Virtual learning allows for adaptation of study strategies in a cohort of U.S. medical students.

BACKGROUND: In response to the COVID-19 pandemic, most U.S. medical schools acutely transitioned from regimented in-person learning to highly flexible virtual asynchronous learning. This transition at our medical school provided a unique opportunity to evaluate if and how students adapted their academic and personal lives in response. METHODS: Medical students in a single class that made this transition were retrospectively provided with 24-hour diaries for three periods - one shortly before the transition, a second early in the transition, and third several months into the transition - and asked to select the academic or personal activities done in each hour. The percentage of medical students performing each activity each hour was analyzed, as was the time spent on each activity per day, and per morning, afternoon, per evening within the day. RESULTS: Overall study time did not change in either virtual period but shifted significantly to the morning (6 AM to 12 PM). Time spent studying in groups fell significantly during both virtual periods, concordant with a significant increase in alone study time in the early virtual period. Early in the transition to virtual learning, students replaced in-person didactics with online faculty lectures; several months later in virtual learning, they had replaced online faculty lectures with commercial products. There was no significant change in time spent on specific personal activities. CONCLUSIONS: Consistent with extensive constraints imposed by the heavy cognitive load of a medical school curriculum, students did not significantly change their overall study time and any self-care-related activities in the transition to virtual learning. However, transitioning to virtual learning allowed our students to adapt their study strategies, i.e. reducing group study time and increasing lone studying time. Furthermore, students shifted studying time to the morning to optimize the management of the cognitive task-load they faced.

Virtual interviewing for graduate medical education recruitment and selection: A BEME systematic review: BEME Guide No. 80.

BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Feasibility and Safety of Using External Counterpulsation to Augment Cerebral Blood Flow in Acute Ischemic Stroke-The Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial.

BACKGROUND: External counterpulsation (ECP) increases perfusion to a variety of organs and may be helpful for acute stroke. METHODS: We conducted a single-blinded, prospective, randomized controlled feasibility and safety trial of ECP for acute middle cerebral artery (MCA) ischemic stroke. Twenty-three patients presenting within 48 hours of symptom onset were randomized into one of two groups. One group was treated with ECP for 1 hour at a pressure of up to 300 mmHg ("full pressure"). During the procedure, we also determined the highest possible pressure that would augment MCA mean flow velocity (MFV) by 15%. The other group was treated with ECP at 75 mmHg ("sham pressure"). Transcranial Doppler MCA flow velocities and National Institutes of Health Stroke Scale (NIHSS) scores of both groups were checked before, during, and after ECP. Outcomes were assessed at 30 days after randomization. RESULTS: Although the procedures were feasible to implement, there was a frequent inability to augment MFV by 15% despite maximal pressures in full-pressure patients. In sham-pressure patients, however, MFV frequently increased as shown by increases in peak systolic velocity and end diastolic velocity. In both groups, starting ECP was often associated with contemporaneous improvements in NIHSS stroke scores. There were no between-group differences in NIHSS, modified Rankin Scale Scores, and Barthel Indices, and no device or treatment-related serious adverse events, deaths, intracerebral hemorrhages, or episodes of acute neuro-worsening. CONCLUSIONS: ECP was safe and feasible to use in patients with acute ischemic stroke. It was associated with unexpected effects on flow velocity, and contemporaneous improvements in NIHSS score regardless of pressure used, with a possibility that even very low ECP pressures had an effect. Further study is warranted.

Learning Outcomes in a Live Virtual versus In-Person Curriculum for Medical and Pharmacy Students.

