Transforming remediation for competency-based medical education.

We care about the future experiences of all health professions trainees as competency-based medical education evolves. It is an exciting new era with many possibilities for progress in learning and competency development. Yet we are concerned that remediation remains a troubled and stigmatized detour from routine learning that can persist as a feared off-ramp from competency development rather than a central avenue for improvement and competency achievement. We believe that it is time to acknowledge that all trainees struggle and to recognize that remediation is an essential aspect of individualized learning. Decisive steps are possible to revitalize remediation and to launch its transformation towards growth-oriented pathways for change.

Bilateral Spontaneous Retrobulbar Hemorrhage due to Warfarin Misuse After Sinus Lavage.

While warfarin has historically played an important role in anticoagulation, direct oral anticoagulants have largely supplanted warfarin due to their improved safety profile and reduced need for monitoring. Herein, the authors report the case of a 64-year-old male who developed severe, bilateral retrobulbar hemorrhage following aggressive nasal lavage due to a supratherapeutic international normalized ratio from warfarin misuse. Visual acuity on arrival was hand-motion OD and no-light-perception OS. He underwent bilateral canthotomy with upper and lower lid cantholysis before transfer to a trauma center where his international normalized ratio was greater than 12. Reversal with vitamin K and prothrombin complex concentrate was initiated. Over the course of hospitalization, vision and swelling continued to improve and at 2-month follow-up his visual acuity was 20/20 OD and no-light-perception OS. This case outlines the risk of bleeding associated with warfarin misuse and advocates for the transition of patients to direct oral anticoagulants when possible.

Ambulatory Care Fragmentation, Emergency Department Visits, and Race: a Nationwide Cohort Study in the U.S.

BACKGROUND: It is unclear whether highly fragmented ambulatory care (i.e., care spread across multiple providers without a dominant provider) increases the risk of an emergency department (ED) visit. Whether any such association varies with race is unknown. OBJECTIVE: We sought to determine whether highly fragmented ambulatory care increases the risk of an ED visit, overall and by race. DESIGN AND PARTICIPANTS: We analyzed data for 14,361 participants ≥ 65 years old from the nationwide prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, linked to Medicare claims (2003-2016). MAIN MEASURES: We defined high fragmentation as a reversed Bice-Boxerman Index ≥ 0.85 (≥ 75th percentile). We used Poisson models to determine the association between fragmentation (as a time-varying exposure) and ED visits, overall and stratified by race, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiologic variables. KEY RESULTS: The average participant was 70.5 years old; 53% were female, and 33% were Black individuals. Participants with high fragmentation had a median of 9 visits to 6 providers, with 29% of visits by the most frequently seen provider; participants with low fragmentation had a median of 7 visits to 3 providers, with 50% of visits by the most frequently seen provider. Overall, high fragmentation was associated with more ED visits than low fragmentation (adjusted risk ratio [aRR] 1.31, 95% confidence interval [CI] 1.29, 1.34). The magnitude of this association was larger among Black (aRR 1.48, 95% CI 1.44, 1.53) than White participants (aRR 1.23, 95% CI 1.20, 1.25). CONCLUSIONS: Highly fragmented ambulatory care was an independent predictor of ED visits, especially among Black individuals.

Frailty, gaps in care coordination, and preventable adverse events.

