Integrating Standardized Multimedia to Supplement Physical Examination Curriculum: An Assessment of Medical Student and Evaluator Perspective.

INTRODUCTION: As a new generation enters the realm of medical education, so do their preferences for technology integration into didactic curricula. An analysis of 106 LCME-accredited medical schools found that 97 percent of programs utilize supplemental e-learning to enhance traditional, face-to-face education in their physical examination curricula. Of these programs, 71 percent produced their multimedia internally. Existing literature indicates medical students benefit from the utilization of multimedia tools and the standardization of the instruction process in the learning of physical examination techniques. However, no studies were found that outline a detailed, reproducible integration model for other institutions to follow. Current literature also fails to assess the effect of multimedia tools on student well-being and largely ignores the educator perspective. This study aims to demonstrate a practical approach to integrating supplemental videos into an existing curriculum and to assess first year medical student and evaluator perspectives at strategic points throughout the process. METHODS: A video curriculum tailored to the Sanford School of Medicine's Objective Structured Clinical Examination (OSCE) requirements was created. The curriculum contained four videos, each designed for a specific examination component - musculoskeletal, head and neck, thorax/abdominal, and neurology examinations. First-year medical students participated in a pre-video integration survey as well as a post-video-integration and OSCE survey assessing student confidence, anxiety reduction, education standardization, and video quality. The OSCE evaluators completed a survey assessing the ability of the video curriculum to standardize the education and evaluation process. All surveys administered were based on a 5-point Likert scale format. RESULTS: Of survey respondents, 63.5 percent (n = 52) utilized at least one of the videos in the series. Prior to implementation of the video series, 30.2 percent of students agreed with the statement, "I am confident in my ability to demonstrate the skills needed to complete the following exam." After implementation, 100 percent of video-users agreed with this statement compared to 94.2 percent of non-video-users. A reported 81.8 percent of video-users agreed that the video series decreased anxiety when performing the neurologic, abdomen/thorax, and head and neck exams, whereas 83.8 percent agreed in the use of the musculoskeletal video series. A reported 84.2 percent of video users agreed the video curriculum standardized the instruction process. OSCE evaluator participation in the survey was 68.8 percent (n=11), and 90.9 percent of these evaluators agreed the videos standardized the education and evaluation process. CONCLUSIONS: Overall, this study outlines the process of augmenting traditional didactic physical examination curricula with multimedia and the support of this process from medical student and OSCE evaluators. Video users report decreased anxiety and increased confidence in performing physical examination skills for the OSCE after integration of the video series. Students and OSCE evaluators found the video series to be a useful tool in the educational process and evaluation standardization.

Adherence Rate of Pediatric Lipid Screening at a Rural, Independently Owned Primary Care and Multispecialty Clinic.

BACKGROUND: In 2011, the AAP endorsed the recommendation of National Heart Lung and Blood Institute (NHLBI) for universal lipid screening in children 9-11 and 17-21 years old given the increasing prevalence of pediatric obesity. In 2017, a study conducted by the AAP showed low adherence with universal pediatric lipid screening. The purpose of this retrospective chart review is to assess the adherence rate for pediatric lipid screening at a rural, independently owned primary care and multispecialty clinic. METHODS: Patient data were compiled from the electronic medical record. Inclusion criteria include patients 9-11 or 17-21 years of age between Jan. 1, 2014-Dec. 31, 2019, with an appointment indication of well-child examination or annual physical. RESULTS: A low percentage of patients underwent a fasting lipid panel in both the 9-11 (n = 663) and 17-21 (n = 118) years age group, 3.3 percent and 4.2 percent respectively. Of those who underwent a fasting lipid panel, 59.0 percent in the 9-11 age group and 80.0 percent in the 17-21 years age group had at least one abnormal lipid level. Of the population classified as overweight and obese, 6.3 percent (16 out of 255) of the 9-11 years age group and 6.1 percent (three out of 49) of the 17-21 years age group underwent a lipid panel screen. DISCUSSION: The data show low adherence with universal lipid screening for patients ages 9-11 and 17-21 years old. Poor adherence may be due to inconsistent endorsement by professional medical societies and incongruent recommendations in the EMR. Further studies are required to determine the national adherence rate with the NHLBI recommendation.

Automated detection of bacterial growth on 96-well plates for high-throughput drug susceptibility testing of Mycobacterium tuberculosis.

