Informed Inclusion Model: Medical Student Wheelchair User in an Obstetrics and Gynecology Clerkship.

ABSTRACT: Students with physical disabilities are underrepresented in medicine, driven in part by ableist beliefs about the ability of individuals with disabilities to complete procedure-based or surgically oriented clerkships, including obstetrics and gynecology (Ob/Gyn). There is a dearth of literature on this topic; however, there is also a growing commitment to disability inclusion by medical and specialty training associations. Nevertheless, published case studies and accommodation protocols for medical student wheelchair users navigating an Ob/Gyn clerkship are absent in the literature. This article describes successful disability inclusion for an Ob/Gyn clerkship, including accommodations for medical student wheelchair users. The authors share mechanisms to address and combat ableist assumptions and facilitate access for future medical students by working collaboratively with student and key stakeholders to develop an inclusive and accessible training experience.These recommendations are shared through the story of a third-year medical student who rotated through the longitudinal clerkships at the Cleveland Clinic Lerner College of Medicine. The student, an individual with osteogenesis imperfecta who uses a power wheelchair with a seat elevator, completed third-year rotations and thrived in her clinical experiences. The authors describe her journey through a robust 4-week Ob/Gyn clerkship, in which she fulfilled the required clinical core conditions and observation skills with reasonable accommodation. Given the high acuity, surgery, and outpatient demands in Ob/Gyn-and the transferrable skills to other clerkships-the student's experience is an excellent exemplar for demonstrating disability inclusion and reasonable accommodation.Ob/Gyn clerkship directors and clinical faculty can broadly use the recommended timelines and communication protocols to create accessible training environments. With student input, minor scheduling adjustments, ongoing communication, reasonable accommodations, and an open mind, medical students on the clinical wards who are wheelchair users can successfully navigate the required expectations of medical training.

Vascular Imaging for the Primary Care Provider: Venous and Arterial Disease.

The vascular laboratory provides important contributions to the diagnosis, workup, and treatment of known or suspected vascular disease. Knowing what tests to order (and when to order them) allows for the best utilization of these resources. This article will focus on the appropriate use of the vascular lab for the primary care clinician regarding a variety of vascular presentations, including swollen leg, suspected peripheral artery disease, vasospastic disease, carotid artery stenosis, and abdominal aortic aneurysms. Patients with known vascular disease often require serial surveillance imaging to document the stability or progression of disease, and consensus guidelines regarding these strategies will be reviewed.

Update on pneumococcal vaccination in adults: Simpler is better.

Recommendations for pneumococcal vaccination in adults have been updated in the hopes not only of preventing more cases of invasive pneumococcal disease but also of making the recommendations simpler and easier to follow.

"Flipped" clinical rotations: A novel approach.

BACKGROUND: Near the beginning of the COVID-19 pandemic in the United States, medical students were pulled out of all in-person patient care activities. This resulted in massive disruption to the required clinical rotations (clerkships), necessitating creative curricular solutions to ensure continued education for medical students. APPROACH: In response to the lockout, our school adopted a "flipped" clinical rotations model that assigned students to remote learning activities prior to in-person patient care activities. This approach allowed students to continue their clinical education virtually with a focus on knowledge for practice while awaiting return to the shortened in-person portions of their rotation. In planning the modified clinical curriculum, educational leaders adhered to several guiding principles including ensuring flexible remote curricular components that would engage students in active learning, designating that no rotation would be completely virtual, and completing virtual educational activities and standardised exams before students returned to in-person experiences. EVALUATION: End of rotation evaluations and standardised exam scores were analysed to determine the effectiveness of this model. Despite the disruption associated with the pandemic and the rapid implementation of the "flipped" rotations, students continued to rate the overall experiences as highly as traditional clinical rotations. Students also performed similarly on standardised exams when compared to cohorts from other classes at the same experience level. IMPLICATIONS: While borne out of necessity during a pandemic, the lessons learned from our implementation of a "flipped" rotations model can be applied to address problems of capacity and clinical preparedness in the clinical setting.

Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline.

BACKGROUND: Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management. OBJECTIVE: To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia. METHODS: A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS: The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes. CONCLUSION: The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.

Social Media as an Early Proxy for Social Distancing Indicated by the COVID-19 Reproduction Number: Observational Study.

BACKGROUND: The magnitude and time course of the COVID-19 epidemic in the United States depends on early interventions to reduce the basic reproductive number to below 1. It is imperative, then, to develop methods to actively assess where quarantine measures such as social distancing may be deficient and suppress those potential resurgence nodes as early as possible. OBJECTIVE: We ask if social media is an early indicator of public social distancing measures in the United States by investigating its correlation with the time-varying reproduction number (Rt) as compared to social mobility estimates reported from Google and Apple Maps. METHODS: In this observational study, the estimated Rt was obtained for the period between March 5 and April 5, 2020, using the EpiEstim package. Social media activity was assessed using queries of "social distancing" or "#socialdistancing" on Google Trends, Instagram, and Twitter, with social mobility assessed using Apple and Google Maps data. Cross-correlations were performed between Rt and social media activity or mobility for the United States. We used Pearson correlations and the coefficient of determination (ρ) with significance set to P<.05. RESULTS: Negative correlations were found between Google search interest for "social distancing" and Rt in the United States (P<.001), and between search interest and state-specific Rt for 9 states with the highest COVID-19 cases (P<.001); most states experienced a delay varying between 3-8 days before reaching significance. A negative correlation was seen at a 4-day delay from the start of the Instagram hashtag "#socialdistancing" and at 6 days for Twitter (P<.001). Significant correlations between Rt and social media manifest earlier in time compared to social mobility measures from Google and Apple Maps, with peaks at -6 and -4 days. Meanwhile, changes in social mobility correlated best with Rt at -2 days and +1 day for workplace and grocery/pharmacy, respectively. CONCLUSIONS: Our study demonstrates the potential use of Google Trends, Instagram, and Twitter as epidemiological tools in the assessment of social distancing measures in the United States during the early course of the COVID-19 pandemic. Their correlation and earlier rise and peak in correlative strength with Rt when compared to social mobility may provide proactive insight into whether social distancing efforts are sufficiently enacted. Whether this proves valuable in the creation of more accurate assessments of the early epidemic course is uncertain due to limitations. These limitations include the use of a biased sample that is internet literate with internet access, which may covary with socioeconomic status, education, geography, and age, and the use of subtotal social media mentions of social distancing. Future studies should focus on investigating how social media reactions change during the course of the epidemic, as well as the conversion of social media behavior to actual physical behavior.

Correction: Men's health 2018.

In the article by Chaitoff et al (Men's health 2018: BPH, prostate cancer, erectile dysfunction, supplements. Cleve Clin J Med 2018; 85(11):871-880, doi:10.3949/ccjm.85a.18011), the prostate-specific antigen level of a 60-year-old man was given as 5.1 mg/dL. The unit of measure should have been 5.1 ng/mL. This has been corrected online.

Men's health 2018: BPH, prostate cancer, erectile dysfunction, supplements.

This review describes the latest research and guidelines for 4 topics in men's health commonly addressed by primary care physicians: the diagnosis and treatment of benign prostatic hyperplasia (BPH), prostate cancer, and erectile dysfunction and the evidence concerning the use of dietary supplements in men.

Medication management in older adults.

Managing medications is a major part of providing care to older adults. Polypharmacy is common in the elderly and is fraught with risks. A careful and systematic approach is needed for managing drug therapy in these patients, recognizing the patient's specific goals.

Probability of developing proximal deep-vein thrombosis and/or pulmonary embolism after distal deep-vein thrombosis.