BACKGROUND: Older US adults often receive care from multiple ambulatory providers. Seeing multiple providers may be clinically appropriate but creates challenges for communication. Whether frailty is a risk factor for gaps in communication among older adults and subsequent preventable adverse events is unknown. METHODS: We conducted a cross-sectional analysis of community-dwelling US adults ≥ 65 years of age in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who attended an in-home study examination in 2013-2016 and completed a survey on experiences with healthcare in 2017-2018 (n = 5,024). Using 5 frailty indicators (low body mass index, exhaustion, slow walk, weakness, and history of falls), we characterized participants into 3 mutually exclusive groups: not frail (0 indicators), intermediate-frail (1-2 indicators), and frail (3-5 indicators). We used survey data on self-reported gaps in care coordination and self-reported adverse events that participants attributed to poor communication among providers (a drug-drug interaction, repeat testing, an emergency department visit, or a hospital admission). RESULTS: Overall, 2,398 (47.7%) participants were not frail, 2,436 (48.5%) were intermediate-frail, and 190 (3.8%) were frail. The prevalence of any gap in care coordination was 37.0%, 40.8%, and 51.1% among participants who were not frail, intermediate-frail and frail, respectively. The adjusted prevalence ratio (PR) for any gap in care coordination among intermediate-frail and frail versus not frail participants was 1.09 (95% confidence interval [95%CI] 1.02-1.18) and 1.34 (95%CI 1.15-1.56), respectively. The prevalence of any preventable adverse event was 7.0%, 11.3% and 20.0% among participants who were not frail, intermediate-frail and frail, respectively. The adjusted PR for any preventable adverse event among those who were intermediate-frail and frail versus not frail was 1.47 (95%CI 1.22-1.77) and 2.24 (95%CI 1.60-3.14), respectively. CONCLUSION: Among older adults, frailty is associated with an increased prevalence for self-reported gaps in care coordination and preventable adverse events. Targeted interventions to address patient-reported concerns regarding care coordination among intermediate-frail and frail older adults may be warranted.

Direct oral anticoagulants decrease treatment failure for acute lower extremity deep venous thrombosis.

OBJECTIVE: Optimal medical therapy for acute lower extremity deep venous thrombosis (DVT) remains an enigma. While clinical trials demonstrate non-inferiority with an oral anti-Xa inhibitor, or direct oral anticoagulant (DOAC), versus combined low-molecular weight heparin (LMWH) and oral vitamin K antagonist (VKA), the most effective regimen remains to be determined. METHODS: This study is a single-center retrospective cohort study from October 2014 to December 2015 of patients with a diagnosis of acute DVT and subsequent serial lower extremity venous duplex. Demographics, medical history, medications, serial ultrasound findings, as well as the primary anticoagulant used for treatment were collected and analyzed by two independent data extractors. Treatment failure was defined as any new DVT or progression of an existing DVT within 3 months of diagnosis of the index clot. Risk factors for treatment failure were assessed using standard odds ratios and Fischer's exact test. RESULTS: Among 496 patients with an acute lower extremity DVT, 54% (n = 266) were men, mean age was 61 years, 35% (n = 174) involved the popliteal or more proximal segments, and 442 had documentation of the primary treatment for DVT: 20% (n = 90) received nothing; 20% (n = 92) received an oral VKA; 34% (n = 149) received a DOAC; 20% (n = 90) received LMWH; and 5% (n = 21) received another class of anticoagulant. Within 3 months, 21% (n=89 out of 427) had treatment failure defined as any new DVT or progression of prior DVT. Patients treated with a DOAC were less likely to experience treatment failure when compared with any other treatment (odds ratio 0.43; 95% confidence intervals [0.23, 0.79]; p = 0.0069) and when compared with traditional oral VKA (OR 0.44; 95% CI [0.21, 0.92]; p = 0.029). None of prior history of DVT, pulmonary embolism, thrombophilia, renal insufficiency, hepatic insufficiency, cancer, or antiplatelet therapy correlated with treatment failure. Treatment outcome did not correlate with being on any anticoagulation versus none (p = 0.74), nor did it correlate with the duration of treatment (<3 months versus ≥3 months) (p = 0.42). Proximal and distal DVTs showed no difference in treatment failure (19% versus 22%, respectively; p = 0.43). CONCLUSION: In summary, the use of a DOAC for acute lower extremity DVT yielded better overall outcomes and fewer treatment failures at 3 months as compared to traditional oral VKA therapy based on serial duplex imaging.

From bench to bedside: updates in basic science, translational and clinical research on muscle fatigue in cancer cachexia.