Background: The coronavirus disease (COVID-19) pandemic has been a source of disruption, changing the face of medical education. In response to infection control measures at the University of California, San Diego, the hybrid in-person and recorded preclerkship curriculum was converted to a completely virtual format. The impact of this exclusive virtual teaching platform on the quality of trainee education is unknown. Objective: To determine the efficacy of a virtual course, relative to traditional hybrid in-person and recorded teaching, and to assess the impact of supplementary educational material on knowledge acquisition. Methods: A retrospective observational cohort study was performed to assess an introductory course, held mostly in person in 2019 versus completely virtual in 2020, for first-year medical students and second-year pharmacy students at the University of California, San Diego, School of Medicine and Skaggs School of Pharmacy and Pharmaceutical Sciences. Results: The midterm and final examination scores were similar for the hybrid and virtual courses. There was no association between the hours of recorded lectures watched and final examination scores for either course. In the 2019 in-person and recorded course, students who demonstrated consistent on-time use of practice quizzes scored statistically higher on the final examination (P = 0.0066). In the 2020 virtual course, students who downloaded quizzes regularly had statistically higher scores on the midterm examination (P < 0.0001). Conclusion: The similar examination scores for the hybrid in-person and recorded and exclusively virtual courses suggest that the short-term knowledge acquired was equivalent, independent of the modality with which the content was delivered. Consistent on-time use of practice quizzes was associated with higher examination scores. Future studies are needed to assess the difference between a completely in-person versus virtual curriculum.

Intravenous thrombolysis plus hypothermia for acute treatment of ischemic stroke (ICTuS-L): final results.

BACKGROUND AND PURPOSE: Induced hypothermia is a promising neuroprotective therapy. We studied the feasibility and safety of hypothermia and thrombolysis after acute ischemic stroke. METHODS: Intravenous Thrombolysis Plus Hypothermia for Acute Treatment of Ischemic Stroke (ICTuS-L) was a randomized, multicenter trial of hypothermia and intravenous tissue plasminogen activator in patients treated within 6 hours after ischemic stroke. Enrollment was stratified to the treatment time windows 0 to 3 and 3 to 6 hours. Patients presenting within 3 hours of symptom onset received standard dose intravenous alteplase and were randomized to undergo 24 hours of endovascular cooling to 33°C followed by 12 hours of controlled rewarming or normothermia treatment. Patients presenting between 3 and 6 hours were randomized twice: to receive tissue plasminogen activator or not and to receive hypothermia or not. Results- In total, 59 patients were enrolled. One patient was enrolled but not treated when pneumonia was discovered just before treatment. All 44 patients enrolled within 3 hours and 4 of 14 patients enrolled between 3 to 6 hours received tissue plasminogen activator. Overall, 28 patients randomized to receive hypothermia (HY) and 30 to normothermia (NT). Baseline demographics and risk factors were similar between groups. Mean age was 65.5±12.1 years and baseline National Institutes of Health Stroke Scale score was 14.0±5.0; 32 (55%) were male. Cooling was achieved in all patients except 2 in whom there were technical difficulties. The median time to target temperature after catheter placement was 67 minutes (Quartile 1 57.3 to Quartile 3 99.4). At 3 months, 18% of patients treated with hypothermia had a modified Rankin Scale score of 0 or 1 versus 24% in the normothermia groups (nonsignificant). Symptomatic intracranial hemorrhage occurred in 4 patients (68); all were treated with tissue plasminogen activator <3 hours (1 received hypothermia). Six patients in the hypothermia and 5 in the normothermia groups died within 90 days (nonsignificant). Pneumonia occurred in 14 patients in the hypothermia and in 3 of the normothermia groups (P=0.001). The pneumonia rate did not significantly adversely affect 3 month modified Rankin Scale score (P=0.32). CONCLUSIONS: This study demonstrates the feasibility and preliminary safety of combining endovascular hypothermia after stroke with intravenous thrombolysis. Pneumonia was more frequent after hypothermia, but further studies are needed to determine its effect on patient outcome and whether it can be prevented. A definitive efficacy trial is necessary to evaluate the efficacy of therapeutic hypothermia for acute stroke.

Implementation and Outcomes of a Community Assessment Service-Learning Activity Within Academic Learning Communities.

