DATA 2000 waiver training for medical students: Lessons learned from a medical school experience.

BACKGROUND: In the midst of this national opioid crisis, it has become apparent that there is a large shortage in the workforce of treatment providers equipped to deliver evidence-based care for opioid use disorders (OUD). Medications for opioid use disorder (MOUD), such as buprenorphine, are crucial in reducing mortality in those with OUD, and yet prescribers must meet federal waiver requirements under the Drug Addiction Treatment Act of 2000 (DATA 2000). There are now several pathways for medical schools to satisfy these waiver requirements for all graduates, but this has not yet become widespread. We propose that including a DATA 2000 waiver training within the medical school curriculum is a feasible and effective way to meet eligibility requirements to prescribe buprenorphine. Methods: As part of a longitudinal opioid curriculum requirement, we implemented a DATA 2000 waiver training for all rising Year 4 medical students. One hundred sixty-nine students completed a hybrid (online and in-person) waiver training. The majority completed a pre- and post-survey. Results: The pre-training survey showed 93% of rising Year 4 medical students (112/120) reported participation in care of patients with OUD. Students six month post-training reported a rise in confidence (1.94 to 2.45; p < 0.01) and knowledge (2.27 to 2.76; p < 0.01) regarding MOUD. They also reported their plans to apply for the buprenorphine waiver once licensed and reported being more likely to prescribe buprenorphine for OUD as a result of the training (mean = 3.35; SD = 1.36; 0 = extremely unlikely to 5 = extremely likely). Conclusions: We successfully implemented a DATA 2000 waiver training as a mandatory requirement for the medical school curriculum. Further studies are needed to determine optimal timing, best format, and frequency of reinforcement of MOUD educational content across the undergraduate and graduate medical education continuum.

A Clustered Randomized Trial of an Educational Intervention During Transplant Evaluation to Increase Knowledge of Living Donor Kidney Transplant.

INTRODUCTION: Maximizing education about living donor kidney transplant (LDKT) during the in-person evaluation at the transplant center may increase the numbers of kidney patients pursuing LDKT. Research Questions and Design: To test the effectiveness of a 1-time LDKT educational intervention, we performed a cluster-randomized trial among 499 patients who presented for evaluation of kidney transplant. We compared usual care education (n = 250) versus intensive LDKT education (n = 249), which was implemented only on the evaluation day and consisted of viewing a 25-minute video of information and stories about LDKT and discussion of LDKT possibilities with an educator. Our primary outcome was knowledge of LDKT, 1 week after the transplant evaluation. RESULTS: One week after evaluation, patients who received intensive education had higher knowledge than patients who received usual care (12.7 vs. 11.7; P = .0008), but there were no differences in postevaluation readiness for LDKT. Among patients who had not previously identified a potential living donor, receiving intensive education was associated with increased willingness to take steps toward LDKT. DISCUSSION: In conclusion, expansion of LDKT education within the evaluation day may be helpful, but interventions that are implemented at multiple times and for greater duration may be necessary to ensure larger and long-term behavioral changes in pursuit of LDKT.

A multicenter study of 30 days complications after deceased donor liver transplantation in the model for end-stage liver disease score era.

Knowledge of risk factors for posttransplant complications is likely to improve patient outcomes. Few large studies of all early postoperative complications after deceased donor liver transplantation (DDLT) exist. Therefore, we conducted a retrospective, cohort study of 30-day complications, their risk factors, and the impact on outcomes after DDLT. Three centers contributed data for 450 DDLTs performed from January 2005 through December 2009. Data included donor, recipient, transplant, and outcome variables. All 30-day postoperative complications were graded by the Clavien-Dindo system. Complications per patient and severe (≥ grade III) complications were primary outcomes. Death within 30 days, complication occurrence, length of stay (LOS), and graft and patient survival were secondary outcomes. Multivariate associations of risk factors with complications and complications with LOS, graft survival, and patient survival were examined. Mean number of complications/patient was 3.3 ± 3.9. At least 1 complication occurred in 79.3%, and severe complications occurred in 62.8% of recipients. Mean LOS was 16.2 ± 22.9 days. Graft and patient survival rates were 84% and 86%, respectively, at 1 year and 74% and 76%, respectively, at 3 years. Hospitalization, critical care, ventilatory support, and renal replacement therapy before transplant and transfusions during transplant were the significant predictors of complications (not the Model for End-Stage Liver Disease score). Both number and severity of complications had a significant impact on LOS and graft and patient survival. Structured reporting of risk-adjusted complications rates after DDLT is likely to improve patient care and transplant center benchmarking. Despite the accomplished reductions in transfusions during DDLT, opportunities exist for further reductions. With increasing transplantation of sicker patients, reduction in complications would require multidisciplinary efforts and institutional commitment. Pretransplant risk characteristics for complications must factor in during payer contracting.