PURPOSE OF REVIEW: Cancer cachexia is a syndrome of loss of weight and muscle mass that leads to reduced strength, poor physical performance and functional impairment. Muscular fatigue is a distressing syndrome that patients with cachexia suffer from and can impair quality of life. Here, we review recent updates in muscular fatigue in cancer cachexia research with a focus on mechanisms, biomarkers and potential therapies. RECENT FINDINGS: Both in mice and humans, research has shown that muscle fatigue can be independent of muscular atrophy and can happen early in cancer development or in precachexia. Inflammatory pathways, mitochondrial dysfunction and gut microbiota have recently been studied to play an important role in muscle fatigue in preclinical models. Exercise can target these pathways and has been studied as a therapeutic intervention to improve muscle fatigue. SUMMARY: Heightened inflammation within muscle, altered muscle function and muscle fatigue can begin prior to clinical evidence of cachexia, making early recognition and intervention challenging. The emergence of cachexia mouse models and translational and clinical research studying muscle fatigue will hopefully lead to new therapies targeting the underlying mechanisms of cancer cachexia. Exercise will need to be tested in larger randomized studies before entering into daily practice.

Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain.

OBJECTIVE: Early diagnosis or rule-out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE-ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high-sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule-out and prolonged observation with repeated hsTnt testing at a high-volume tertiary care emergency department. PATIENTS AND METHODS: We conducted a pre- and post-changeover analysis 3 months before and 3 months after transition from less (hsTnt cut-off 30 ng/L, 3-hour rule-out) to more conservative (hsTnt cut-off 14 ng/L, 1-hour rule-out) guidelines in 2015, comparing proportions of patients requiring repeated testing. RESULTS: We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early-rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision. CONCLUSION: The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.

Outcomes of Isolated Fetal Ventriculomegaly That Resolve In Utero.

OBJECTIVE: Isolated fetal ventriculomegaly is often an incidental finding on antenatal ultrasound. It is benign in up to 90% of cases, although it can be associated with genetic, structural, and neurocognitive disorders. The literature suggests that over 40% of isolated mild ventriculomegaly will resolve in utero, but it is unclear if resolution decreases the associated risks.The aim of this study is to compare the fetal and neonatal genetic outcomes of ventriculomegaly that persists or resolves on subsequent ultrasound. STUDY DESIGN: This is a retrospective cohort study of women diagnosed with isolated ventriculomegaly via fetal ultrasound at a tertiary referral center between 2011 and 2019. Patients were excluded if other structural anomalies were identified on ultrasound. RESULTS: A total of 49 patients were included in the study, 19 in the resolved ventriculomegaly group and 30 in the persistent ventriculomegaly group. Women in the resolved ventriculomegaly group were more likely to be diagnosed earlier (24 vs. 28 weeks, p = 0.007). Additionally, they were more likely to have mild ventriculomegaly (63 vs. 84%, p = 0.15), and less likely to have structural neurological abnormalities diagnosed on postnatal imaging (5 vs. 17%, p = 0.384), although these were not statistically significant. Aneuploidy risk for resolved compared with persistent ventriculomegaly was similar (5 vs. 7%, p = 0.999). CONCLUSION: This study suggests that resolution of isolated ventriculomegaly in utero may not eliminate the risk of genetic or chromosomal abnormalities in this population and may warrant inclusion as part of the counselling of these at-risk patients. Larger prospective studies are needed to confirm these findings. KEY POINTS: · Ventriculomegaly is known to be associated with genetic and chromosomal abnormalities.. · Resolution of the ventriculomegaly in utero may not eliminate those risks.. · Patients with resolved ventriculomegaly should be offered aneuploidy screening or testing..

ACGME Case Log Reminder Does Not Improve Resident Accuracy in Logging Cases.

