The Opaque Language of Sexuality: Medical Students' and Providers' Beliefs About Virginity.

Although virginity is not a medical term and is instead socially constructed, it remains unknown what medical providers believe about the biological basis of virginity. This study explored providers' and medical students' beliefs about virginity and the potential impact of such beliefs on healthcare. This was a concurrent mixed-method survey study of 124 medical students and 216 healthcare providers (Registered Nurse, Physician Assistant, Nurse Practitioner, and Doctor of Medicine) at Penn State Health and The Pennsylvania State University College of Medicine. Participants rated their level of agreement with common misconceptions about virginity on a six-point Likert scale. Open-ended questions gave respondents the opportunity to define virginity and to describe terms like virgin and virginal in the context of sexual experience and the medical lexicon. We identified common themes in the qualitative data using thematic analysis. Frequencies of misconceptions and statistically significant demographic associations were identified in the quantitative data. Definitions of virginity were varied and vague, most with negative connotations. A majority of respondents said that virginity has no biological basis. Many participants identified downsides to use of terms like virgin, virginity, and virginal in medicine. The most prevalent misconceptions about virginity were related to the hymen. Seventeen percent of students and 26% of providers at least somewhat agreed that it was possible to determine whether a person has engaged in vaginal intercourse through a gynecological exam. Misconceptions about virginity persist in medicine and bias, even if unintended, may impact the quality-of-care people with vaginas receive. Language around sexual health should be specific, inclusive, clinically relevant, and free from judgment. Medical education must continue to work to eliminate the concept of a biological basis to virginity.

Visual thinking Strategies and the peril of 'see one, do one, teach one'.

Visual Thinking Strategies is an arts and humanities pedagogical intervention increasingly incorporated into medical education. As a straightforward method that appears easy to use, its nuances are often overlooked or-less frequently-improperly implemented entirely. Such haphazard use can lead to lessened impact for learners, and result in inconsistent and non-generalizable findings in studies in the nascent field of arts and humanities medical education. Critical and often glossed-over components of Visual Thinking Strategies include choosing the appropriate artwork, adhering to the specific 3-question language of the method, facilitating dialogue with effective paraphrasing, framing and linking of participant comments, intentionally utilizing non-verbal communication, and carefully setting up the environment. These components can be systematically taught by strengthening Visual Thinking Strategies training for faculty and adopting faculty development techniques from the K-12 education realm, namely peer and video feedback, where VTS has been used and fine-tuned for decades. It is an opportune time to begin rigorous faculty coaching for Visual Thinking Strategies facilitation and set the standard for art and humanities interventions in medical education.

How to design and implement a Group Poem activity.

Museum-based learning activities provide interactive and innovative ways to integrate the arts and humanities into medical education. Like other museum-based activities, the Group Poem supports the development of multiple clinically relevant skills and attributes, such as observation, communication, perspective-taking, empathy, and implicit bias awareness. In this paper, we present a step-by-step guide for educators seeking to design and implement a museum-based Group Poem activity for medical learners. The overall 'task' of the activity is for learners to collectively create a poem that they perform for others, a process that participants find to be engaging and meaningful to their formation as physicians. In this paper, we provide specific directions on pre-selecting the works of art, preparing the supplies, dividing into small groups, providing iterative instructions to learners, managing the timing of the session, and debriefing the activity. Although designed to be experienced in an art museum, we note that the Group Poem activity can also be conducted in the classroom or virtually using photographic or digital reproductions of artwork.

Bringing Needed Change to Medical Student Well-Being: A Call to Expand Accreditation Requirements.

