Extending growth curves: a trajectory monitoring approach to identification and interventions in struggling medical student learners.

Given gaps in both identifying and providing targeted interventions to struggling learners, the purpose of this study is to both improve rapid identification and to improve individualized academic advising for learners using this visual representation of performance. Across three graduating classes, individual growth curves were calculated for each student on National Board of Medical Examiners customized assessments during the pre-clerkship period using their deviation from the class average at each assessment point. These deviation scores were cumulatively summed over time and were regressed onto the sequence of exams. We analyzed the difference between the regression slopes of those students placed on Academic Probation (AP) versus not, as well as differences in slopes based on the timing of when a struggling learner was placed on AP to explore learner trajectory after identification. Students on AP had an average growth slope of - 6.06 compared to + 0.89 for those not on AP. Findings also suggested that students who were placed on AP early during pre-clerkship showed significant improvement (positive changes in trajectory) compared to students identified later in the curriculum. Our findings suggest that earlier academic probation and intervention with struggling learners may have a positive effect on academic trajectory. Future research can better explore how academic trajectory monitoring and performance review can be regularly used in advising sessions with students.

Well-being at a Military Medical School and Implications for Military Retention.

INTRODUCTION: Physical and psychological well-being play a critical role in the academic and professional development of medical students and can alter the trajectory of a student's quality of personal and professional life. Military medical students, given their dual role as officer and student, experience unique stressors and issues that may play a role in their future intentions to continue military service, as well as practice medicine. As such, this study explores well-being across the 4 years of medical school at Uniformed Services University (USU) and how well-being relates to a student's likelihood to continue serving in the military and practicing medicine. METHODS: In September 2019, 678 USU medical students were invited to complete a survey consisting of three sections-the Medical Student Well-being Index (MSWBI), a single-item burnout measure, and six questions regarding their likelihood of staying in the military and medical practice. Survey responses were analyzed using descriptive statistics, analysis of variance (ANOVA), and contingency table analysis. Additionally, thematic analysis was conducted on open-ended responses included as part of the likelihood questions. RESULTS: Our MSWBI and burnout scores suggest that the overall state of well-being among medical students at USU is comparable to other studies of the medical student population. ANOVA revealed class differences among the four cohorts, highlighted by improved well-being scores as students transitioned from clerkships to their fourth-year curriculum. Fewer clinical students (MS3s and MS4s), compared to pre-clerkship students, indicated a desire to stay in the military. In contrast, a higher percentage of clinical students seemed to "reconsider" their medical career choice compared to their pre-clerkship student counterparts. "Medicine-oriented" likelihood questions were associated with four unique MSWBI items, whereas "military-oriented" likelihood questions were associated with one unique MSWBI item. CONCLUSION: The present study found that the overall state of well-being in USU medical students is satisfactory, but opportunities for improvement exist. Medical student well-being seemed to have a stronger association with medicine-oriented likelihood items than with military-oriented likelihood items. To obtain and refine best practices for strengthening engagement and commitment, future research should examine if and how military and medical contexts converge and diverge throughout training. This may enhance the medical school and training experience and, ultimately, reinforce, or strengthen, the desire and commitment to practice and serve in military medicine.

Performance of five FDA-approved rapid antigen tests in the detection of 2009 H1N1 influenza A virus.

Rapid antigen tests are commonly used by clinicians for rapid, simple, point-of-care testing. Five rapid antigen tests were shown to have low sensitivity (40.3-58.8%) when compared to real-time RT-PCR using nasal wash specimens from patients with influenza-like-illness (N = 167) that were collected previously and confirmed as 2009 pandemic influenza A (H1N1)-positive by PCR. Rapid antigen test sensitivity correlated with virus levels in nasal secretions when comparisons were made to cycle threshold (C(T)) values obtained from real-time RT-PCR. When C(T) values are <25 (equating to viral concentrations of >10(4) TCID(50)/ml) sensitivity for all five rapid antigen kits was high (range: 83-94% positive); however, when C(T) values are >30 (10(2) TCID(50)/ml), sensitivities of only 16-18% were observed for four of five rapid antigen kits. The Directigen EZ Flu A + B test detected more positive samples (35%) at lower viral concentrations with C(T) values >30 when compared with other commercial kits (P = 0.05). Rapid antigen test results must be interpreted with caution, and negative specimens may need confirmation by sensitive molecular assays.