How Neighborhood Poverty Structures Types and Levels of Social Integration.

Social integration is fundamental to health and well-being. However, few studies have explored how neighborhood contexts pattern types and levels of social integration that individuals experience. We examined how neighborhood poverty structures two dimensions of social integration: integration with neighbors and social integration more generally. Using data from the United States Third National Health and Nutrition Examination Survey, we linked study participants to percent poverty in their neighborhood of residence (N = 16,040). Social integration was assessed using a modified Social Network Index and neighborhood integration based on yearly visits with neighbors. We fit multivariate logistic regression models that accounted for the complex survey design. Living in high poverty neighborhoods was associated with lower social integration but higher visits with neighbors. Neighborhood poverty distinctly patterns social integration, demonstrating that contexts shape the extent and quality of social relationships.

Cardiopulmonary bypass has a modest association with cancer progression: a retrospective cohort study.

BACKGROUND: Given their frequency of occurrence in the United States, cancer and heart disease often coexist. For patients requiring open-heart surgery, this raises concern that the use of cardiopulmonary bypass (CPB) may cause a transient immunosuppression with the potential to promote the spread and growth of coexisting cancer cells. This study examined the association of cardiopulmonary bypass with cancer progression in a large population-based setting using linked data from several state-wide registries. METHODS: A retrospective cohort study of cancer risk, stage, and mortality in 43,347 patients who underwent coronary artery bypass graft (CABG) surgery with and without CPB in New Jersey between 1998-2004 was conducted. A competing risk analogue of the Cox proportional hazards model with propensity score adjustment and regression on the cause-specific hazard was used to compute relative risk ratios (95% confidence intervals [CIs]) for patients undergoing CABG surgery with and without CPB. RESULTS: An increased risk for overall cancer incidence (17%) and cancer-specific mortality (16% overall, 12% case fatality) was observed; yet these results did not reach statistical significance. Of 11 tumor-specific analyses, an increased risk of skin melanoma (1.66 [95% CI, 1.08-2.55: p=0.02]) and lung cancer (1.36 [95% CI, 1.02-1.81: p=0.03]) was observed for patients with pump versus off-pump open-heart surgery. No association was found with cancer stage. CONCLUSIONS: These results suggest that there may be a relationship between CPB and cancer progression. However, if real, the effect is likely modest at most. Further research may still be warranted with particular focus on skin melanoma and lung cancer which had the strongest association with CPB.

A 10-year review of assault-related open-globe injuries at an urban hospital.

BACKGROUND: To describe the demographics and outcomes of assault-related open-globe injuries (OGI) at University Hospital (UH), Newark, New Jersey over a ten-year period. METHODS: The medical records of all subjects presenting to a single university referral center with an OGI were retrospectively analyzed to identify prognostic factors for enucleation and final visual acuity (VA) of no light perception (NLP). RESULTS: One hundred and forty-eight eyes of 147 patients presented to UH with assault-related OGI. Eighty-two percent of patients were male, and the mean age was 35.9 years. The anatomic site of the wound was zone 3 in the majority (54.1 %) of eyes. Most common type of injury noted was rupture (57.4 %), followed by penetrating injury (35.1 %). Mean initial presenting and final VA in LogMAR were 2.38 ± 0.12 and 2.18 ± 0.16 respectively. Initial Snellen VA was no light perception (NLP) in 57 eyes (38.5 %); four eyes had an initial VA of ≥ 20/40 (2.7 %). Final VA was NLP in 68 eyes (45.9 %) of which 46 were enucleated (31.1 %); 18 eyes (12.2 %) had a final VA of ≥ 20/40. Fifty eyes (33.8 %) underwent pars plana vitrectomy (PPV). Significant risk factors of final VA of NLP or enucleation included initial VA of NLP, perforating or rupture type of OGI, and zone 3 injury. Eyes that sustained penetrating injuries were less likely to have final VA of NLP or require enucleation. CONCLUSIONS: Assault-related OGIs carry an extremely poor visual prognosis and a high rate of enucleations. Only eighteen eyes (12.2 %) recovered VA ≥ 20/40. We found initial VA of NLP and zone 3 injury to be significant predictors of final VA of NLP or undergoing enucleation. Penetrating injuries were less likely to have a final VA of NLP or an enucleation.

