In paroxysmal AF, first-line catheter ablation vs. antiarrhythmic drugs reduces atrial arrhythmia recurrence.

SOURCE CITATION: Imberti JF, Ding WY, Kotalczyk A, et al. Catheter ablation as first-line treatment for paroxysmal atrial fibrillation: a systematic review and meta-analysis. Heart. 2021;107:1630-6. 34261737.

Implementation of a Mini-CEX Requirement Across All Third-Year Clerkships.

PROBLEM: Direct observation of medical students performing clinical tasks, such as eliciting a patient history or examining a patient, and the provision of feedback, are foundational to student improvement but have been reported to occur infrequently. The mini clinical evaluation exercise (mini-CEX) is a tool that can facilitate direct observation and feedback. This study assessed the impact of a mini-CEX requirement across all 3rd-year clerkships on student report of direct observation by faculty and objectively measured clinical skills. INTERVENTION: A mini-CEX requirement across all 3rd-year clerkships was implemented in the 2012-2013 academic year. The impact of the mini-CEX requirement on student report of direct observation was assessed by end-of-clerkship surveys and Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) items on direct observation. The impact on students' clinical skills was assessed by a summative Objective Structured Clinical Examination (OSCE). Pre/post comparisons were assessed with chi-square and Fisher's exact tests. CONTEXT: A mini-CEX requirement had been in place for the internal medicine clerkship, and student reports of direct observation were historically higher for the internal medicine clerkship than for other clerkships. Faculty, residents, and students at each of the clinical sites across all 6 clerkships were oriented to the use of the mini-CEX; the feasibility of its use during usual patient interaction settings and the importance of direct observation and feedback for student improvement were emphasized during these sessions. OUTCOME: Adherence to the mini-CEX requirement was high: 92% of required forms were completed, and 78% of completed forms indicated that specific feedback was given. The proportion of students reporting direct observation of physical examination significantly increased in all clerkships, with the largest relative increase occurring in surgery (from 49% to 87%), χ2(1, N = 225) = 37.70, p < .0001. Significant increases were seen in faculty observation of history taking in pediatrics, surgery, and psychiatry. Direct observation rates also increased on the AAMC GQ items for history taking and physical exam for all clerkships. Failures on the summative OSCE decreased from 12% preintervention to 2% postintervention (p = .0046). LESSONS LEARNED: Institution of a mini-CEX requirement was feasible across all 3rd-year clerkships and was associated with a significant increase in student report of direct observation by faculty and a decrease in summative OSCE failure rates.

Pharmacist-led workshops to enhance pharmacotherapy knowledge for medical students.

BACKGROUND: Graduating medical students have reported concern regarding inadequate training in pharmacotherapy. Teaching by clinical pharmacists may improve medical students' pharmacotherapy knowledge. PURPOSE: To assess the impact of pharmacist led workshops on 4th year medical students' knowledge of pharmacotherapy and satisfaction. METHODS: Senior medical students enrolled in intensive care unit rotations at a US medical school were randomized to an intervention of pharmacist led case-based workshops or a control group without an explicit pharmacotherapy curriculum. Intervention group students attended four weekly 1-hour workshops that covered topics in pharmacokinetics, pharmacodynamics, drug interactions and toxicity. A multiple-choice test of clinical vignettes assessed students' knowledge of pharmacotherapy. An end of clerkship survey assessed student satisfaction with teaching. RESULTS: Of 176 medical students eligible, 148 agreed to participate and were randomized to the intervention (n = 63) or control groups (n = 85). Student satisfaction with pharmacist led workshops was high. End of clerkship performance on clinical vignettes (minimum score 0, maximum 100) was similar between the groups (mean score 47 (SD = 12.2) for intervention vs 44 (SD = 13.0) for control group, p = 0.16). On end of clerkship survey, only 8% of control group students agreed or strongly agreed that the standard curriculum provided sufficient teaching in pharmacotherapy. The majority of students (82%) felt that pharmacotherapy should be taught formally in the clinical years. CONCLUSION: Pharmacist led workshops on pharmacotherapy were well received by senior medical students but did not improve performance on a test of pharmacotherapy knowledge. Further study is needed to define optimal strategies for improving medical students' pharmacotherapy knowledge.

A trial of team-based versus small-group learning for second-year medical students: does the size of the small group make a difference?