Issue: Noting high rates of burnout, depression, and suicidality among medical students, academic medical communities are trying to identify preventive and curricular measures that protect and promote student well-being. To date, the effectiveness of these efforts is unclear. In addition, evidence increasingly suggests that the major drivers of distress appear to be factors within the social, learning, and work environments. Specific to medical schools in the United States, neither the Liaison Committee on Medical Education nor the Commission on Osteopathic College Accreditation include accreditation standards regarding well-being curricula and, as such, these curricula are not well-integrated into students' medical school experience. Current accreditation standards also do not specifically require institutions to assess or address systemic factors of the learning environment that negatively affect student well-being. Evidence: This paper proposes expanding current Liaison Committee on Medical Education and Commission on Osteopathic College Accreditation standards on professionalism to incorporate well-being as a core component of professional identity formation by requiring individual and institutional-level actions. Proposed changes to accreditation standards include (1) institutional assessment of the impact of the learning environment on student well-being; (2) continuous quality improvement efforts to address structural factors associated with student well-being and modification of practices that impair student well-being; and (3) integrated curriculum with related assessment to educate students on empirically-supported strategies for well-being. Implications: Refining undergraduate medical education accreditation standards in the United States to include language specific to student well-being will facilitate long overdue changes to the learning environment. In the end, the goal is not just to improve medical student well-being, but to provide a workforce better equipped for a sustainable and meaningful career.

δ13C methane source signatures from tropical wetland and rice field emissions.

The atmospheric methane (CH4) burden is rising sharply, but the causes are still not well understood. One factor of uncertainty is the importance of tropical CH4 emissions into the global mix. Isotopic signatures of major sources remain poorly constrained, despite their usefulness in constraining the global methane budget. Here, a collection of new δ13CCH4 signatures is presented for a range of tropical wetlands and rice fields determined from air samples collected during campaigns from 2016 to 2020. Long-term monitoring of δ13CCH4 in ambient air has been conducted at the Chacaltaya observatory, Bolivia and Southern Botswana. Both long-term records are dominated by biogenic CH4 sources, with isotopic signatures expected from wetland sources. From the longer-term Bolivian record, a seasonal isotopic shift is observed corresponding to wetland extent suggesting that there is input of relatively isotopically light CH4 to the atmosphere during periods of reduced wetland extent. This new data expands the geographical extent and range of measurements of tropical wetland and rice δ13CCH4 sources and hints at significant seasonal variation in tropical wetland δ13CCH4 signatures which may be important to capture in future global and regional models. This article is part of a discussion meeting issue 'Rising methane: is warming feeding warming? (part 2)'.

Utility of machine learning algorithms in degenerative cervical and lumbar spine disease: a systematic review.

Machine learning is a rapidly evolving field that offers physicians an innovative and comprehensive mechanism to examine various aspects of patient data. Cervical and lumbar degenerative spine disorders are commonly age-related disease processes that can utilize machine learning to improve patient outcomes with careful patient selection and intervention. The aim of this study is to examine the current applications of machine learning in cervical and lumbar degenerative spine disease. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of PubMed, Embase, Medline, and Cochrane was conducted through May 31st, 2020, using the following terms: "artificial intelligence" OR "machine learning" AND "neurosurgery" AND "spine." Studies were included if original research on machine learning was utilized in patient care for degenerative spine disease, including radiographic machine learning applications. Studies focusing on robotic applications in neurosurgery, navigation, or stereotactic radiosurgery were excluded. The literature search identified 296 papers, with 35 articles meeting inclusion criteria. There were nine studies involving cervical degenerative spine disease and 26 studies on lumbar degenerative spine disease. The majority of studies for both cervical and lumbar spines utilized machine learning for the prediction of postoperative outcomes, with 5 (55.6%) and 15 (61.5%) studies, respectively. Machine learning applications focusing on degenerative lumbar spine greatly outnumber the current volume of cervical spine studies. The current research in lumbar spine also demonstrates more advanced clinical applications of radiographic, diagnostic, and predictive machine learning models.

Parental deployment and distress, and adolescent disordered eating in prevention-seeking military dependents.

OBJECTIVE: Parental military deployment can lead to stress in the family system due to concerns about the deployed service-member's safety and increased responsibilities for those not deployed. Parent-related stress can impact adolescent disordered eating. Given the important role that stress plays in disordered eating and obesity, it is crucial to understand the impacts of unique stressors to which vulnerable populations are exposed. METHOD: We studied 126 adolescent (14.3 ± 1.6 years; 59.5% girls; 44.4% non-Hispanic White; BMI-z, 1.91 ± .39) military dependents prior to entering an obesity and binge-eating disorder prevention trial. The Eating Disorder Examination was used to assess adolescent disordered eating. Parents self-reported their own distress and family deployment history that occurred during the adolescent's lifetime. RESULTS: Parental distress interacted with frequency of parental deployments such that for those with high parental distress, more frequent deployment was associated with greater adolescent shape and weight concerns (ß = .21, p = .012) and global eating pathology (ß = .18, p = .024). DISCUSSION: In this hypothesis-generating study, the combination of number of deployments and parental distress may be associated with disordered eating among adolescent military dependents seeking prevention of binge-eating disorder and adult obesity. If these preliminary findings are supported longitudinally, interventions to reduce parental stress related to deployment may be warranted to reduce disordered eating in adolescent dependents.

