of the LC model for advising and mentoring in the COM at UAMS. Uniquely, this study identifies not only learners' satisfaction with their LC but also highlights areas for improvement which are widely generalizable and important to consider for institutions with or planning to start an LC.

Empowering Medical Students to Respond to Discriminatory Comments from Patients: A Just-in-Time Training Method.

This article was migrated. The article was marked as recommended. Physicians in training may experience harassment and discrimination from supervisors, consultants, colleagues, or patients and families. Instances of discrimination towards students may impact students' self-esteem, self-efficacy, and ultimately performance. In this particular time, many institutions are looking to enhance their curriculum regarding bias. More tools are needed to help students feel empowered to respond professionally when they encounter challenging situations. This study was designed to assess the impact of a training intervention in addressing biased patient statements. The training was strategically placed prior to clinical interactions. The authors' intention was to present discriminatory statements by patients as one of the many difficult clinical situations that students are being trained to navigate. The authors developed a clinical rubric for decision-making in flowchart style to mimic the decision trees used in diagnostic or treatment decisions. They then created a workshop to help learners use the flowsheet. The workshop was delivered to third-year medical students as part of "Junior Bootcamp," a day-long session of events to orient students to the clinical experiences of the M3 year. The workshop was delivered in the summer of 2019. Respondents indicated that they were more likely to be able to appropriately respond to discriminatory comments after completing the workshop. They also felt that they were more likely to be able to engage in respectful dialogue with a patient and to debrief with a faculty member. Fewer participants felt that they were likely to use the flowchart. Findings indicate that the workshop was useful to participants. It may be especially useful to educators dealing with the COVID pandemic because it is scalable and easily delivered remotely. Further studies are needed to determine if introducing this topic in the clinical years of medical school leads to improved skill in addressing instances of bias that come from patients and families.

What Do Medical Students Actually Want from Learning Communities? A Comprehensive Needs Assessment.

This article was migrated. The article was marked as recommended. Purpose: The demanding nature of medical education has been well-described. Learning Communities (LCs) have been formed in a number of medical schools to address unmet needs such as wellness, social support, and academic/career counseling. However, there is limited information regarding the student perspective in shaping LC goals and activities. This study examined that perspective using a needs assessment survey. Methods: A formal needs assessment survey was completed by 510 medical students. The survey included 16 Likert-scale items and one open response item. Topics focused on student well-being, career planning, meaningful professional relationships, and academic success. Results: As expected, residency success and academic performance were the domains ranked as most important. Of note, the domain of wellness was ranked as less important overall. Results also varied by medical school year and gender. Conclusion: Formal assessment of student needs can serve as a guide to the development of LC programming, hopefully increasing student engagement.

Using Charlson Comorbidity Index to Predict Short-Term Clinical Outcomes in Hospitalized Older Adults.

This study examined the prognostic value of the Charlson Comorbidity Index (CCI) in predicting short-term clinical outcomes in hospitalized older adults. We conducted a retrospective cohort study of patients, older than 75 years, admitted to the medicine service at a large tertiary hospital (New York). We used the Enhanced International Classification of Disease, 9th Revision, Clinical Modification adaptation to abstract the CCI from electronic medical records. The CCI scores were compared, using the standard Deyo version and the Schneeweiss version. Outcome measures included in-hospital mortality, length of stay (LOS), and 30-day readmissions. When comparing Charlson/Deyo and Charlson/Deyo/Schneeweiss with and without age, we found similar significant association with regard to in-hospital mortality, with a moderate predictive ability (area under the curve [AUC]: 0.5906-0.6433). However, for 30-day readmissions and LOS, the predictive ability was poor (AUC: 0.5598-0.6106 and ρ: 0.11-0.12, respectively). The CCI is, at most, a moderate predictor of in-hospital mortality and a poor predictor of other important healthcare outcomes relevant to administrative healthcare practices.

Maternal-Fetal Physiology, Intrapartum Care, Postpartum Care: A Team-Based Learning Module for Normal Obstetrics.

Introduction: Team-based learning (TBL) is an active learning strategy used at the University of Arkansas for Medical Sciences in both the preclinical and clinical years of medical school. The Department of Obstetrics and Gynecology (OB/GYN) uses TBLs during a 6-week clinical clerkship. This TBL is the first in a series of six and was designed to teach the topic of normal obstetrics to third-year medical students. Methods: Prior to the TBL, students were provided with learning objectives and a list of advance preparation resources. These resources included a reading assignment from the student textbook, as well as optional online videos and optional online interactive quizzes. The students then came to class and completed an individual readiness assurance test (iRAT) and a group readiness assurance test (gRAT). The majority of in-class time was spent working through complex application exercises in the form of case vignettes. The TBLs were facilitated by a faculty member in the OB/GYN department. Results: Since its initiation in June 2018, 93 students have participated in this TBL activity. The mean score on the iRAT was 88.9%, and the mean score on the gRAT was 98.8%. Ninety-eight percent of students reported that they were satisfied with this learning activity. Discussion: This TBL was well received by students and unique in that it utilized a variety of types of advance preparation resources. With few other published OB/GYN TBLs available, we believe that this module could be a valuable resource for OB/GYN clerkships.