BACKGROUND: Team-based learning is a large-group instructional modality intended to provide active learning with modest faculty resources. PURPOSE: The goal is to determine if team-based learning could be substituted for small-group learning in case sessions without compromising test performance or satisfaction. METHODS: One hundred and sixty-seven students were assigned to team-based or small-group learning for 6 case discussion sessions. Examination scores and student satisfaction were compared. RESULTS: Instruction modality had no meaningful effect on examination score, 81.7% team based versus 79.7% small-group, p=.56 after multivariate adjustment. Student satisfaction was lower with team-based learning, 2.45 versus 3.74 on a 5-point scale, p<.001. Survey responses suggested that the very small size (8-10 students) of our small groups influenced the preference for small-group learning. CONCLUSIONS: Team-based learning does not adversely affect examination performance. However, student satisfaction may be inferior, especially if compared to instruction in very small groups of 10 or fewer students.

Impact of an evidence-based medicine curriculum on resident use of electronic resources: a randomized controlled study.

BACKGROUND: Evidence-based medicine (EBM) is widely taught in residency, but evidence for effectiveness of EBM teaching on changing residents' behavior is limited. OBJECTIVE: To investigate the impact of an EBM curriculum on residents' use of evidence-based resources in a simulated clinical experience. DESIGN/PARTICIPANTS: Fifty medicine residents randomized to an EBM teaching or control group. MEASUREMENTS: A validated test of EBM knowledge (Fresno test) was administered before and after intervention. Post intervention, residents twice completed a Web-based, multiple-choice instrument (15 items) comprised of clinical vignettes, first without then with access to electronic resources. Use of electronic resources was tracked using ProxyPlus software. Within group pre-post differences and between group post-test differences were examined. RESULTS: There was more improvement in EBM knowledge (100-point scale) for the intervention group compared to the control group (mean score increase 22 vs. 12, p = 0.012). In the simulated clinical experience, the most commonly accessed resources were Ovid (71% of residents accessed) and InfoPOEMs (62%) for the EBM group and UptoDate (67%) and MDConsult (58%) for the control group. Residents in the EBM group were more likely to use evidence-based resources than the control group. Performance on clinical vignettes was similar between the groups both at baseline (p = 0.19) and with access to information resources (p = 0.89). CONCLUSIONS: EBM teaching improved EBM knowledge and increased use of evidence-based resources by residents, but did not improve performance on Web-based clinical vignettes. Future studies will need to examine impact of EBM teaching on clinical outcomes.

Survey for resistance to four insecticides in Myzus persicae clones from peach trees and weeds in south-central Washington.

The insecticides esfenvalerate, endosulfan, imidacloprid, and methamidophos were screened against 74 clonal populations of the green peach aphid, Myzus persicae (Sulzer), collected as fundatrices from peach (Prunus spp.) and as apterous virginoparae from various weeds near potato (Solanum spp.) fields in the Yakima Valley and Columbia Basin regions of Washington state. Response to diagnostic concentration of four insecticide products demonstrated a bimodal pattern of survival to endosulfan (Phaser), suggesting two phenotype classes responding to this insecticide. This pattern was not observed with the other products. Moderately significant correlations in mortality of aphid clones treated with diagnostic concentrations of endosulfan versus clones treated with methamidophos and similarly with the correlation of mortalities for imidacloprid-treated versus methamidophos-treated clones suggested modest levels of cross tolerance. No significant correlations were observed with the remaining four possible comparisons. Concentration-response bioassays were conducted on 16 clones with the four insecticides. The greatest difference between resistant and susceptible clones (expressed as the ratio of lethal concentrations producing 50% mortality; RR) was only seven-fold observed in the endosulfan-treated clones. The greatest RR was five-fold for imidacloprid, four-fold for esfenvalerate, and three-fold for methamidophos-treated clones. Only the endosulfan response is likely to be ofbiological significance and reflects the same cyclodiene resistance discovered in this region over a decade ago.

Impact of Required Versus Self-Directed Use of Virtual Patient Cases on Clerkship Performance: A Mixed-Methods Study.

PURPOSE: To explore how students use and benefit from virtual patient cases (VPCs). METHOD: In academic years 2013-2014 and 2014-2015, cohorts of students in pediatrics (Peds), family medicine (FM), and internal medicine (IM) clerkships were allocated to either core required use (CRU) or self-directed use (SU) of MedU VPCs. Outcomes included number and time of case review, student perception of learning from VPCs, National Board of Medical Examiners (NBME) subject examination scores, and summative clinical ratings for medical knowledge and differential diagnoses/problem solving. Focus groups were conducted each year. Mean differences were compared by t test. RESULTS: A total of 255 students participated in the study. Mean number of cases completed by the CRU group was significantly higher than that by the SU group (13.9 vs. 3.1 for FM, 16.1 vs. 3.9 for Peds, and 10.4 vs. 1.2 for IM) (P < .001). Student-perceived value ratings of VPCs were similar between groups. Students described VPCs as time consuming but useful for supplementing clinical conditions not seen in person. Mean scores on NBME subject examinations for CRU versus SU groups were not different between groups in any clerkship, nor were there significant differences in the summative clinical ratings for medical knowledge or differential diagnosis/clinical reasoning. CONCLUSIONS: Although VPCs continue to serve an important role in exposing students to clinical conditions not seen in person, the optimal employment of this technology in clerkship pedagogy requires further exploration.