Examination of the Interpersonal Model With Adolescent Military Dependents at High Risk for Adult Obesity.

OBJECTIVE: Adolescent military dependents may be at higher risk for psychosocial stressors and disordered eating compared with civilian youths, but the mechanisms underlying these risks are unclear. Interpersonal theory proposes that difficult relationships lead to negative affect, thereby promoting emotional eating, which has been linked to and predictive of disordered eating. The interpersonal model may have particular relevance for understanding disordered eating among adolescent military dependents, given the unique stressors related to their parents' careers. This study aimed to examine the premise of the interpersonal model (that negative emotions mediate the association between multiple aspects of social functioning and emotional eating) among a cohort of adolescent military dependents. METHODS: Military dependents (N=136; 56% female, mean±SD age=14±2 years, body mass index adjusted for age and sex [BMIz]=2.0±0.4) at risk for adult obesity and binge eating disorder, as indicated by reported loss-of-control eating and/or anxiety symptoms, were assessed prior to participation in a study of excess weight-gain prevention. Bootstrapped mediation analyses were conducted to examine depressive symptoms as a potential mediator of the relationship between social functioning and emotional eating. Analyses were adjusted for age, sex, race-ethnicity, BMIz, and presence of reported loss-of-control eating and anxiety. RESULTS: Depressive symptoms were a significant mediator of the relationship between multiple domains of social functioning, including loneliness, social adjustment related to family and friends, attachment to father and peers, and emotional eating (p<0.05). CONCLUSIONS: The interpersonal model may contribute to our understanding of excess weight gain and binge eating disorder among adolescent military dependents. Prospective data are needed to determine the utility of interpersonal theory in predicting treatment response and outcomes among this population.

Team-Based Clinic Redesign of Opioid Medication Management in Primary Care: Effect on Opioid Prescribing.

PURPOSE: Six key elements of opioid medication management redesign in primary care have been previously identified. Here, we examine the effect of implementing these Six Building Blocks on opioid-prescribing practices. METHODS: Six rural-serving organizations with 20 clinic locations received support for 15 months during the period October 2015 to May 2017 to implement the Six Building Blocks. Patients undergoing long-term opioid therapy (LtOT) at these study sites were compared with patients undergoing LtOT enrolled in a regional health plan who did not receive care at the study sites but who resided in the same primary care service areas (control group). Outcomes were monthly trend in the proportion of patients undergoing LtOT prescribed a ≥100 morphine equivalent dose (MED) of opioids daily and the total number of patients receiving an opioid prescription. An interrupted time series using difference-indifference analysis was used for tests of significance. RESULTS: The proportion of patients prescribed a ≥100 MED of opioids daily decreased 2.2% (11.8% to 9.6%) among patients at the intervention clinics and 1.3% (14.0% to 12.7%) among patients in the control group. The rate of decrease was significantly greater among study patients than among patients in the control group (P = .018). The rate of decrease in the number of patients on LtOT at intervention clinics increased during the intervention period compared with the preintervention period (P <.001). CONCLUSIONS: Efforts to redesign opioid medication management in primary care resulted in a significant decrease in opioid prescribing. Future research is needed to determine if these results are generalizable to other settings and to assess implications for patient-reported outcomes.

Dental Problems in Primary Care.