ACGME Milestones in the Real World: A Qualitative Study Exploring Response Process Evidence.

Background: Since the Accreditation Council for Graduate Medical Education (ACGME) introduced the Milestones in 2013, the body of validity evidence supporting their use has grown, but there is a gap with regard to response process. Objective: The purpose of this study is to qualitatively explore validity evidence pertaining to the response process of individual Clinical Competency Committee (CCC) members when assigning Milestone ratings to a resident. Methods: Using a constructivist paradigm, we conducted a thematic analysis of semi-structured interviews with 8 Transitional Year (TY) CCC members from 4 programs immediately following a CCC meeting between November and December 2020. Participants were queried about their response process in their application of Milestone assessment. Analysis was iterative, including coding, constant comparison, and theming. Results: Participant interviews identified an absence of formal training and a perception that Milestones are a tool for resident assessment without recognizing their role in program evaluation. In describing their thought process, participants reported comparing averaged assessment data to peers and time in training to generate Milestone ratings. Meaningful narrative comments, when available, differentiated resident performance from peers. When assessment data were absent, participants assumed an average performance. Conclusions: Our study found that the response process used by TY CCC members was not always consistent with the dual purpose of the Milestones to improve educational outcomes at the levels of residents and the program.

Curricular Change and Resiliency in the Era of Coronavirus (COVID-19): The Uniformed Services University of the Health Sciences (USU) Experience.

INTRODUCTION: The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation's only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives. METHODS: This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated. RESULTS: Six key "lessons learned" were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System. CONCLUSIONS: Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.

Peripheral Eosinophilia Found in Pediatric Enterobius vermicularis Infections.

Enterobius vermicularis, the common pinworm, is well known in North America as a parasitic infection, mainly affecting children. It is a very contagious organism, and it is responsible for a high number of infections in the United States each year. A rise in eosinophilia is linked to most parasitic infections. However, the correlation between eosinophilia and enterobiasis infections is not well documented in the literature. In this article, we present 3 cases involving patients seen for pediatric gastroenterology consultation with concern for inflammatory bowel disease. As part of their evaluation, each patient was found to have eosinophilia of unknown significance with an ultimate diagnosis of pinworm infections made by endoscopy. Their illness presentation did not include classic enterobiasis symptoms such as rectal pruritus or nighttime irritability. These cases support a link between eosinophilia and enterobiasis that may be instructive for pediatric providers seeing patients with eosinophilia for which there is no readily apparent underlying cause.

Successful treatment of vancomycin-resistant enterococcal ventriculitis in a pediatric patient with linezolid.

Although vancomycin-resistant Enterococcus infection of the central nervous system is not common, this organism is becoming an increasing problem in nosocomial infections. We report a 17-month-old male infant with an externalized ventricular peritoneal shunt secondary to infection who subsequently developed a vancomycin-resistant Enterococcus faecium ventriculitis. This infection was successfully treated with a 28-day course of linezolid while monitoring linezolid drug levels in both the cerebral spinal fluid and serum. This case supports the use of linezolid in treating such resistant infections. However, our drug level results suggest that further investigation is needed to determine the optimal dosing of linezolid in treatment of central nervous system infection in pediatric patients.

Tolerability of Japanese Encephalitis Vaccine in Pediatric Patients.

BACKGROUND.: Japanese encephalitis virus (JEV) is a mosquito-borne flavivirus endemic to parts of Asia. Manufacture of JE-VAX, the mouse brain-derived vaccine against JEV, was discontinued in February 2011. IXIARO, an inactivated cell culture-derived vaccine, was approved in 2009 for use in adult patients. Although IXIARO was not licensed for pediatric patients until 2013, our clinic routinely used this vaccine in at-risk children starting in 2011. The purpose of this study was to review our experience as to the tolerability of the new IXIARO vaccine in children. METHODS.: We performed a retrospective chart review of all patients less than 18 years of age who received at least 1 dose of IXIARO in our Family Travel Clinic from November 2011 through August 2014. Subjects' electronic medical records were reviewed for any documented medical visits within 3 months after vaccination. Each visit was assessed for possible adverse events with relationship to vaccine administration as determined by the reviewer. RESULTS.: Ninety-two patients less than 18 years of age received a total of 145 doses of IXIARO between November 2011 and August 2014. Seven adverse events were documented. Only 1 was deemed to be possibly related. No serious adverse events were found on chart review. CONCLUSIONS.: Our study reinforces the recent decision to expand IXIARO vaccination to the pediatric population. The experience in our clinic since vaccine introduction shows it to be overall tolerable when used in routine clinical practice. Practitioners should feel comfortable recommending vaccination against JEV for any pediatric traveler to an area of risk.

Postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following arthroscopic anterior cruciate ligament reconstruction in an adolescent: A case report and review of the literature.

We present a case of postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following an arthroscopic anterior cruciate ligament reconstruction in an adolescent male with no pertinent medical history. The patient presented to the emergency department nine days after the operation with fever, an elevated white blood cell count, knee pain, and effusion. Arthrocentesis of the knee yielded purulent fluid that tested positive for S. mitis. Repeat intraoperative cultures revealed E. corrodens. In addition to antibiotics, the patient's treatment course included arthroscopic irrigation and debridement in the operating room as well as removal of graft material and fixation devices. To our knowledge, this is the first case of a polymicrobial infection of E. corrodens and S. mitis causing septic arthritis in a teenager following arthroscopic anterior cruciate ligament reconstruction.

Changing Susceptibility of Staphylococcus aureus in a US Pediatric Population.

BACKGROUND: Staphylococcus aureus is a major cause of infection in both adult and pediatric populations. After several decades of increasing prevalence, the proportion of S aureus infections due to methicillin-resistant S aureus has been reported to be in decline in adults. Data for similar changes in pediatric populations are limited. METHODS: Evaluation of S aureus susceptibility data for pediatric patients receiving care in the US Military Health System was performed. Microbiology and demographic data were collected for years 2005 through 2014. Trends in antibiotic susceptibility results were evaluated. Clinical and demographic characteristics were explored to assess for association with antibiotic susceptibilities. RESULTS: In this study, 41 745 S aureus isolates from 39 207 pediatric patients were included. An overall increase in susceptibility of isolates to oxacillin was noted over this 10-year period; with over 60% of isolates oxacillin-susceptible in 2014. S aureus susceptibility to clindamycin declined over the study period; notably methicillin-susceptible S aureus susceptibility to clindamycin declined from 90% to 83% (P < .0001). Differences in oxacillin susceptibility between US regions decreased over time. CONCLUSIONS: Similar to recent trends seen in adults, the proportion of pediatric S aureus infections secondary to methicillin-resistant S aureus appear to be decreasing, as is variability in US geographical resistance rates. Increasing clindamycin resistance among methicillin-susceptible S aureus should raise caution in the use of empirical clindamycin in presumed S aureus infection. Clinicians should be aware of regional susceptibility patterns when choosing empirical regimens.

Antimicrobial resistance acquisition after international travel in U.S. travelers.

BACKGROUND: Prior studies have shown an increase in multidrug-resistant (MDR) E. coli colonization from two percent in U.S.-based to 11 % in deployed, healthy military personnel. It is unclear if colonization with MDR organisms occurs through deployment exposures or risks related to routine overseas travel. This study prospectively evaluates rates and risk factors associated with MDR gram-negative bacterial and methicillin-resistant S. aureus (MRSA) colonization after international travel. METHODS: Participants traveled internationally for five or more days. Pre- and post-travel, colonizing bacteria from oropharyngeal, nares, groin, and peri-rectal (PR) areas were collected using BD CultureSwab™ MaxV(+). Identification and susceptibilities were done utilizing the BD Phoenix™ Automated Microbiology System. Non-MDR pre- and post-travel MDR bacteria within a subject were compared by pulsed-field gel electrophoresis (PFGE). A questionnaire solicited demographics and potential risk factors for MDR acquisition. RESULTS: Of 58 participants, 41 % were male and median age was 64 years. Pre- and post-travel swabs were obtained a median of ten and seven days before and after travel, respectively. Itineraries included 18 participants traveling to the Caribbean and Central America, 17 to Asia, 16 to Africa, 5 to Europe, 4 to South and North America. Seventeen of 22 travelers used atovaquone/proguanil for malaria prophylaxis. The only MDR organism isolated was extended-spectrum ß-lactamase (ESBL)-producing E. coli in five (9 %) participants post-travel (all PR and unrelated by PFGE). There were no statistically significant associations between exposure risks and new ESBL-producing E.coli colonization. Of 36 participants colonized with E. coli pre- and post-travel, new resistance was detected: TMP/SMX in 42 % of isolates (p < 0.01), tetracycline in 44 % (p < 0.01), and ampicillin-sulbactam in 33 % (p = 0.09). No participants were colonized with MRSA pre- or post-travel. CONCLUSION: Consistent with prior studies, new antimicrobial resistance was noted in colonizing E. coli after international travel. Nine percent of participants acquired new strains of ESBL-producing E.coli without identified risks.