Protocol of a cluster randomized trial of an educational intervention to increase knowledge of living donor kidney transplant among potential transplant candidates.

BACKGROUND: The best treatment option for end-stage renal disease is usually a transplant, preferably a live donor kidney transplant (LDKT). The most effective ways to educate kidney transplant candidates about the risks, benefits, and process of LDKT remain unknown. METHODS/DESIGN: We report the protocol of the Enhancing Living Donor Kidney Transplant Education (ELITE) Study, a cluster randomized trial of an educational intervention to be implemented during initial transplant evaluation at a large, suburban U.S. transplant center. Five hundred potential transplant candidates are cluster randomized (by date of visit) to receive either: (1) standard-of-care ("usual") transplant education, or (2) intensive education that is based upon the Explore Transplant series of educational materials. Intensive transplant education includes viewing an educational video about LDKT, receiving print education, and meeting with a transplant educator. The primary outcome consists of knowledge of the benefits, risks, and process of LDKT, assessed one week after the transplant evaluation. As a secondary outcome, knowledge and understanding of LDKT are assessed 3 months after the evaluation. Additional secondary outcomes, assessed one week and 3 months after the evaluation, include readiness, self-efficacy, and decisional balance regarding transplant and LDKT, with differences assessed by race. Although the unit of randomization is the date of the transplant evaluation visit, the unit of analysis will be the individual potential transplant candidate. DISCUSSION: The ELITE Study will help to determine how education in a transplant center can best be designed to help Black and non-Black patients learn about the option of LDKT. TRIAL REGISTRATION: Clinicaltrials.gov number NCT01261910.

Self-reported non-adherence to immune-suppressant therapy in liver transplant recipients: demographic, interpersonal, and intrapersonal factors.

Adherence to immune suppressants and follow-up care regimen is important in achieving optimal long-term outcomes after organ transplantation. To identify patients most at risk for non-adherence, this cross-sectional, descriptive study explores the prevalence and correlates of non-adherence to immune-suppressant therapy among liver recipients. Anonymous questionnaires mailed consisted of the domains: (i) adherence barriers to immune suppressants, (ii) immune suppressants knowledge, (iii) demographics, (iv) social support, (v) medical co-morbidities, and (vi) healthcare locus of control and other beliefs. Overall response was 49% (281/572). Data analyzed for those transplanted within 10 yr of study reveal 50% (119/237) recipients or 9.2/100 person years reporting non-adherence. Non-adherence was reported highest in the 2-5 yr post-transplant phase (69/123, 56%). The highest immune-suppressant non-adherence rates were in recipients who are: divorced (26/34, 76%, p=0.0093), have a history of substance or alcohol use (42/69, 61%, p=0.0354), have mental health needs (50/84, 60%, p=0.0336), those who missed clinic appointments (25/30, 83%, p<0.0001), and did not maintain medication logs (71/122, 58%, p=0.0168). Respondents who were non-adherent with physician appointments were more than four and a half times as likely (OR 4.7, 95% CI 1.5-14.7, p=0.008) to be non-adherent with immune suppressants. In conclusion, half of our respondents report non-adherence to immune suppressants. Factors identified may assist clinicians to gauge patients' non-adherence risk and target resources.

A Multi-Modal Remote Clinical Skills Mini-Course Utilizing a Teaching TeleOSCE.

