White Matter Integrity and Chronic Poststroke Upper Limb Function: An ENIGMA Stroke Recovery Analysis.

BACKGROUND: Integrity of the corticospinal tract (CST) is an important biomarker for upper limb motor function following stroke. However, when structurally compromised, other tracts may become relevant for compensation or recovery of function. METHODS: We used the ENIGMA Stroke Recovery data set, a multicenter, retrospective, and cross-sectional collection of patients with upper limb impairment during the chronic phase of stroke to test the relevance of tracts in individuals with less and more severe (laterality index of CST fractional anisotropy ≥0.25) CST damage in an observational study design. White matter integrity was quantified using fractional anisotropy for the CST, the superior longitudinal fascicle, and the callosal fibers interconnecting the primary motor cortices between hemispheres. Optic radiations served as a control tract as they have no a priori relevance for the motor system. Pearson correlation was used for testing correlation with upper limb motor function (Fugl-Meyer upper extremity). RESULTS: From 1235 available data sets, 166 were selected (by imaging, Fugl-Meyer upper extremity, covariates, stroke location, and stage) for analyses. Only individuals with severe CST damage showed a positive association of fractional anisotropy in both callosal fibers interconnecting the primary motor cortices (r[21]=0.49; P=0.025) and superior longitudinal fascicle (r[21]=0.51; P=0.018) with Fugl-Meyer upper extremity. CONCLUSIONS: Our data support the notion that individuals with more severe damage of the CST depend on residual pathways for achieving better upper limb outcome than those with less affected CST.

Orbital cellulitis, sinusitis and intracranial abnormalities in two adolescents with COVID-19.

We review two cases of adolescents with orbital cellulitis, sinusitis and SARS- CoV-2 infection presenting to emergency departments within a 24 hour period. SARS-CoV-2 samples obtained within 24 hours were positive, supporting prior infection despite relatively limited early symptoms of COVID-19. Unusual clinical and radiographic characteristics included hemorrhagic abscess with blood of varying age in the first, intracranial epidural abscess in the second, radiographic signal consistent with hemorrhagic or thrombotic phenomena, retro-maxillary antral fat changes, and meningeal enhancement or extension in both cases. Radiographic findings thereby mimic fungal infection, although final cultures and ancillary investigation for allergic and invasive fungal disease have remained negative. These cases highlight two unusual orbital presentations of cellulitis occurring in the context of SARS-CoV-2 co-infection.

Using ChatGPT in the Development of Clinical Reasoning Cases: A Qualitative Study.

Background There has been an explosion of commentary and discussion about the ethics and utility of using artificial intelligence in medicine, and its practical use in medical education is still being debated. Through qualitative research methods, this study aims to highlight the advantages and pitfalls of using ChatGPT in the development of clinical reasoning cases for medical student education. Methods Five highly experienced faculty in medical education were provided instructions to create unique clinical reasoning cases for three different chief concerns using ChatGPT 3.0. Faculty were then asked to reflect on and review the created cases. Finally, a focus group was conducted to further analyze and describe their experiences with the new technology. Results Overall, faculty found the use of ChatGPT in the development of clinical reasoning cases easy to use but difficult to get to certain objectives and largely incapable of being creative enough to create complexity for student use without heavy editing. The created cases did provide a helpful starting point and were extremely efficient; however, faculty did experience some medical inaccuracies and fact fabrication. Conclusion There is value to using ChatGPT to develop curricular content, especially for clinical reasoning cases, but it needs to be comprehensively reviewed and verified. To efficiently and effectively utilize the tool, educators will need to develop a framework that can be easily translatable into simple prompts that ChatGPT can understand. Future work will need to strongly consider the risks of recirculating biases and misinformation.

Internal Medicine and Internal Medicine-Pediatrics Residency Program Website Traffic Patterns Across Two Institutions and Five Electronic Residency Application Service (ERAS) Cycles.