Oral health directly affects overall health and quality of life. More Americans lack dental insurance than medical insurance. Patients with poor oral health are more likely to have respiratory and cardiovascular diseases, adverse pregnancy outcomes, and diabetes mellitus. Early childhood caries is the most common chronic condition in American children. Certain illicit and prescription drugs increase the risk of enamel erosion and caries formation in adults. Incision and drainage is the treatment of choice for dental abscess. Risk factors for periodontal disease include smoking, diabetes, human immunodeficiency virus infection, use of certain medications, and genetic susceptibility. Patients with gingivitis typically present with swollen, erythematous gum tissue that bleeds easily with brushing or flossing. One in three children will have an injury to the primary teeth, and one in five 12-year-old children will have an injury to the permanent teeth. All dental fractures should be evaluated with imaging and managed in conjunction with a dental professional. Immediate reimplantation is the preferred treatment for avulsed permanent teeth. Primary care clinicians are well positioned to reduce rates of oral disease. Family physicians can incorporate oral health into routine practice through counseling about diet, oral hygiene, smoking cessation, and fluoride supplementation; application of fluoride varnish; and screening for dental disease.

Effect of adapted interpersonal psychotherapy versus health education on mood and eating in the laboratory among adolescent girls with loss of control eating.

OBJECTIVE: Interpersonal psychotherapy (IPT) is aimed at improving negative affect that is purported to contribute to the development and maintenance of loss-of-control (LOC) eating. Although youth who report LOC over eating tend to consume more snack-foods than those without LOC, it is unknown if IPT impacts objective energy intake. METHODS: To test if IPT improves mood and eating in the laboratory, we examined a sample of 88 girls with LOC eating who were randomized to either IPT (n = 46) or a standard-of-care health education (HE) group program. At baseline, and 6-month (follow-up 1) and 1-year (follow-up 2) following the initiation of the groups, girls consumed lunch from a multi-item meal with an instruction designed to model a LOC episode. Girls also reported mood state immediately before each meal. RESULTS: Girls in IPT experienced no significant changes in pre-meal state depressive affect, while girls in HE experienced a non-significant improvement by follow-up 1 and then returned to baseline by follow-up 2 (p < .04). We found no significant group difference for changes in total intake relative to girls' daily energy needs (p's ≥ .25). However, IPT reduced, while HE increased, the percentage of daily energy needs consumed from snack-foods by follow-up 2 (p = .04). Within-groups, HE increased their snack food intake from follow-up 1 to follow-up 2 (p = .01). CONCLUSIONS: In adolescent girls with LOC, IPT did not change total intake at the test meal and was associated with reduced snack-food intake. Data are required to determine if IPT effectively prevents excess weight gain in the longer-term. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:490-498).

Fortified breakfast cereal consumed daily for 12 wk leads to a significant improvement in micronutrient intake and micronutrient status in adolescent girls: a randomised controlled trial.

BACKGROUND: Poor micronutrient status is reported among adolescents across Europe and USA. This may be related to the well-documented decline in the regular consumption of breakfast by this group. The regular consumption of a breakfast cereal offers a possible means to improve micronutrient status; fortified cereal is likely to have enhanced benefit. A study was conducted to determine the efficacy of the regular consumption of a fortified cereal with milk, compared with unfortified cereal, consumed either as a breakfast or a supper, in improving micronutrient intake and micronutrient status of adolescent girls. METHODS: A randomised, double-blind, placebo-controlled intervention trial was conducted in girls recruited at ages 16-19 years, from schools and colleges in Sheffield, UK. Girls were randomised to receive 50 g fortified or unfortified cereal, with 150 ml semi-skimmed milk, daily, for 12 weeks, as a breakfast or as a supper. Dietary intake was estimated using a 4-d food diary and blood collected for the assessment of nutritional status. Within-group changes were tested using a paired sample t test; two-way ANOVA was used to analyse effects of the intervention, with cereal type and time of consumption as factors, correcting for baseline values. The analysis was conducted on 71 girls who completed the study. RESULTS: Consumption of unfortified cereal elicited an increase in the intake of vitamins B1, B2 and B6; consumption of fortified cereal elicited increases in vitamins B1, B2, B6, B12, folate and iron (P < 0.001) and of vitamin D (P = 0.007), all increases were significantly greater than for unfortified cereal. Consumption of the fortified cereal also led to a significant improvement in biomarkers of status for vitamins B2, B12, folate and of iron, compared with girls receiving the unfortified cereal, and maintained vitamin D status, in contrast with the girls receiving the unfortified cereal (P < 0.001). CONCLUSIONS: The daily consumption of cereal with milk for 12 weeks by adolescent girls, increased intakes of micronutrients. The consumption of fortified cereal elicited greater increases than for unfortified cereal and improved biomarkers of micronutrient status. The findings justify strategies to encourage the consumption of fortified cereal with milk by adolescents, either as a breakfast or a supper. TRIAL REGISTRATION: Registered with Current Controlled Trials (Registration: ISRCTN55141306 ).