In the setting of the coronavirus pandemic, medical schools across the world transitioned to a remote learning curriculum with the challenge of developing innovative methods to teach clinical skills. During the pandemic, we designed a 2-week remote clinical skills mini-course for third year medical students. The focus was on clinical reasoning, counseling, and the following the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs): 1 (history and physical exam), 2 (prioritize a differential diagnosis), 3 (recommend and interpret diagnostic tests), and 5 (document a clinical encounter). A multi-modal approach included large and small group virtual case-based discussions, a teaching TeleOSCE (Objective Structured Clinical Examination), and feedback on patient note skills. Students were asked to self-assess their skills before and after the course based on the core EPAs, counseling skills, and overall preparedness for United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills exam. Students demonstrated statistically significant increases in mean self-rated scores in all areas except interpreting results of basic studies. They found the teaching TeleOSCE and feedback on their notes the most useful. Future curricula will consider integration of peer-peer remote OSCE practice sessions as well as faculty feedback for individualized learning plans. Lessons learned will be useful for remote structured clinical skills courses in the setting of the pandemic.

Integrating the Bleeding Control Basic course into medical school curriculum.

BACKGROUND: The American College of Surgeons has pioneered hemorrhage control through its lifesaving bleeding control (BCon) basics course. A gap exists in teaching these skills to medical students. We sought to integrate BCon into the medical school curriculum. METHODS: BCon programs taught to entering Year 1 medical students in Academic Years 2017-2018. Post-course surveys assessed effectiveness of teaching and learner confidence in performing skills. Refreshers in Year 2 and Year 3 of study were implemented to reinforce skills. RESULTS: Post-course surveys (n = 348) showed that 98% of students felt that they were effectively taught how to stop bleeding and 92% felt comfortable using these skills. CONCLUSION: The BCon program is feasible to implement in medical school. It is easily integrated into pre-existing curricula in addition to other life support skills taught to medical students. SUMMARY: Bleeding control is increasingly a topic of national concern with mass casualty incidents. We used a peer training model to teach BCon techniques to all our medical students on entry into medical school and these skills were refreshed longitudinally in the next two years. Combining BCon training with other basic life support skills training is feasible and medical students find this training effective.

Analysis of testing with multiple choice versus open-ended questions: Outcome-based observations in an anatomy course.

The pedagogical approach for both didactic and laboratory teaching of anatomy has changed in the last 25 years and continues to evolve; however, assessment of student anatomical knowledge has not changed despite the awareness of Bloom's taxonomy. For economic reasons most schools rely on multiple choice questions (MCQ) that test knowledge mastered while competences such as critical thinking and skill development are not typically assessed. In contrast, open-ended question (OEQ) examinations demand knowledge construction and a higher order of thinking, but more time is required from the faculty to score the constructed responses. This study compares performances on MCQ and OEQ examinations administered to a small group of incoming first year medical students in a preparatory (enrichment) anatomy course that covered the thorax and abdomen. In the thorax module, the OEQ examination score was lower than the MCQ examination score; however, in the abdomen module, the OEQ examination score improved compared to the thorax OEQ score. Many students attributed their improved performance to a change from simple memorization (superficial learning) for cued responses to conceptual understanding (deeper learning) for constructed responses. The results support the view that assessment with OEQs, which requires in depth knowledge, would result in student better performance in the examination. Anat Sci Educ 11: 254-261. © 2017 American Association of Anatomists.

The Health and Social Isolation of American Veterans Denied Veterans Affairs Disability Compensation.

Authors comparatively analyzed health and social isolation between U.S. military veterans denied Veterans Affairs (VA) disability compensation and veterans awarded VA disability compensation. The 2001 National Survey of Veterans was used to create a sample of 4,522 veterans denied or awarded VA disability compensation. Using the Andersen health services utilization model as a conceptual framework, multivariate logistic regression was applied to assess relationships between VA disability compensation award status, three separate domains of health, and correlates of social isolation. Results indicate that denied applicants were more likely than those awarded to have poor overall health (odds ratio [OR] = 1.45, 95% confidence interval [CI]: 1.23, 1.70), and limitations in activities of daily living (OR = 1.12, 95% CI: 1.03, 1.21). Denied applicants' physical functioning (40.3) and mental functioning (41.2) composite summary scores were not clinically different from those of awarded applicants (39.0 and 40.1, respectively), indicating that both were comparably impaired. Veterans denied VA disability compensation had poor health and functional impairments. They also experienced poverty and isolation, suggesting that they may be in need of additional supportive services. Connecting veterans to community resources could be a vital service to provide to all veterans applying for disability compensation.

Regulation of gene expression by translation factor eIF5A: Hypusine-modified eIF5A enhances nonsense-mediated mRNA decay in human cells.