Background Since the start of the COVID-19 pandemic in Spring 2020, medical residency program recruitment has become increasingly web-based due to the transition to virtual interviews. Although social media use by residency programs has soared during this time, applicant surveys show that official program websites remain the most used online resource. According to survey-based studies, the content that applicants favor on program websites tends to mirror their priorities in choosing programs. However, it is unclear whether applicant-reported priorities in program choice and website content truly drive program website traffic. In this analysis, we will elucidate website traffic patterns from two Internal Medicine residency programs and two Internal Medicine-Pediatrics programs, both in terms of the thematic content of high-traffic pages and changes in traffic patterns throughout the Electronic Residency Application Service (ERAS) application cycle. We will provide novel, data-driven guidance to residency program leadership regarding website content. Methodology For each of the four programs included in the analysis, total pageviews on a monthly basis were obtained for the annual ERAS application cycles taking place from 2017 through 2022. For one Internal Medicine program, data was only available for its current website from 2020 to 2022. The mean monthly pageviews were calculated for each page within each website. The total site traffic trends across each year and within high-traffic months were totaled as well. Results As expected, the highest traffic period for all programs in all years was the days before the application deadline, with a secondary, smaller spike in traffic around Match Day. In general, the most popular pages for all four programs were thematically in line with the top five applicant priorities in the 2022 National Resident Matching Program applicant survey, namely, geographic location, goodness of fit, program reputation, work/life balance, and current program residents. Three of the websites featured unique content that unexpectedly proved to be as popular as the top survey-reported topics, such as pages related to a new major clinical site, a new integrated subspecialty pathway, and, most profoundly, a pipeline program for certain applicants from groups that are underrepresented in medicine. Alumni career content was also heavily trafficked across all four programs. Conclusions Program directors should plan twice-yearly updates to residency program websites, timed to be finished by the start of the ERAS cycle in the fall, and again just before Match Day in March. Program directors should include specific, up-to-date information about unique program features. Future research should incorporate a more diverse variety of programs, software-based page content analysis, and traffic source data.

Posttraumatic Amputations Epidemiology and Outcomes Within the National Trauma Data Bank: Improved Survival Over Time Results in Increased Population in Need of Rehabilitation Support.

OBJECTIVE: Acute trauma care has significantly reduced mortality over the last two decades. The last study to examine the epidemiology of traumatic amputees predates these gains. The majority of those who sustain traumatic amputation are male; therefore, limited data exist on female amputees. This study aimed to (1) provide a current epidemiological analysis of traumatic amputees and (2) compare male and female amputees. DESIGN: All patients sustaining a major limb amputation in the National Trauma Data Bank from 2013 to 2017 were identified. First, descriptive analyses of patient demographics and injury characteristics were performed and compared with a previous 2000-2004 National Trauma Data Bank study. Second, female and male traumatic amputees were compared in this study. RESULTS: From 2013 to 2017, we identified 7016 patients who underwent major limb amputation. Compared with previous years, the current amputees were older and more severely injured. Mortality was 6.3% in the current years compared with 13.4% in the previous years (odds ratio, 0.44, 95% CI = 0.37-0.51, P < 0.001). After multivariable analysis, mortality remained significantly decreased, with no difference in hospital length of stay. CONCLUSIONS: Contemporary National Trauma Data Bank analysis demonstrated that patients with traumatic amputations, regardless of sex, often survive until hospital discharge, despite more severe injuries.

Data-driven biomarkers better associate with stroke motor outcomes than theory-based biomarkers.