A community needs assessment and engagement activity was implemented in 2013 in the core preclinical curriculum as part of the doctoring course within Academic Communities at UC San Diego School of Medicine. This required educational experience included curricular learning objectives as well as goals to strengthen community service within academic communities. This activity was implemented and sustained within the academic communities with each community serving a different community of San Diego. Survey data from preclinical students from 2014 to 2017 consistently reported that the community assessment activity helped sustain or develop a service project in the academic community (67.1%-79.6% strongly agree or agree) and increased students' knowledge of the needs in the assigned San Diego community (76.3%-80.6% strongly agree or agree). Students felt that the community assessment and engagement activity was a valuable learning experience (62.5%-77.8% strongly agree or agree). As a result of this educational intervention, 14 projects were implemented in the community. A subset of particularly interested and motivated medical students then took on leadership roles in these projects. Student-led scholarly assessment of the impact of some of these interventions resulted in 2 peer-reviewed publications thus far and 9 national presentations at the time of this publication. These assessments demonstrate not only educational impact, but health-system-level changes and meaningful change in patient outcomes.

Can urine dipstick be used as a surrogate for serum creatinine in emergency department patients who undergo contrast studies?

Contrast-induced nephropathy (CIN) is a complication associated with contrasted computed tomography (CT). Elevated creatinine (Cr) is often used to screen for CIN. This study evaluates dipstick urinalysis (Udip) detection of Cr > 1.5 mg/dL. If sufficiently sensitive, Udip results could then be incorporated into future rapid screening protocols for patients undergoing contrast studies. This retrospective record review evaluated all Emergency Department patients over 2 years with documented Udip and serum creatinine results. Patient demographics and pertinent past medical history were also collected. Data were collected on 2421 patient visits, with 241 having Cr > 1.5 mg/dL (9.9%). There were 923 patient visits with a negative Udip (38.1%). Sensitivity and negative predictive value for abnormal Udip in detecting elevated creatinine were 85.5% and 96.2% (p < 0.01), respectively. Thirty-five patient visits (among 26 patients) had negative urine dip and Cr > 1.5 mg/dL, but each reported at least one of the following at triage: prior renal disease, hypertension, diabetes, congestive heart failure, or age > 60 years. Udip is a sensitive screening test, but alone is not accurate enough to predict patients at potential risk for CIN (Cr > 1.5 mg/dL). However, combining Udip results with risk factor screening may allow a rapid method for predicting which patients may safely undergo contrast CT scanning in the ED, but this needs prospective evaluation.

Acute Stroke: Current Evidence-based Recommendations for Prehospital Care.

INTRODUCTION: In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. METHODS: We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. RESULTS: Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80 mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. CONCLUSION: Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Comparison of the post-embolization effects of tissue-plasminogen activator and simvastatin on neurological outcome in a clinically relevant rat model of acute ischemic stroke.

Data has emerged, largely from non-thromboembolic animal models of stroke, that suggests that statins, which have efficacy in preventing strokes when given pre-ischemically, may have a positive effect on stroke even when given post-ischemically, possibly through pleitropic cerebrovascular effects. The goal of this study was to characterize the effects of IV tPA in a clinically relevant model of stroke utilizing a vascular occlusion with a freshly formed clot, and evaluate the effects of post-ischemic administration of simvastatin on stroke outcome in this model. Neurological deficit, clot burden, and lesion volume were assessed after treatment with tPA in one experiment, and after treatment with simvastatin in another. In the tPA experiment, treatment with 10mg/kg of tPA IV (with 20% given as an initial bolus, and 80% given as an infusion over the remaining 30 min), starting within an hour after stroke, resulted in significant reductions, compared with control animals, in neurological deficit (mean+/-SD neuroscores of 21.5+/-21.1 and 30+/-29.3, respectively, p=0.005), clot burden (p=0.010) and lesion volume (p=0.049) at 24h. In the simvastatin experiment on the other hand, treatment with a 20mg/kg of simvastatin as a single intraperitoneal dose within an hour after stroke resulted in no salutary effects on neurological deficit, clot burden or lesion volume compared with controls at 24h. These results suggest that more research needs to be done to fully ascertain the therapeutic potential and optimal dosing paradigm of a post-ischemic treatment with a statin.

Therapeutic hypothermia is associated with a decrease in urine output in acute stroke patients.