To assess competency of residents prior to graduation, the Accreditation Council for Graduate Medical Education (ACGME) maintains a case log system, where residents self-report cases they perform. This mechanism results in underreporting of resident involvement in patient care. To determine if an intraoperative case log reminder would increase the frequency of ACGME case logging amongst anesthesiology residents. An intraoperative ACGME case log reminder was implemented on March 13, 2019. The authors collected data for all 53 PGY2-4 anesthesiology residents at the authors' institution from July 14, 2018 to July 16, 2019 from the electronic medical record and ACGME system to calculate the proportion of cases logged and the "lag time" between case occurrence and logging. Data was analyzed for all residents, classes, and individuals. A total of 16,342 anesthetics were performed, and a total of 11,713 cases were logged. The reminder did not improve overall logging rates. Case-logging rates amongst PGY2 residents remained unchanged and declined for PGY3 and PGY4 residents. The lag time between case occurrence and logging increased. An automatic reminder did not improve logging frequency. This may be because residents are unable to log cases intraoperatively in many instances, or they may not feel as though they have participated enough in a case to log it. Additionally, senior residents may log cases less frequently once they have met required case minimums. An automatic case-logging system that transmits resident information directly to the ACGME may be the best way to increase logging accuracy.

Social Support, Insomnia, and Adherence to Cognitive Behavioral Therapy for Insomnia After Cancer Treatment.

OBJECTIVE/BACKGROUND: While cognitive-behavioral therapy for insomnia (CBT-I) has been shown to be efficacious in treating cancer survivors' insomnia, 30-60% of individuals have difficulty adhering to intervention components. Psychosocial predictors of adherence and response to CBT-I, such as social support, have not been examined in intervention studies for cancer survivors. PARTICIPANTS: Data from a randomized placebo-controlled 2 x 2 trial of CBT-I and armodafinil (a wakefulness promoting agent) were used to assess adherence. Ninety-six cancer survivors participated in the trial (mean age 56, 86% female, 68% breast cancer). METHODS: CBT-I and armodafinil were administered over the course of seven weeks, and participants were assessed at baseline, during intervention, postintervention, and at a three-month follow-up. Social support was assessed using a Functional Assessment of Chronic Illness Therapy subscale, insomnia severity was assessed using the Insomnia Severity Index, and adherence was measured based on CBT-I sleep prescriptions. RESULTS: At baseline, social support was negatively correlated with insomnia severity (r = -0.30, p = 0.002) and associations between social support, CBT-I, and insomnia were maintained through the three-month follow-up. Social support was positively associated with adherence to CBT-I during intervention weeks 3, 4, and 5, and with overall intervention adherence. At postintervention, both social support and treatment with CBT-I independently predicted decreased insomnia severity (p < 0.01) when controlling for baseline insomnia severity. CONCLUSIONS: Higher social support is associated with better intervention adherence and improved sleep independent of CBT-I. Additional research is needed to determine whether social support can be leveraged to improve adherence and response to CBT-I.

Yoga for the Management of Cancer Treatment-Related Toxicities.

PURPOSE OF REVIEW: To (1) explain what yoga is, (2) summarize published literature on the efficacy of yoga for managing cancer treatment-related toxicities, (3) provide clinical recommendations on the use of yoga for oncology professionals, and (4) suggest promising areas for future research. RECENT FINDINGS: Based on a total of 24 phase II and one phase III clinical trials, low-intensity forms of yoga, specifically gentle hatha and restorative, are feasible, safe, and effective for treating sleep disruption, cancer-related fatigue, cognitive impairment, psychosocial distress, and musculoskeletal symptoms in cancer patients receiving chemotherapy and radiation and cancer survivors. Clinicians should consider prescribing yoga for their patients suffering with these toxicities by referring them to qualified yoga professionals. More definitive phase III clinical trials are needed to confirm these findings and to investigate other types, doses, and delivery modes of yoga for treating cancer-related toxicities in patients and survivors.

Twelve tips for developing and maintaining a remediation program in medical education.