M. tuberculosis grows slowly and is challenging to work with experimentally compared with many other bacteria. Although microtitre plates have the potential to enable high-throughput phenotypic testing of M. tuberculosis, they can be difficult to read and interpret. Here we present a software package, the Automated Mycobacterial Growth Detection Algorithm (AMyGDA), that measures how much M. tuberculosis is growing in each well of a 96-well microtitre plate. The plate used here has serial dilutions of 14 anti-tuberculosis drugs, thereby permitting the MICs to be elucidated. The three participating laboratories each inoculated 38 96-well plates with 15 known M. tuberculosis strains (including the standard H37Rv reference strain) and, after 2 weeks' incubation, measured the MICs for all 14 drugs on each plate and took a photograph. By analysing the images, we demonstrate that AMyGDA is reproducible, and that the MICs measured are comparable to those measured by a laboratory scientist. The AMyGDA software will be used by the Comprehensive Resistance Prediction for Tuberculosis: an International Consortium (CRyPTIC) to measure the drug susceptibility profile of a large number (>30000) of samples of M. tuberculosis from patients over the next few years.

Human IL-31 is induced by IL-4 and promotes TH2-driven inflammation.

BACKGROUND: The pruritic cytokine IL-31 has been shown to be expressed by murine activated effector T Lymphocytes of a TH2 phenotype. Like IL-17 and IL-22, IL-31 is a tissue-signaling cytokine the receptor of which is mainly found on nonimmune cells. An overabundance of IL-31 has been shown in patients with atopic disorders, including dermatitis, as well as asthma, and therefore represents a promising drug target, although its regulation in the context of the human TH2 clusters is not yet known. OBJECTIVE: We sought to address the gene regulation of human IL-31 and to test whether IL-31 possesses a similar proallergic function as members of the human TH2 cytokine family, such as IL-4, IL-5, and IL-13. METHODS: Polyclonal and purified protein derivative of tuburculin-specific T-cell clones were generated. TH phenotype was determined, and IL-31 was measured by means of ELISA. Gene expression of primary bronchial epithelial cells treated with IL-31 was also measured. RESULTS: IL-31 was expressed by all of the TH2 clones and not by TH1, TH17, or TH22. This expression was dependent on autocrine IL-4 expression from these clones because it could be reduced if blocking antibodies to IL-4 were present. Interestingly, TH1 clones were able to express IL-31 if IL-4 was added to culture. This IL-31 expression was transient and did not affect the phenotype of the TH1 clones. IL-31 was able to induce proinflammatory genes, such as CCL2 and granulocyte colony-stimulating factor. CONCLUSION: IL-31 is not a TH2 cytokine in the classical sense but is likely to be expressed by a number of cells in an allergic situation in which IL-4 is present and possibly contribute to the allergic reaction.

Tailoring Can Improve Consumers' Hygienic Food-Handling Behavior to Reduce the Transmission Risk of Antimicrobial-Resistant Bacteria through Food.

Antimicrobial-resistant (AMR) bacteria spread via food to humans and can seriously impair infection treatment. Hygienic food handling is an effective measure to avoid the transmission of bacteria. Therefore, we tested three types of interventions (tailored, generic, and no intervention) for their effectiveness in improving consumers' hygienic food handling against the spread of antimicrobial-resistant bacteria through foods in a longitudinal randomized control trial. We based the determinants of hygienic food-handling behavior on the Health Action Process Approach (HAPA). The tailored intervention raised self-reported hygienic food handling, self-efficacy, and perceived likelihood of risk compared to no intervention. Moreover, interventions yielded different effects for participants with high vs. low intentions to improve their food-handling behavior. However, there were no differences between the tailored and generic interventions. More research is needed to find out whether including other behavior change techniques in the tailored intervention may increase the effect of tailoring.

Association of pro-inflammatory cytokines with clinical features in euthymic patients with Bipolar-I-Disorder.

BACKGROUND: A chronic low-grade inflammatory state appears to be a relevant mechanism in the pathophysiology of bipolar disorder. Pro-inflammatory cytokines may influence disease course and individual symptomatology; and biological markers correlating with illness features may be of utility in clinical decision making during euthymia. METHODS: 51 euthymic outpatients with Bipolar-I-Disorder (BD-I) and 93 healthy controls (HC) were investigated. Comparisons between groups, and correlations with clinical features were performed. Serum concentrations of interleukin-1ß (IL-1ß), tumor necrosis factor-α (TNF-α), and soluble interleukin-6 receptor (sIL-6R) were evaluated by ELISA under highly standardized conditions. Clinical features included duration of illness, number of previous suicide attempts and mood episodes (manic, hypomanic, depressive), scores of the Young Mania Rating Scale (YMRS), the Inventory of Depressive Symptoms (IDS-30), the Pittsburg Sleep Quality Index (PSQI), and the Global Assessment of Functioning (GAF). RESULTS: No significant difference in serum concentrations of IL-1ß, TNF-α, and sIL-6R between BD-I euthymic patients and HC could be identified. Among euthymic BD-I patients, a positive correlation of rs = 0.47 (p = 0.004) between levels of IL-1ß and IDS-30 score was identified. LIMITATIONS: The design was cross-sectional, most patients were receiving medication, only 3 cytokines were assessed, only euthymic BD-I patients were evaluated. CONCLUSIONS: The findings suggest that elevated pro-inflammatory cytokine concentrations are likely state rather than trait markers of BD-I. It also seems unlikely that cytokine concentrations are clinically informative interepisode. An inflammatory component might possibly be involved in the pathophysiology of subsyndromic depression in BD-I, and conceivably of bipolar depression per se.