AIMS: It is unclear what effect therapeutic hypothermia may have on renal function, because its effect has so far been primarily evaluated in settings in which there may be possible confounding perturbations in cardiovascular and renal physiology, such deep intraoperative hypothermia, general anesthesia, and post-cardiac arrest. We sought to determine if therapeutic hypothermia affects renal function in awake patients with normal renal function who were enrolled into a clinical trial of hypothermia plus intravenous thrombolysis for acute ischemic stroke. METHODS: Eleven patients with normal renal function were cooled to 33°C for 24 h using an endovascular catheter, and then re-warmed over 12 h to 36.5°C, while hourly temperature, blood pressure, and fluid status data was recorded. Blood samples for blood urea nitrogen (BUN), creatinine, and hematocrit were drawn prior to treatment (baseline), immediately after hypothermia and re-warming (day 2), and again at day 7 or discharge, and values compared. RESULTS: On initiation of cooling, temperatures dropped from a median pre-treatment value of 36.1°C (IQR: 35.8-36.4°C) to 33.1°C (IQR: 33.1-33.4°C). Urine output decreased 5.1 ml/h for every 1°C decrease in body temperature (p-value=0.001), with no associated serious adverse events. There were no statistically significant changes in BUN, creatinine, or hematocrit in the hypothermia patients. CONCLUSION: Inducing hypothermia in patients with relatively unperturbed renal physiology results in a decrease in urine output that is linearly correlated with the decrease in core temperature. This has important implications for fluid management in patients undergoing therapeutic hypothermia.

Effect of endovascular hypothermia on acute ischemic edema: morphometric analysis of the ICTuS trial.

INTRODUCTION: Pilot studies of hypothermia for stroke suggest a potential benefit in humans. We sought to test whether hypothermia decreases post-ischemic edema using CT scans from a pilot trial of endovascular hypothermia for stroke. METHODS: Eighteen patients with acute ischemic stroke underwent therapeutic hypothermia (target = 33 degrees C) for 12 or 24 h followed by a 12-h controlled re-warm using an endovascular system. CT scans obtained at baseline, 36-48 h (right after cooling and re-warming) and 30 days were digitized, intracranial compartment volumes measured using a validated stereological technique, and the calculated change in CSF volume between the three time-points were used as an estimate of edema formation in each patient. Patients were grouped retrospectively for analysis based on whether they cooled effectively (i.e., to a temperature nadir of less than 34.5 degrees C within 8 h) or not. RESULTS: Eleven patients were cooled partially or not at all, and seven were effectively cooled. Baseline demographics and compartment volumes and densities were similar in both groups. At 36-48 h, the total CSF volume had significantly decreased in the not-cooled group compared to the cooled group (P < 0.05), with no significant difference in mean volume of ischemia between them (73 +/- 73 ml vs. 54 +/- 59 ml, respectively), suggesting an ameliorative effect of hypothermia on acute edema formation. At 30 days, the difference in CSF volumes had resolved, and infarct volumes (73 +/- 71 ml vs. 84 +/- 102 ml, respectively) and functional outcomes were comparable. CONCLUSIONS: Endovascular hypothermia decreases acute post-ischemic cerebral edema. A larger trial is warranted to determine if it affects final infarct volume and outcome in stroke.

Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience.