Chronic motor impairments are a leading cause of disability after stroke. Previous studies have associated motor outcomes with the degree of damage to predefined structures in the motor system, such as the corticospinal tract. However, such theory-based approaches may not take full advantage of the information contained in clinical imaging data. The present study uses data-driven approaches to model chronic motor outcomes after stroke and compares the accuracy of these associations to previously-identified theory-based biomarkers. Using a cross-validation framework, regression models were trained using lesion masks and motor outcomes data from 789 stroke patients from the Enhancing NeuroImaging Genetics through Meta Analysis (ENIGMA) Stroke Recovery Working Group. Using the explained variance metric to measure the strength of the association between chronic motor outcomes and imaging biomarkers, we compared theory-based biomarkers, like lesion load to known motor tracts, to three data-driven biomarkers: lesion load of lesion-behaviour maps, lesion load of structural networks associated with lesion-behaviour maps, and measures of regional structural disconnection. In general, data-driven biomarkers had stronger associations with chronic motor outcomes accuracy than theory-based biomarkers. Data-driven models of regional structural disconnection performed the best of all models tested (R 2 = 0.210, P < 0.001), performing significantly better than the theory-based biomarkers of lesion load of the corticospinal tract (R 2 = 0.132, P < 0.001) and of multiple descending motor tracts (R 2 = 0.180, P < 0.001). They also performed slightly, but significantly, better than other data-driven biomarkers including lesion load of lesion-behaviour maps (R 2 = 0.200, P < 0.001) and lesion load of structural networks associated with lesion-behaviour maps (R 2 = 0.167, P < 0.001). Ensemble models - combining basic demographic variables like age, sex, and time since stroke - improved the strength of associations for theory-based and data-driven biomarkers. Combining both theory-based and data-driven biomarkers with demographic variables improved predictions, and the best ensemble model achieved R 2 = 0.241, P < 0.001. Overall, these results demonstrate that out-of-sample associations between chronic motor outcomes and data-driven imaging features, particularly when lesion data is represented in terms of structural disconnection, are stronger than associations between chronic motor outcomes and theory-based biomarkers. However, combining both theory-based and data-driven models provides the most robust associations.

Data-driven biomarkers outperform theory-based biomarkers in predicting stroke motor outcomes.

Chronic motor impairments are a leading cause of disability after stroke. Previous studies have predicted motor outcomes based on the degree of damage to predefined structures in the motor system, such as the corticospinal tract. However, such theory-based approaches may not take full advantage of the information contained in clinical imaging data. The present study uses data-driven approaches to predict chronic motor outcomes after stroke and compares the accuracy of these predictions to previously-identified theory-based biomarkers. Using a cross-validation framework, regression models were trained using lesion masks and motor outcomes data from 789 stroke patients (293 female/496 male) from the ENIGMA Stroke Recovery Working Group (age 64.9±18.0 years; time since stroke 12.2±0.2 months; normalised motor score 0.7±0.5 (range [0,1]). The out-of-sample prediction accuracy of two theory-based biomarkers was assessed: lesion load of the corticospinal tract, and lesion load of multiple descending motor tracts. These theory-based prediction accuracies were compared to the prediction accuracy from three data-driven biomarkers: lesion load of lesion-behaviour maps, lesion load of structural networks associated with lesion-behaviour maps, and measures of regional structural disconnection. In general, data-driven biomarkers had better prediction accuracy - as measured by higher explained variance in chronic motor outcomes - than theory-based biomarkers. Data-driven models of regional structural disconnection performed the best of all models tested (R2 = 0.210, p < 0.001), performing significantly better than predictions using the theory-based biomarkers of lesion load of the corticospinal tract (R2 = 0.132, p< 0.001) and of multiple descending motor tracts (R2 = 0.180, p < 0.001). They also performed slightly, but significantly, better than other data-driven biomarkers including lesion load of lesion-behaviour maps (R2 =0.200, p < 0.001) and lesion load of structural networks associated with lesion-behaviour maps (R2 =0.167, p < 0.001). Ensemble models - combining basic demographic variables like age, sex, and time since stroke - improved prediction accuracy for theory-based and data-driven biomarkers. Finally, combining both theory-based and data-driven biomarkers with demographic variables improved predictions, and the best ensemble model achieved R2 = 0.241, p < 0.001. Overall, these results demonstrate that models that predict chronic motor outcomes using data-driven features, particularly when lesion data is represented in terms of structural disconnection, perform better than models that predict chronic motor outcomes using theory-based features from the motor system. However, combining both theory-based and data-driven models provides the best predictions.

A Case of Growth Hormone Use in Dyggve-Melchior-Clausen Syndrome.