CRISPR/Cas9 Editing of the Codling Moth (Lepidoptera: Tortricidae) CpomOR1 Gene Affects Egg Production and Viability.

The codling moth, Cydia pomonella (L.) (Lepidoptera: Tortricidae), is a major pest of pome fruit worldwide. Incorporation of semiochemicals, including the main sex pheromone (codlemone), into codling moth IPM programs has drastically reduced the amount of chemical insecticides needed to control this orchard pest. Odorant receptors located in sensory neuron membranes in the antennae are key sensors in the detection of semiochemicals and trigger downstream signaling events leading to a behavioral response. CpomOR1 is an odorant receptor belonging to the pheromone receptor subfamily in codling moth, and is a prime candidate for being a codlemone receptor based on its high expression levels in male antennae. In this study, the CpomOR1 gene was targeted using CRISPR/Cas9 genome editing to knockdown functional OR1 protein production to determine physiological function(s). By injecting early stage eggs, mutations were successfully introduced, including both deletions and insertions. When attempting to create stable populations of codling moth through mating of males with females containing mutations of the CpomOR1 gene, it was found that fecundity and fertility were affected, with edited females producing nonviable eggs. The role of CpomOR1 in fecundity and fertility in codling moth is unknown and will be the focus of future studies.

Brief report: Utilizing an audiotape for outpatient preceptor faculty development.

BACKGROUND: Faculty development for busy and geographically dispersed ambulatory preceptors is a difficult task for course directors. PURPOSE: A faculty development audiotape intended for playing in the preceptor's car was created. The feasibility of this form of faculty development was tested in this pilot study. METHODS: A short audiotape, focusing on strategies for the provision of independence to students in the office setting, was made and distributed to all preceptors of students taking a fourth-year required clerkship in ambulatory medicine. Preceptor behavior was reported by students on postclerkship evaluations before and after tape distribution. RESULTS: In the year before tape distribution, 21% of evaluations indicated a lack of independence on the part of the student, compared with 14% in the year following the intervention (P=.03). There was no regression of behavior among preceptors already providing independence. Among the preceptors initially identified as not following recommendations for student independence, the percentage of evaluations indicating a lack of independence went from 72% preintervention to 42% postintervention (P<.001). CONCLUSIONS: A short audiotape is a novel form of faculty development, which was acceptable to preceptors and may influence teaching behavior in the desired manner.

What Are We Telling Our Students? A National Survey of Clerkship Directors' Advice for Students Applying to Internal Medicine Residency.

BACKGROUND: Little is known about the advice fourth-year medical students receive from their advisors as they prepare to apply for residency training. OBJECTIVE: We collected information on recommendations given to medical students preparing to apply to internal medicine residencies regarding fourth-year schedules and application strategies. METHODS: Clerkship Directors in Internal Medicine conducted its annual member survey in June 2013. We analyzed responses on student advising using descriptive and comparative statistics, and free-text responses using content analysis. RESULTS: Of 124 members, 94 (76%) responded, and 83 (88%) advised fourth-year medical students. Nearly half (45%) advised an average of more than 20 students a year. Advisors encouraged students to take a medicine subinternship (Likert scale mean 4.84 [1, strongly discourage, to 5, strongly encourage], SD = 0.61); a critical care rotation (4.38, SD = 0.79); and a medicine specialty clinical rotation (4.01, SD = 0.80). Advisors reported they thought fourth-year students should spend a mean of 6.5 months doing clinical rotations (range 1-10, SD = 1.91). They recommended highest academic quartile students apply to a median of 10 programs (range 1-30) and lowest quartile students apply to 15 programs (range 3-100). Top recommendations involved maximizing student competitiveness, valuing program fit over reputation, and recognizing key decision points in the application process. CONCLUSIONS: Undergraduate medical advisors recommended specific strategies to enhance students' competitiveness in the Match and to prepare them for residency. The results can inform program directors and encourage dialogue between undergraduate medical education and graduate medical education on how to best utilize the fourth year.