Leading with compassion in health care organisations.

Purpose The purpose of this paper is to report an evaluation of a leading-with-compassion recognition scheme and to present a new framework for compassion derived from the data. Design/methodology/approach Qualitative semi-structured interviews, a focus group and thematic data analysis. Content analysis of 1,500 nominations of compassionate acts. Findings The scheme highlighted that compassion towards staff and patients was important. Links to the wider well-being strategies of some of the ten organisations involved were unclear. Awareness of the scheme varied and it was introduced in different ways. Tensions included the extent to which compassion should be expected as part of normal practice and whether recognition was required, association of the scheme with the term leadership, and the risk of portraying compassion as something separate, rather than an integral part of the culture. A novel model of compassion was developed from the analysis of 1,500 nominations. Research limitations/implications The number of respondents in the evaluation phase was relatively low. The model of compassion contributes to the developing knowledge base in this area. Practical implications The model of compassion can be used to demonstrate what compassion "looks like", and what is expected of staff to work compassionately. Originality/value A unique model of compassion derived directly from descriptions of compassionate acts which identifies the impact of compassion on staff.

Exploiting passive nanomedicine accumulation at sites of enhanced vascular permeability for non-cancerous applications.

Over the past few decades, enhanced permeability of tumor vasculature was actively exploited for targeted delivery of anticancer nanomedicines resulting in numerous pharmaceutical products. Formation of new immature and leaky vessels along with inflammatory remodeling of existing vessels accompany development of numerous diseases beyond cancer and present an opportunity for passive accumulation of intravenously administered nanomedicines in many pathological tissues. To date, applications of non-cancerous enhanced permeation have been relatively unexploited as target tissues and may create new therapy and prevention technologies for many disorders. Herein, we summarize the current knowledge on the nature of enhanced vascular permeability in multiple non-cancerous pathological tissues. We also discuss the clinical status of nanotherapeutics with selectivity based on passive accumulation in non-cancerous target tissues, their challenges, and prospects.

Cyanotoxins in inland lakes of the United States: Occurrence and potential recreational health risks in the EPA National Lakes Assessment 2007.

A large nation-wide survey of cyanotoxins (1161 lakes) in the United States (U.S.) was conducted during the EPA National Lakes Assessment 2007. Cyanotoxin data were compared with cyanobacteria abundance- and chlorophyll-based World Health Organization (WHO) thresholds and mouse toxicity data to evaluate potential recreational risks. Cylindrospermopsins, microcystins, and saxitoxins were detected (ELISA) in 4.0, 32, and 7.7% of samples with mean concentrations of 0.56, 3.0, and 0.061µg/L, respectively (detections only). Co-occurrence of the three cyanotoxin classes was rare (0.32%) when at least one toxin was detected. Cyanobacteria were present and dominant in 98 and 76% of samples, respectively. Potential anatoxin-, cylindrospermopsin-, microcystin-, and saxitoxin-producing cyanobacteria occurred in 81, 67, 95, and 79% of samples, respectively. Anatoxin-a and nodularin-R were detected (LC/MS/MS) in 15 and 3.7% samples (n=27). The WHO moderate and high risk thresholds for microcystins, cyanobacteria abundance, and total chlorophyll were exceeded in 1.1, 27, and 44% of samples, respectively. Complete agreement by all three WHO microcystin metrics occurred in 27% of samples. This suggests that WHO microcystin metrics based on total chlorophyll and cyanobacterial abundance can overestimate microcystin risk when compared to WHO microcystin thresholds. The lack of parity among the WHO thresholds was expected since chlorophyll is common amongst all phytoplankton and not all cyanobacteria produce microcystins.

Staurosporine resistance in inflammatory neutrophils is associated with the inhibition of caspase- and proteasome-mediated Mcl-1 degradation.