Isolation of bacterial cerebrospinal fluid culture contaminants at a major military medical center.

In recent decades, bacterial meningitis rates have decreased secondary to the success of routine vaccinations. Ironically, the decreased incidence may contribute to the challenge of establishing accurate and timely diagnoses. Studies have suggested that in immunocompetent patients with normal cerebrospinal fluid (CSF) white blood cell counts (WBC), positive CSF cultures may be disregarded as presumed contaminants, making the initial CSF WBC increasingly relevant. This single-institution retrospective study sought to integrate clinical data with positive cultures in an era when CSF contaminants may be more commonly isolated in culture than true pathogens. A total of 7715 adult and pediatric CSF samples from 1995 to 2009 were obtained at a major military medical center. Clinical and laboratory data from 121 positive bacterial cultures were reviewed. Our bacterial CSF contamination rate (false positives) was 0.91% (70/7715). True-positive (TP) CSF cultures totaled 51 (0.66%). Among TPs, 16% (8/51) demonstrated normal CSF cell counts. The notably low 15-year CSF contamination rate of 0.91%, suggests that positive cultures are likely to represent true infection in our institution. We believe efforts to decrease the contamination rate are among the most cost-effective, while targeted clinical re-evaluation for all patients with positive CSF cultures remains vital. In light of this data, a targeted approach to re-evaluating positive cultures while incorporating the clinical context remains prudent.

The seroprevalence and seroincidence of dengue virus infection in western Kenya.

Epidemics of dengue fever have been documented throughout the African continent over the past several decades, however little is known about the prevalence or incidence of dengue virus infection in the absence of an outbreak. No studies have analyzed the prevalence of dengue infection in western Kenya to date. This study describes the seroincidence and seroprevalence of dengue infection in western Kenya. Banked sera obtained from 354 healthy, afebrile children ages 12-47 months from Kisumu District, Kenya, were analyzed for antibodies to dengue virus using an IgG indirect ELISA. We found a seroprevalence of 1.1% (4 of 354 samples) and incidence of 8.5 seroconversions per 1000 persons per year in this study population. This appears to be similar to that previously reported in coastal regions of the country outside of known epidemic periods. Since there has never been a reported dengue epidemic in western Kenya, continued investigation and evaluation in a patient population presenting with fever is necessary to further confirm this finding.

Varicella-specific immunoglobulin G titers in commercial intravenous immunoglobulin preparations.

BACKGROUND AND OBJECTIVES: Since the introduction of an effective vaccine in 1995, the incidence of primary varicella zoster virus (VZV) has greatly decreased. However, newborns and immunocompromised patients remain at risk for serious disease. Currently, varicella-specific immunoglobulin is recommended for treatment of nonimmune, exposed, high-risk patients with varicella-specific immunoglobulin. However, product inavailability has led to substitution of intravenous immunoglobulin (IVIg) for such prophylaxis on the basis of studies from the preimmunization era. No studies in the post-vaccine era have shown that IVIg contains adequate varicella-specific antibodies to protect patients at high risk. The overall effect of vaccination on varicella-specific immunoglobulin G (IgG) levels in donor-pooled IVIg products is unknown. We compared the varicella-specific IgG levels in prevaccine and current IVIg products. METHODS: We used stored historic IVIg samples and current samples from our inpatient pharmacy. All samples were tested for varicella-specific IgG levels by enzyme-linked immunosorbent assay. RESULTS: Ten historic lots and 24 current lots were tested. The overall mean value of varicella-specific IgG in the historic lots was 3.07 (SD: 0.70); the current lots had a mean of 3.83 (SD: 0.58). The postvaccine IVIg contained higher levels of antibody than the prevaccine lots. CONCLUSIONS: We found that current IVIg preparations continue to have high levels of varicella-specific IgG despite the changing epidemiology of how immunity has been obtained. Given the results of this study, it is reasonable for physicians to comfortably substitute IVIg for varicella-specific immunoglobulin preparations when treating high-risk patients exposed to VZV.