Remediation in medical education, the process of facilitating corrections for physician trainees who are not on course to competence, predictably consumes significant institutional resources. Although remediation is a logical consequence of mandating, measuring, and reporting clinical competence, many program leaders continue to take an unstructured approach toward organizing effective, efficient plans for struggling trainees, almost all of who will become practicing physicians. The following 12 tips derive from a decade of remediation experience at each of the authors' three institutions. It is informed by the input of a group of 34 interdisciplinary North American experts assembled to contribute two books on the subject. We intend this summary to guide program leaders to build better remediation systems and emphasize that developing such systems is an important step toward enabling the transition from time-based to competency-based medical education.

A novel role for thrombopoietin in regulating osteoclast development in humans and mice.

Emerging data suggest that megakaryocytes (MKs) play a significant role in skeletal homeostasis. Indeed, osteosclerosis observed in several MK-related disorders may be a result of increased numbers of MKs. In support of this idea, we have previously demonstrated that MKs increase osteoblast (OB) proliferation by a direct cell-cell contact mechanism and that MKs also inhibit osteoclast (OC) formation. As MKs and OCs are derived from the same hematopoietic precursor, in these osteoclastogenesis studies we examined the role of the main MK growth factor, thrombopoietin (TPO) on OC formation and bone resorption. Here we show that TPO directly increases OC formation and differentiation in vitro. Specifically, we demonstrate the TPO receptor (c-mpl or CD110) is expressed on cells of the OC lineage, c-mpl is required for TPO to enhance OC formation in vitro, and TPO activates the mitogen-activated protein kinases, Janus kinase/signal transducer and activator of transcription, and nuclear factor-kappaB signaling pathways, but does not activate the PI3K/AKT pathway. Further, we found TPO enhances OC resorption in CD14+CD110+ human OC progenitors derived from peripheral blood mononuclear cells, and further separating OC progenitors based on CD110 expression enriches for mature OC development. The regulation of OCs by TPO highlights a novel therapeutic target for bone loss diseases and may be important to consider in the numerous hematologic disorders associated with alterations in TPO/c-mpl signaling as well as in patients suffering from bone disorders.

Twelve tips for teaching evidence-based physical examination.

BACKGROUND: Practicing evidence-based physical examination (EBPE) requires clinicians to apply the diagnostic accuracy of PE findings in relation to a suspected disease. Though it is important to effectively teach EBPE, clinicians often find the topic challenging. AIMS: There are few resources available to guide clinicians on strategies to teach EBPE. We seek to fill that need by presenting tips for effectively teaching EBPE in the clinical context. METHODS: This report is based primarily on the authors' experience and is supported by the available literature. RESULTS: We present 12 practical tips targeting the clinician educator. The first six tips condense key preparatory steps for the teacher, including basic statistics underpinning EBPE. The final six tips provide specific guidance on how to teach EBPE in the clinical environment. CONCLUSIONS: By practicing the 12 tips provided, clinicians will develop the confidence needed to effectively teach EBPE in inpatient or outpatient settings.

Explorations in statistics: the analysis of change.

Learning about statistics is a lot like learning about science: the learning is more meaningful if you can actively explore. This tenth installment of Explorations in Statistics explores the analysis of a potential change in some physiological response. As researchers, we often express absolute change as percent change so we can account for different initial values of the response. But this creates a problem: percent change is really just a ratio, and a ratio is infamous for its ability to mislead. This means we may fail to find a group difference that does exist, or we may find a group difference that does not exist. What kind of an approach to science is that? In contrast, analysis of covariance is versatile: it can accommodate an analysis of the relationship between absolute change and initial value when percent change is useless.

Beyond ethical and curricular guidelines in global health: attitudinal development on international service-learning trips.