Study Habits of Medical Students: An Analysis of which Study Habits Most Contribute to Success in the Preclinical Years.

This article was migrated. The article was marked as recommended. Academic performance during the first two years of medical school is an important predictor of success on the United States Medical Licensing Exam Step 1. Research is lacking into what study methods successful students use, with success being defined as achieving a grade point average of above 90% in all or in most of the courses in the preclinical years.This study sought to identify specific study habits that successful students use and to demonstrate an association between preclinical grades and Step 1 scores. In this study, an anonymous survey was sent to first, second, and third year medical students that included various questions about their study habits, as well as their course grades (A, B, C, or fail) and, if applicable, their Step 1 score. Results demonstrated statistically significant differences existed between Step 1 scores and grades in the second year of medical school, with A students earning higher scores. A students tended to attend class, limit use of online lectures, study for 6-8 hours a day, and review lectures the same day they were given significantly more than B and C students did. This study demonstrates that certain study habits are employed consistently by successful students. These study habits should be shared with medical students early in the preclinical years to help students reach maximum potential both in class and on Step 1, which in turn will allow students to match into their choice of residency.

Giant Right Coronary Artery Aneurysm: A Case Report.

Coronary artery aneurysms are not very uncommon but 'giant' coronary artery aneurysms are rare, with a reported prevalence of 0.02% to 0.2%. Coronary artery aneurysm may be symptomatic or asymptomatic depending on their size and location but it is very unusual for a giant coronary artery aneurysm to be asymptomatic. Here, we present a case in which the giant coronary artery aneurysm remained undiagnosed and asymptomatic for several years.

Crystal clear or tin ear: how do medical students interpret derogatory comments about patients and other professionals?

PURPOSE: To assess the learning environment at our medical school, third-year medical students complete an 11-item survey called the Learning Environment for Professionalism (LEP) at the end of each clerkship. The LEP survey asks about the frequency of faculty and resident professional and unprofessional behaviors that students observed; two of the items specifically address derogatory comments. This study used focus group methodology to explore how medical students interpret the derogatory comments they reported on the LEP survey. METHODS: Seven focus groups were conducted with 82 medical students after they completed the LEP survey. Analysis of focus group transcripts was performed to better understand the nature and meaning that students ascribe to derogatory comments. RESULTS: The study results provide insights into the types of derogatory comments that medical students heard during their clerkship rotations, why the comments were made and how they were interpreted. Emergent themes, labeled by the authors as 1) 'onstage-offstage', 2) 'one bad apple', and 3) 'pressure cooker environment', highlight the contextual aspects and understandings ascribed by students to the derogatory comments. Incidentally, students felt that the comments were not associated with fatigue, but were associated with cumulative stress and burn-out. CONCLUSIONS: The results suggest students have a clear understanding of the nature of unprofessional comments made by role models during clerkships and point to important systems-related issues that could be leveraged to improve clinical learning environments.

Phytopreventive antihypercholesterolmic and antilipidemic perspectives of zedoary (Curcuma Zedoaria Roscoe.) herbal tea.