Cardiac Rehabilitation: Improving Function and Reducing Risk.

Cardiac rehabilitation is a comprehensive multidisciplinary program individually tailored to the needs of patients with cardiovascular disease. The overall goals focus on improving daily function and reducing cardiovascular risk factors. Cardiac rehabilitation includes interventions aimed at lowering blood pressure and improving lipid and diabetes mellitus control, with tobacco cessation, behavioral counseling, and graded physical activity. The physical activity component typically involves 36 sessions over 12 weeks, during which patients participate in supervised exercise under cardiac monitoring. There are also intensive programs that include up to 72 sessions lasting up to 18 weeks, although these programs are not widely available. Additional components of cardiac rehabilitation include counseling on nutrition, screening for and managing depression, and assuring up-to-date immunizations. Cardiac rehabilitation is covered by Medicare and recommended for patients following myocardial infarction, bypass surgery, and stent placement, and for patients with heart failure, stable angina, and several other conditions. Despite proven benefits in mortality rates, depression, functional capacity, and medication adherence, rates of referral for cardiac rehabilitation are suboptimal. Groups less likely to be referred are older adults, women, patients who do not speak English, and persons living in areas where cardiac rehabilitation is not locally available. Additionally, primary care physicians refer patients less often than cardiologists and cardiothoracic surgeons.

Comparison of overweight and obese military-dependent and civilian adolescent girls with loss-of-control eating.

OBJECTIVE: Limited data suggest that the children of U.S. service members may be at increased risk for disordered-eating. To date, no study has directly compared adolescent military-dependents to their civilian peers along measures of eating pathology and associated correlates. We, therefore, compared overweight and obese adolescent female military-dependents to their civilian counterparts along measures of eating-related pathology and psychosocial functioning. METHOD: Adolescent females with a BMI between the 85th and 97th percentiles and who reported loss-of-control eating completed interview and questionnaire assessments of eating-related and general psychopathology. RESULTS: Twenty-three military-dependents and 105 civilians participated. Controlling for age, race, and BMI-z, military-dependents reported significantly more binge episodes per month (p < 0.01), as well as greater eating-concern, shape-concern, and weight-concern (p's < 0.01) than civilians. Military-dependents also reported more severe depression (p < 0.05). DISCUSSION: Adolescent female military-dependents may be particularly vulnerable to disordered-eating compared with civilian peers. This potential vulnerability should be considered when assessing military-dependents.

Early dipeptide repeat pathology in a frontotemporal dementia kindred with C9ORF72 mutation and intellectual disability.

Familial cases of frontotemporal dementia (FTD) provide an opportunity to study the pathophysiology of this clinically diverse condition. The C9ORF72 mutation is the most common cause of familial FTD, recent pathological descriptions challenge existing TDP-43 based hypotheses of sporadic FTD pathogenesis. Non-ATG dependent translation of the hexanucleotide expansion into aggregating dipeptide repeat (DPR) proteins may represent a novel pathomechanism. We report detection of the DPR aggregates very early in C9ORF72 FTD development and also describe childhood intellectual disability as a clinical feature preceding dementia. The index case presented with psychiatric symptoms, progressing into typical FTD. Autopsy revealed extensive neuronal DPR aggregates but only minimal TDP-43 pathology. Her intellectually disabled elder son, also carrying the C9ORF72 mutation, died aged 26 years and at autopsy only DPR aggregates without TDP-43 were found. A second son also has intellectual disability, his C9ORF72 status is unknown, but chromosomal microarray revealed no other cause of disability. These cases both extend the existing phenotype of C9ORF72 mutation and highlight the potential significance of DPR translation early in disease development.

An Update on Heart Failure: New Definitions and Treatment.

Heart failure is defined by stages that are based on symptoms from at risk individuals to those with refractory symptoms. Along this continuum of care, we initiate optimal treatment that is then based on an individual's ejection fraction. Therapy is designed to reduce the progression of heart failure while reducing heart failure complications, deaths and hospitalizations.