BACKGROUND: Prehospital personnel in Emergency Medical Service (EMS) systems have varying levels of accuracy in stroke recognition. Identifying the accuracy of emergency medical dispatcher using Medical Priority Dispatch Systems (MPDS) stroke protocol and paramedics may help understand the accuracy of stroke recognition in about 3000 emergency medical dispatch systems and prehospital systems world wide. OBJECTIVE: Our aim was to assess the accuracy of stroke identification in emergency medical dispatchers (EMD) with high compliance to MPDS protocol and paramedics using Cincinnati Prehospital Stroke Scale (CSS). METHODS: This was a retrospective observational study. Data was acquired from a computer assisted dispatch (CAD) system, a computerized paramedic record database and discharge diagnosis from billing records or stroke registry containing all stroke assessments of patients who presented to the participating study hospitals within 12 hours of symptom onset. We included patients 18 years or older, identified as having stroke by EMD and city agency paramedics. We excluded patients taken to hospitals not participating in the study, patients with a dispatch determinant of Stroke (card 28) not transported by City EMS agency (SDMSE) to participating hospitals, patients in the stroke registry not transported by SDMSE or patients with no final outcome data. A stroke neurologist or hospital discharge diagnosis of stroke (physician diagnosis) was used to determine the sensitivity and predictive values of EMD and paramedic recognition of stroke. RESULTS: Of 882 patients with a dispatch determinant of stroke using MPDS Stroke protocol, 367 had a final discharge diagnosis of stroke. This gives a sensitivity of 83% and a positive predictive value of 42% for EMD using MPDS Stroke protocol. Of 477 patients with a paramedic assessment of stroke using CSS, 193 had a final discharge diagnosis of stroke. This gives a sensitivity of 44% and a PPV of 40% for paramedics using CSS. CONCLUSIONS: In our EMS system, EMD using MPDS Stroke protocol with a high compliance has a higher sensitivity than paramedics using CSS.

A trial of therapeutic hypothermia via endovascular approach in awake patients with acute ischemic stroke: methodology.

BACKGROUND: Therapeutic hypothermia has been shown to be of benefit in improving neurological outcome in cardiac arrest. It now is being investigated in acute stroke and myocardial infarction. The majority of the literature describes its use in intubated, pharmacologically paralyzed patients, using surface cooling techniques that are susceptible to patient shivering, imprecise temperature control, time lag to target-temperature acquisition, and rebound hyperthermia. OBJECTIVES: To develop a method of inducing therapeutic hypothermia in a rapid, precise, and tolerable fashion in awake, nonintubated patients. METHODS: This method was developed for an ongoing clinical trial investigating a combination of therapeutic hypothermia and intravenous thrombolysis for acute ischemic stroke. In the protocol, an endovascular cooling device is placed in the inferior vena cava of a patient, and a combination of buspirone, meperidine, and cutaneous warming with a heating blanket is used to suppress shivering as the patient is cooled to a target temperature of 33 degrees C, kept there for a total of 24 hours from hypothermia initiation, and then rewarmed in a controlled fashion during the next 12 hours. RESULTS: Ten patients underwent the therapeutic hypothermia protocol. The median pretreatment core temperature was 36.1 degrees C (interquartile range [IQR]: 35.8 degrees C-36.4 degrees C). On initiation of cooling, the core temperatures dropped rapidly and then leveled off, approaching a median plateau value of 33.4 degrees C (IQR: 33.2 degrees C-33.9 degrees C) in a mean time of 1.7 (+/- 0.7) hours from cooling initiation, with a median average postplateau temperature during the cooling phase of 33.8 degrees C (IQR: 33.3 degrees C-34.6 degrees C), and a median lowest temperature of 33.1 degrees C (IQR: 33.0 degrees C-33.3 degrees C). The procedure was well tolerated, with minimal shivering and no rebound hyperthermia. CONCLUSIONS: This is a method by which a rapid and precise therapeutic decrease in core temperature can be achieved without the necessity for intubation or neuromuscular blockade and with minimal patient discomfort or shivering.

Traumatic brain injury.

Traumatic brain injury (TBI) is a serious health issue in the United States, killing 100,000 people a year and serving as a source of long-term disability for many more. It is the leading cause of death in patients under the age of 45 years. Successful management of TBI requires first an appreciation that a significant part of the neuronal injury incurred following trauma is secondary and is a result of disordered homeostatic mechanisms rather than the mechanical energy of the initial insult. Key skills in the care of brain-injured patients include adequately gauging the severity of injury, recognizing the primacy of sufficient blood flow and oxygen delivery to the injured brain, and being able to detect and correct when possible local and global physiological abnormalities that frequently put the injured brain at ongoing risk within the intensive care unit. This article discusses these issues, including invasive hemodynamic and intracranial monitoring, useful methods for reducing intracranial pressure, and management of complications arising from acute head injury.