BACKGROUND: Metabolic syndrome is an increasingly prevalent problem, not only in industrialized developed countries, but in developing countries as well. The modern healthcare to reduce the dysfunction of metabolic syndrome is burdened with great problems of unsafe medicines and certain degree of side effects. Medicinal plants and derived component products are becoming increasingly popular in modern society as natural alternatives to synthetic multiple drugs for the treatment of hypercholesterolemia and hypertriglyceridemia. The present research work was carried out to evaluate the zedoary (Curcuma zedoaria Roscoe.) herbal tea (ZHT) for antihypercholestrolemic and antilipidemic perspectives in discerning consumers. METHODS: Zedoary rhizome dried powder (ZRDP) after proximate composition analysis was used to prepared ZHT samples as T1 (500 mg ZRDP), T2 (1 g ZRDP) and T3 (1.5 g ZRDP) in 200 mL boiling water for 5 minutes, respectively. ZHT samples were characterized for total phenolic compounds (TPC), DPPH inhibition, total flavonoids, color tonality (L*, a* and b* value), pH, acidity, total soluble solids (TSS) and sensory acceptance. Thirty mild-hypercholestrolemic male human volunteers were randomly allocated to three groups (G1, G2 and G3) and each group consisting of 1o mild-hypercholestrolemic male human subjects. The volunteers were assigned ZHT samples for consecutive two months. The blood drawn for day 0, day 30 and day 60 after an overnight 12 h fast was analyzed for serum parameters such as total cholesterol (TC), high-density lipoprotein cholesterol (HDL-cholesterol), low-density lipoprotein cholesterol (LDL-cholesterol) and triglycerides (TG) concentration. RESULTS: The ZRDP possessed abundantly the crude protein (13.5 ± 0.68 %), total dietary fiber (21.86 ± 0.71 %), acid detergent fiber (13.22 ± 0.44 %), neutral detergent fiber (18.68 ± 0.53 %) and mineral contents. Highest TPC, DPPH inhibition and total flavonoids values were observed 9.74 ± 0.64 (mg GAE/g DW), 47.28 ± 1.62 (%) and 17.12 ± 0.75 (QE mg/g), respectively in T3. L* value was significantly (p ≤ 0.05) low for T3 samples. In contrast, a* value and b* value was significantly (p ≤ 0.05) higher for T3 when compared with T1 and T2. T3 samples showed lower pH (5.13 ± 0.13) and higher acidity (0.25 ± 0.08) values than T1 (5.64 ± 0.25, 0.17 ± 0.05) and T2 (5.42 ± 0.21, 0.21 ± 0.06), respectively. Similarly, an increasing trend in TSS contents was observed. Sensory scores assigned to color, flavor, aroma and overall acceptability attributes varied in a quite narrow range for all ZHT samples. The lowest evaluation scores were recorded for T3 samples. The G3 showed the more reduction in body weight and BMI during efficacy study as compared to G1 and G2. The decrease in serum TC for G1, G2 and G3 on day 60 was observed 9 %, 14 % and 17 %, respectively when compared with reference value at day 0. The consumption of T3 resulted in significant increase (6.8 %) of HDL-cholesterol after two months. A trend in decrease of serum LDL-cholesterol (5.6 %) and TG (12.5 %) was also observed after consumption of T3 at day 60. CONCLUSIONS: The results of the present study conclude that the strong phenolic contents and radical scavenging activity of zedoary rhizome have protective role against hypercholesterolemic and lipidemic conditions.

Rapidly improving stroke symptoms: a pilot, prospective study.

BACKGROUND: Rapidly improving stroke symptoms (RISSs) are a controversial exclusion for intravenous recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke (AIS). We estimated the frequency of 4 prespecified RISS definitions and explored their relationship to clinical outcome. METHODS: Pilot, prospective study of AIS patients admitted within 4.5 hours of symptom onset. Serial assessments using National Institute of Health Stroke Scale (NIHSS) were performed every 20 ± 5 minutes until a rt-PA treatment decision was made, independent of the study. Improvement was calculated as the difference between baseline NIHSS and treatment decision NIHSS. RISS was defined as a 4-point or greater improvement, 25% or greater, 50% or greater, and according to the previously reported TREAT (The Re-examining Acute Eligibility for Thrombolysis) criteria. Unfavorable outcome was defined as modified Rankin Scale score more than 1 at 90 days after stroke. Logistic regression determined if RISS definition(s) related to the outcome. RESULTS: Fifty patients with AIS were enrolled: mean age 65 years; median baseline NIHSS score 5 (interquartile range, 2-11). RISS frequencies were 10%-22% based on definition. Median treatment decision NIHSS score is 5 (interquartile range, 2-9). Twenty-three (46%) patients received rt-PA. None of the 3 non-TREAT RISS definitions was independently associated with the outcome. Five of fifty (10%) were RISS according to the TREAT criteria, all 5 had good outcome without rt-PA. CONCLUSIONS: A Serial NIHSS assessment before treatment decision is feasible and may help determine the frequency and magnitude of RISS. This is the first prospective estimate of RISS frequency and outcome according to various prespecified definitions. The TREAT RISS frequency as a more restrictive definition may better predict good outcome of RISS in future, larger studies.

Evidence for validity of a survey to measure the learning environment for professionalism.

BACKGROUND: With the emphasis on professionalism in academic health settings, including recently added accreditation requirements for US medical schools, there is a need for a valid and feasible method to assess the learning environment for professionalism. AIM: This article describes the development and investigation of the validity of a brief measure, the learning environment for professionalism (LEP) survey, designed to assess medical student perceptions of professionalism among residents and faculty during clinical rotations. METHOD: Two successive cohorts of third-year medical students completed the 22-item LEP survey at the conclusion of clerkship rotations, providing a total of 902 responses for scale reliability and principal components factor analysis, as well as assessment of changes in scores over time and correlations with a related clerkship evaluation item. RESULTS: The internal structure of the LEP survey was consistent with intended goals to assess both positive and negative professionalism behaviors. Acceptable internal consistency, sensitivity to change over time, and positive relationships between LEP scores and a concurrent measure of professionalism were observed. CONCLUSIONS: Use of the instrument could help identify clinical learning environments for professionalism that represent either best practices or areas in need of improvement, assess the impact of professionalism initiatives, and help satisfy accreditation requirements.