Short stature has many causes including genetic disease, skeletal dysplasias, endocrinopathies, familial short stature, and nutritional deficiencies. Recombinant growth hormone (rGH) therapy may be employed to improve stature based on the underlying etiology and growth velocity. Skeletal dysplasia in Dyggve-Melchior-Clausen (DMC) syndrome tends to be progressive, typically with hip involvement, and ultimately leads to bilateral dislocation of the hip joints. Here, we present a pediatric patient with short stature treated with rGH therapy, complicated by the development of debilitating, bilateral hip pain, and found to have DMC syndrome. Our patient had limited range of motion at several joints including the hips after receiving 6 months of rGH therapy. Given the timing of the patient's rGH therapy and the progression of her disease, it is difficult to determine if there were any benefits and instead, is concerning for worsening of her skeletal dysplasia with rGH therapy use. Consequently, patients with severe short stature should have a thorough workup for genetic causes like DMC syndrome, before initiating rGH therapy to determine any potential benefits or harms of treatment.

Learning in the Pandemic: Medical Students' Perceived Effects of COVID-19 on Their Clinical Experiences and Career Choices During the Internal Medicine Clerkship.

Introduction: The COVID-19 pandemic forced changes to undergraduate medical education with its impact still not fully understood. This is the first US study to assess the pandemic's perceived impact on medical education after return to in-person clerkships. Materials and Methods: We conducted a survey of third-year medical students completing their medicine clerkship during the 2020-2021 and 2021-2022 academic years (AY). Survey questions assessed students' attitudes on perceived risk of COVID-19 infection, impact on clinical encounters, and students' specialty interests. Results: Of 312 students enrolled, 283 (90.71%) completed the survey. Concern for COVID-19 infection was highest in the second rotation (3.98 [95% CI 3.64, 4.31]) of the 2020-2021 AY and the third rotation of the 2021-2022 AY (3.41 [95% CI 3.06, 3.76]), corresponding to the surges of COVID-19 cases and subsequent variants. Conversely, as incidence increased, students reported a greater perceived impact on histories, physicals, and time spent with patients with no differences in patient rapport or specialty interests. Discussion: Although concern for infection was initially high, it decreased after the introduction of the COVID-19 vaccine despite increasing incidence nationally and then peaked again during the Omicron surge. The degree of concern did not exceed initial levels, despite unprecedentedly high disease prevalence. Higher infection rates correlated with greater perceived impact on clinical experiences. Our study underscores the importance of vaccination, highlights learners' concerns and resilience throughout the pandemic, and should be considered in balancing student exposure with maintaining clinical opportunities. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01589-8.

Environments, processes, and outcomes - using the LEPO framework to examine medical student learning preferences with traditional and electronic resources.

Changes in medical student learning preferences help drive innovation in teaching and require schools and commercial resources to quickly adapt. However, few studies have detailed the relationship of learner preferences to the environment and teaching modalities used in the pre-clerkship years, nor do they incorporate third-party resources. Our study attempts to analyze learner preferences by comparing the use of traditional and third-party resources. In 2017-18, a survey was distributed to medical students and residents at two accredited medical schools. Participants noted preferred styles of learning regarding lecture duration, timing, location, format, third-party resources, learner types and USMLE Step 1 scores. The 'Learning Environment, Learning Processes, and Learning Outcomes' (LEPO) framework [5] was used to examine learner preferences, with responses compared using the Mann-Whitney U and two proportion z-tests. A total of 329 respondents completed the survey: 62.7% medical students and 37.3% residents. The majority of participants identified their learning style by Kolb [6] as converging (33.0%) or accommodating (39.2%). Students preferred lectures 30-40 minutes long (43.3%), during morning hours (54.2%), in their own homes (52.0%), via online lectures with simultaneous drawings (56.0%), and classroom/podcast lectures with PowerPoint® presentations (54.3%). Overall, students rated third-party resource characteristics higher than traditional curricula, including effectiveness of teachers, length, quality, time of day, and venue (p < 0.001), but also preferred small group formats. Students reported animated videos (46.6%) and simultaneous drawings (46.5%) as the most effective means of retaining information. Understanding changing learner preferences is important in creating optimal curricula for today's students. Using the LEPO framework, this study identifies critical preferences in successfully teaching medical students, inclusive of commercial and traditional resources. These results can also help guide changes in pedagogy necessary due to the more recent COVID-19 pandemic.