BACKGROUND: Health professionals from high-income countries are increasingly becoming involved in international service-learning trips in low and low/middle-income countries. While much has been written about the ethics and curricular guidelines related to such endeavors, scant attention has been paid to the attitudes with which trainees and clinicians enter into or return from them. In this essay the authors explore how attitudes contribute to the success or failure of international service-learning trips. DISCUSSION: The authors submit that the attitudes with which visiting health professionals approach international service-learning trips are much more critical to the success of these experiences than their demonstrated knowledge base or specialized skill sets. They list five attitudes that can aid those participating in international service-learning trips. They list five troubling attitudes that, while common, those participating in international service-learning trips can learn to recognize and avoid. They suggest five strategies key to learning respectful attitudes that can foster success in such cross-cultural activities. Lastly, the authors review several concepts related to attitude development in short or long-term global health work. SUMMARY: The attitudes with which visiting health professionals approach international service-learning activities can be important components of the success or failure of the experiences. Through thoughtful consideration of attitudes and approaches, participants on such trips can build a framework for rich and rewarding experiences in global medicine and global health.

Faculty development to enhance humanistic teaching and role modeling: a collaborative study at eight institutions.

BACKGROUND: There is increased emphasis on practicing humanism in medicine but explicit methods for faculty development in humanism are rare. OBJECTIVE: We sought to demonstrate improved faculty teaching and role modeling of humanistic and professional values by participants in a multi-institutional faculty development program as rated by their learners in clinical settings compared to contemporaneous controls. DESIGN: Blinded learners in clinical settings rated their clinical teachers, either participants or controls, on the previously validated 10-item Humanistic Teaching Practices Effectiveness (HTPE) questionnaire. PARTICIPANTS: Groups of 7-9 participants at 8 academic medical centers completed an 18-month faculty development program. Participating faculty were chosen by program facilitators at each institution on the basis of being promising teachers, willing to participate in the longitudinal faculty development program. INTERVENTION: Our 18-month curriculum combined experiential learning of teaching skills with critical reflection using appreciative inquiry narratives about their experiences as teachers and other reflective discussions. MAIN MEASURES: The main outcome was the aggregate score of the ten items on the questionnaire at all institutions. KEY RESULTS: The aggregate score favored participants over controls (P = 0.019) independently of gender, experience on faculty, specialty area, and/or overall teaching skills. CONCLUSIONS: Longitudinal, intensive faculty development that employs experiential learning and critical reflection likely enhances humanistic teaching and role modeling. Almost all participants completed the program. Results are generalizable to other schools.

Influence of obesity assessments on cardiometabolic risks in African and European American women.

OBJECTIVES: African American women (AAW) have increased odds of developing cardiometabolic (CME) risks and cardiovascular diseases (CVD) compared with European American women (EAW). The influence of obesity on other CME risks and the CVD disparity is unclear. The purpose of our study was to develop a CME index and evaluate the obesity and CME risk index relationships based on race. DESIGN: A comparative research design was employed in our study as 213 women (132 AAW; 81 EAW) from the Louisiana Delta were evaluated for CME risk clustering patterns by race, based on BMI, dual energy X-ray absorptiometry % body fat and waist conference. Fasting glucose, triglyceride (TC), high density lipoprotein cholesterol (HDL-C), systolic (SBP) and diastolic blood pressure (DBP) were the measured CME risks. FINDINGS: In summary, when the CME indexes were evaluated by obesity classification categories the ones that were CVD risk or near risk for the AAW were SBP and TG. The trend of CME index risk for the EAW was SBP and glucose. The stepwise regression equations indicate that HDL-C and SBP/DBP were the best indicators of the effects of obesity on CME risks in AAW and that SBP/DBP and glucose were the best indicators of CME risks in EAW. CONCLUSIONS: Our results indicate that CME risks as evaluated based on obesity categories are different for AAW than for EAW.

Laser-driven electron source suitable for single-shot Gy-scale irradiation of biological cells at dose rates exceeding 10

We report on the first systematic characterization of a tuneable laser-driven electron source capable of delivering Gy-scale doses in a duration of 10-20 ps in a single irradiation, thus reaching unprecedented dose rates in the range of 10^{10}-10^{12} Gy/s. Detailed characterization of the source indicates, in agreement with Monte Carlo simulations, dose delivery over cm-scale areas with a high degree of spatial uniformity. The results reported here confirm that a laser-driven source of this kind can be used for systematic studies of the response of biological cells to picosecond-scale radiation at ultrahigh dose rates.