Apoptosis resistance in activated neutrophils is known to be associated with collateral damage of surrounding tissue, as well as immune and organ dysfunction. Thus, the safe removal of neutrophils by apoptosis induction represents a prerequisite for the resolution of inflammation. Here, we report that intrinsic apoptosis resistance in human neutrophils, isolated from severely injured patients, is based on enhanced stabilization of antiapoptotic myeloid cell leukemia 1 and subsequent impairment of downstream apoptotic pathways. Whereas extrinsic apoptosis induction by the activation of Fas death receptor on inflammatory neutrophils was accompanied by caspase- and proteasome-mediated myeloid cell leukemia 1 degradation, intrinsic apoptosis induction by staurosporine led to a significant stabilization of myeloid cell leukemia 1 protein, which impeded on truncated forms of B cell lymphoma 2-associated X protein and B cell lymphoma 2 homology domain 3-interacting domain death translocation and subsequent cytochrome c release from the mitochondria. We show further that profound inhibition of myeloid cell leukemia 1 degradation is based on the inhibition of caspases and sustained activation of kinases involved in cell survival, such as Akt. Accordingly, impeded myeloid cell leukemia 1 phosphorylation on Ser159 by glycogen synthase kinase 3 and protein ubiquitination has been demonstrated. Inhibition of myeloid cell leukemia 1 activity markedly increased sensitivity to staurosporine-induced cell death. Altogether, these results provide new insights into the mechanisms underlying myeloid cell leukemia 1-mediated apoptosis resistance to staurosporine under inflammatory situations and should be considered for the development of novel therapeutic strategies.

In Vitro Evidence for Immune-Modulatory Properties of Non-Digestible Oligosaccharides: Direct Effect on Human Monocyte Derived Dendritic Cells.

Infant formulas containing non-digestible oligosaccharides (NDO) similar to the composition in breast milk or a combination of lactic acid bacteria (LAB) and NDO have been shown to harbor preventive effects towards immune-regulatory disorders. The aim of this study was to investigate the immune-modulatory potential of non-digestible short chain galacto- and long chain fructo-oligosaccharides (scGOS/lcFOS) mimicking the natural distribution of oligosaccharides in human breast milk in presence or absence of certain LAB strains in human monocyte derived dendritic cells (MoDC). Immature human MoDC prepared from peripheral blood of healthy non-atopic volunteers were screened in vitro after stimulation with specific scGOS/lcFOS in presence or absence of LAB. IL-10 and IL-12p70 release was analyzed after 24 hours in cell-free supernatants by enzyme-linked immunosorbent assay (ELISA). A luminex-based assay was conducted to assess further cytokine and chemokine release by MoDC. To investigate the resulting T cell response, stimulated MoDC were co-incubated with naïve T cells in allogeneic stimulation assays and intracellular Foxp3 expression, as well as immune-suppressive capacity was determined. Oligosaccharides did not induce relevant amounts of IL-12p70 production, but did promote IL-10 release by MoDC. Furthermore, scGOS/lcFOS mixtures exerted a significant enhancing effect on LAB induced IL-10 secretion by MoDC while no increase in IL-12p70 production was observed. Blocking toll like receptor (TLR)4 abrogated the increase in IL-10 in both the direct stimulation and the LAB stimulation of MoDC, suggesting that scGOS/lcFOS act via TLR4. Finally, scGOS/lcFOS-treated MoDC were shown to upregulate the number of functional suppressive Foxp3 positive T cells following allogeneic stimulation. Our results indicate anti-inflammatory and direct, microbiota independent, immune-modulatory properties of scGOS/lcFOS mixtures on human MoDC suggesting a possible induction of regulatory T cells (Tregs). The tested combinations of LAB and scGOS/lcFOS might represent a useful dietary ingredient for the maintenance of intestinal homeostasis via the induction of Tregs.

Distress, trauma, and recovery: adjustment to first episode psychosis.

OBJECTIVE: To understand the experiences that people with early psychosis are adjusting to and their perceived barriers to recovery. METHOD: Semi-structured interviews were conducted with eight participants. Grounded Theory was applied to the design and analysis. Sampling and coding ceased when saturation of the data was reached. Respondent validation was sought from participants. RESULTS: A theoretical model was developed using Strauss and Corbin's (1998) framework. A core category of distress was elicited, which was evident in all participants' accounts of their recovery. Overall six main categories were identified and it was proposed that individuals were adjusting to the distress of past experiences, uncertainty, a challenged identity, being in a psychiatric system, the reaction of others and social disadvantage. CONCLUSIONS: Recovery from the distress and trauma of early psychosis does not simply involve adjustment to and recovery from a single experience or set of symptoms. The results are discussed in relation to trauma, developmental, and social inequality frameworks. Specific implications for clinical practice include incorporating the findings within formulations, developing interventions that focus on trauma, identity, and uncertainty as well as addressing the social and systemic issues identified.