Using virtual reality as a replacement for hospital tours during residency interviews.

BACKGROUND: Residency programs invest a significant amount of time and resources on the recruitment process, and maintaining efficiency and cost-effectiveness are very important. Virtual Reality (VR) has become an adaptive substitute for 'real life' experiences and its use during the interview season could help save time and resources. OBJECTIVE: With the intention to maximize the interview day and provide a cost-effective alternative to facility tours, a Med-Peds residency training program introduced a VR tour of their children's hospital during recruitment. DESIGN: The Med-Peds program replaced an in-person facility tour of the children's hospital with a VR tour. Applicants were asked to complete an anonymous, voluntary survey on their VR experience at the end of the interview season, and rank features of the interview day in order of importance. RESULTS: There were 33 respondents out of 54 interviewees. Approximately two thirds (63-66%) agreed that VR was non-inferior and superior to in-person facility tours, and that the use of VR had a favorable impact on their perception of the program. However, almost 50% of the applicants had some difficulty using VR technology. CONCLUSION: Use of VR facility tours as an alternative to in-person tours of affiliate training facilities during a residency interview day is a viable and innovative option that can save time and money and favorably impact the applicant's impression of the program. More research is necessary to assess whether VR tours can replace in-person tours at the main teaching site, however, while social distancing measures are in place, VR tours may become necessary for programs moving forward. ABBREVIATIONS: Med-Peds: Internal Medicine-Pediatrics; VR: Virtual Reality; AAMC: Association of American Medical Colleges; IRB: Institutional Review Board.

Marked Sinus Bradycardia Associated With Remdesivir in COVID-19: A Case and Literature Review.

Remdesivir has seen extensive use during the coronavirus disease-2019 pandemic given its clinically proven efficacy against severe acute respiratory syndrome coronavirus type 2. There has been little cited regarding adverse effects. Here we present the case of a patient with marked sinus bradycardia that began acutely on initiation of remdesivir and resolved almost immediately on cessation of the drug. (Level of Difficulty: Beginner.).

Sodium reduction strategies through use of meat extenders (white button mushrooms vs. textured soy) in beef patties.

Lowering the sodium content in meat products, particularly in beef patties, can be challenging because sodium plays many functional roles in these products. Meat extenders can contribute to lower sodium content by imparting complementary flavors while reducing caloric and sodium content. A systematic comparison of two meat extenders, namely mushrooms and textured soy (TSP) in terms of physical and sensory characteristics, is presented herein. The physical properties of the samples suggested that the use of mushroom and TSP extender would perform statistically similar to an all-meat control depending on the level of substitution. Hedonic sensory analysis showed meat extension using mushrooms yielded liking scores more similar to the all-meat formulations than TSP in reduced sodium applications. The results of this research suggest that mushrooms have the potential to be successfully incorporated into reduced sodium meat products to provide a healthier product.

Utilizing Mushrooms to Reduce Overall Sodium in Taco Filling Using Physical and Sensory Evaluation.