Isolated distal deep-vein thrombosis (DDVT) of the lower extremities can be associated with subsequent proximal deep-vein thrombosis (PDVT) and/or acute pulmonary embolism (PE). We aimed to develop a model predicting the probability of developing PDVT and/or PE within three months after an isolated episode of DDVT. We conducted a retrospective cohort study of patients with symptomatic DDVT confirmed by lower extremity vein ultrasounds between 2001-2012 in the Cleveland Clinic Health System. We reviewed all the ultrasounds, chest ventilation/perfusion and computed tomography scans ordered within three months after the initial DDVT to determine the incidence of PDVT and/or PE. A multiple logistic regression model was built to predict the rate of developing these complications. The final model included 450 patients with isolated DDVT. Within three months, 30 (7 %) patients developed an episode of PDVT and/or PE. Only two factors predicted subsequent thromboembolic complications: inpatient status (OR, 6.38; 95 % CI, 2.17 to 18.78) and age (OR, 1.02 per year; 95 % CI, 0.99 to 1.05). The final model had a bootstrap bias-corrected c-statistic of 0.72 with a 95 % CI (0.64 to 0.79). Outpatients were at low risk (< 4 %) of developing PDVT/PE. Inpatients aged ≥ 60 years were at high risk (> 10 %). Inpatients aged < 60 were at intermediate risk. We created a simple model that can be used to risk stratify patients with isolated DDVT based on inpatient status and age. The model might be used to choose between anticoagulation and monitoring with serial ultrasounds.

Starting insulin in patients with type 2 diabetes: An individualized approach.

Because type 2 diabetes mellitus is a progressive disease, most patients eventually need insulin. When and how to start insulin therapy are not one-size-fits-all decisions but rather must be individualized. This paper reviews the indications, goals, and options for insulin therapy in type 2 diabetes.

Quantitative and qualitative perceptions of the 2011 residency duty hour restrictions: a multicenter, multispecialty cross-sectional study.

BACKGROUND: July 2011 saw the implementation of the newest duty hour restrictions, further limiting the working hours of first year residents and necessitating a variety of adaptations on the part of residency programs. The present study sought to characterize the perceived impact of these restrictions on residency program personnel using a multi-specialty and multi-site approach. METHODS: We developed and administered a survey to internal medicine and general surgery residency programs at three academic medical centers within an urban region. The survey combined quantitative and qualitative components to gain a broader understanding of the impact of the newest regulations. Quantitative responses were compared between Internal Medicine and General Surgery programs with Student t-tests. Other comparisons were performed using ANOVA or Kruskal-Wallis testing as appropriate. For all comparisons, the threshold for significance was set at 0.01. Two independent reviewers coded all qualitative data and assigned one or more themes based on content. Descriptive statistics were calculated and the diversity of themes identified. No between-group comparisons were conducted with the qualitative data. RESULTS: We found significant differences in the overall perceptions of duty hour restrictions across specialty (internal medicine more positive than general surgery) and across position (first year residents more positive than senior residents and faculty). Notably, individuals who trained at osteopathic medical schools reported significantly more negative views of the duty hour restrictions than those who had trained at allopathic or international medical schools, suggesting an influence of undergraduate medical training. The complementary qualitative data offered insights into the perceived strengths and weaknesses of the duty hour restrictions, as well as actionable suggestions that could help to improve residency program function. CONCLUSION: This study characterizes responses to the new duty hour restrictions from a variety of perspectives. Our findings show that individual (type of undergraduate medical education, role in graduate medical education) and program-wide (e.g., specialty) factors contribute to participant satisfaction with DHR. This research highlights the value of a mixed methods approach in the study of duty hour restrictions, with our qualitative arm yielding rich data that complemented and expanded upon the insights derived from the quantitative data.

Six screening tests for adults: What's recommended? What's controversial?

This paper discusses guidelines from the US Preventive Services Task Force (USPSTF) and other recommending bodies for screening for abdominal aortic aneurysm and cancers of the colon, cervix, lung, breast, and prostate.

Keeping up with immunizations for adults.

This paper discusses recommendations from the US Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices for vaccinating adults against influenza, tetanus, measles, mumps, rubella, varicella, hepatitis A and B, human papillomavirus, shingles (zoster), pneumonia, and meningitis.