This project investigated the use of integrating mushrooms into beef taco filling as a means to reduce overall sodium for food service applications. Initial product development used physical characterization analysis (moisture, yield, color, and texture) to determine initial threshold of mushroom inclusion with minimal differences against an all-meat control. Increasing mushroom inclusion increased moisture and yield before draining but decreased yield after draining, lightness, redness, and texture. Results showed that inclusion under 50% by weight minimized physical attribute deviation from an all-meat control. Additional physical analysis investigated a variety of other factors (mushroom type, blanching, and particle size) to determine if other attributing mushroom characteristics would yield statistical similarity to the all-meat control. Results showed that a formulation containing up to 45% mushrooms can be integrated into beef fillings using un-blanched, white button mushrooms with small grind (1 to 5 mm), which maximized mushroom usage while minimizing differences from the all-meat control. Additional sodium analysis showed that varying salt level in formulations did not affect physical characteristics and mushroom inclusion could not significantly reduce overall sodium level. Optimized mushroom samples were then fielded in a hedonic sensory study to untrained consumers to evaluate product liking attributes (overall liking, aroma, color, flavor, juiciness, saltiness, and texture). Samples with overall liking scores that closely matched the control were then fielded in a paired-preference test to determine acceptance. Consumers preferred a 45% mushroom with reduced sodium taco filling compared to its full sodium counterpart in a food service fielded paired-preference sensory test. PRACTICAL APPLICATION: Although diet can significantly reduce the risk of heart disease, American consumers continue to eat detrimental diets high in fat and sodium. Products need to be made that decrease fat and sodium intake while still delivering acceptable taste. Mushroom substitution into meat-based products can be a strategy to develop products that can decrease fat and sodium consumption while increasing vegetable intake without compromising the quality and taste consumers demand. This research shows how consumers can accept meat-based products containing mushrooms with potential for direct food service application.

Adolescent HIV viral load in an urban hospital in Newark, New Jersey.

BACKGROUND AND OBJECTIVES: Human immunodeficiency virus (HIV) in adolescents is a growing concern. Amid psychosocial challenges, adolescents must successfully transition into adult-centered care; however, little is known about outcome measurements within this period. We assessed the trend in adolescent HIV viral loads (VLs) in a community with a high HIV prevalence, allowing physicians to better recognize the challenges of transitioning adolescents with HIV to adult care. PATIENTS AND METHODS: All HIV RNA VLs from the Molecular Virology Lab at University Hospital in Newark, New Jersey, from 2007 to 2010 were obtained. Patients were divided into pediatric (<13 years of age), adolescent (13-25 years of age), and adult (>25 years of age) age groups. Univariate and multivariate analyses assessed characteristics of patients by age and gender. RESULTS: A minimum of 40 pediatric, 178 adolescent, and 1335 adult patients were identified per year. There was a statistically significant increase in VLs of adolescents when compared to pediatric patients (P < .02). In 3 of the 4 years, there was a statistically significant increase in the rate of male adolescents reaching undetectable VLs compared to female adolescents. The average VL by age demonstrated increasing VLs from age 12 through age 24, while the percentage of patients reaching undetectable VLs peaked at 80% at age 8 and declined through age 24. CONCLUSION: Successful transitional care programs should focus on pediatric needs to address the noticeable decrease in virologic control beginning at 8 years of age and the decreased rate of virologic suppression in females, creating concern for potential gender inequalities and increased risk of vertical transmission.

Establishing legal limits for driving under the influence of marijuana.

Marijuana has become the most commonly detected non-alcohol substance among drivers in the United States and Europe. Use of marijuana has been shown to impair driving performance and increase crash risk. Due to the lack of standardization in assessing marijuana-induced impairment and limitations of zero tolerance legislation, more jurisdictions are adopting per se laws by specifying a legal limit of Δ9-tetrahydrocannabinol (THC) at or above which drivers are prosecuted for driving under the influence of marijuana. This review examines major considerations when developing these threshold THC concentrations and specifics of legal THC limits for drivers adopted by different jurisdictions in the United States and other countries.

Testicular trauma resulting in shock and systemic inflammatory response syndrome: a case report.

INTRODUCTION: Acute painful scrotum in children may be associated with torsion of the testis, hematocele, epididymitis and direct testicular injury with hematoma formation. More frequently, however, acute scrotum occurs without a precipitating factor. While most traumatic testicular injuries resolve with conservative management, many require surgical exploration and some are life-threatening. CASE PRESENTATION: A 13-year-old boy with a history of testicular trauma presented with severe scrotal swelling and shock. This case study examines the presentation and possible role of cytokines in the development of systemic inflammatory response syndrome in a child with acute traumatic epididymitis. CONCLUSION: Post-traumatic epididymitis presenting as shock in boys is rarely reported. We advocate early recognition of the chain of events leading to clinical presentation of shock and prompt treatment to preserve testicular viability.