Nonsense-mediated mRNA decay (NMD) couples protein synthesis to mRNA turnover. It eliminates defective transcripts and controls the abundance of certain normal mRNAs. Our study establishes a connection between NMD and the translation factor eIF5A (eukaryotic initiation factor 5A) in human cells. eIF5A modulates the synthesis of groups of proteins (the eIF5A regulon), and undergoes a distinctive two-step post-translational modification (hypusination) catalyzed by deoxyhypusine synthase and deoxyhypusine hydroxylase. We show that expression of NMD-susceptible constructs was increased by depletion of the major eIF5A isoform, eIF5A1. NMD was also attenuated when hypusination was inhibited by RNA interference with either of the two eIF5A modifying enzymes, or by treatment with the drugs ciclopirox or deferiprone which inhibit deoxyhypusine hydroxylase. Transcriptome analysis by RNA-Seq identified human genes whose expression is coordinately regulated by eIF5A1, its modifying enzymes, and the pivotal NMD factor, Upf1. Transcripts encoding components of the translation system were highly represented, including some encoding ribosomal proteins controlled by alternative splicing coupled to NMD (AS-NMD). Our findings extend and strengthen the association of eIF5A with NMD, previously inferred in yeast, and show that hypusination is important for this function of human eIF5A. In addition, they advance drug-mediated NMD suppression as a therapeutic opportunity for nonsense-associated diseases. We propose that regulation of mRNA stability contributes to eIF5A's role in selective gene expression.

Corneal Haze as Prognostic Indicator of Intraocular Pressure in Primary Congenital Glaucoma.

PURPOSE: To perform a longitudinal analysis on the association of corneal haze with intraocular pressure (IOP) in eyes with primary congenital glaucoma (PCG) over 3 years. PATIENTS AND METHODS: Charts of all patients diagnosed with glaucoma of childhood from 2002 to 2012 at our institution were retrospectively reviewed. Inclusion criteria were age 18 years and below, plus elevated IOP or characteristic clinical signs. Exclusion criteria were eyes with secondary glaucoma or corneal haze not from PCG and patients with prior ocular surgery or incomplete follow-up. RESULTS: Of 79 eyes with childhood glaucoma during this period, 36 eyes had PCG [25 patients; 15 male (60.0%), 14 bilateral (56.0%)]. Eighteen eyes (13 patients) presented with corneal haze, whereas 18 eyes (12 patients) did not. Eyes with haze were diagnosed at a younger age than eyes without haze (0.79 vs. 5.2 y, P<0.02). During year 1, eyes with haze underwent significantly more IOP-lowering procedures and used significantly fewer IOP-lowering medications. Multivariate analysis revealed that corneal haze increased IOP by 4.63 mm Hg when controlling for treatment over time (P<0.01). Eyes with haze had lower survival curves and a failure hazard of 1.3 times that of eyes without haze. These eyes had a lower proportion of qualified successes than eyes without haze at year 1 (P<0.05) but this was reversed at year 3 (P<0.02). CONCLUSIONS: Eyes with PCG-related corneal haze generally presented more severely than did those without haze, but postmanagement outcomes may be similar to those in eyes without haze.

The joint contribution of neighborhood poverty and social integration to mortality risk in the United States.

PURPOSE: A well-established literature has shown that social integration strongly patterns health, including mortality risk. However, the extent to which living in high-poverty neighborhoods and having few social ties jointly pattern survival in the United States has not been examined. METHODS: We analyzed data from the Third National Health and Nutrition Examination Survey (1988-1994) linked to mortality follow-up through 2006 and census-based neighborhood poverty. We fit Cox proportional hazards models to estimate associations between social integration and neighborhood poverty on all-cause mortality as independent predictors and in joint-effects models using the relative excess risk due to interaction to test for interaction on an additive scale. RESULTS: In the joint-effects model adjusting for age, gender, race/ ethnicity, and individual-level socioeconomic status, exposure to low social integration alone was associated with increased mortality risk (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.28-1.59) while living in an area of high poverty alone did not have a significant effect (HR: 1.10; 95% CI: 0.95-1.28) when compared with being jointly unexposed. Individuals simultaneously living in neighborhoods characterized by high poverty and having low levels of social integration had an increased risk of mortality (HR: 1.63; 95% CI: 1.35-1.96). However, relative excess risk due to interaction results were not statistically significant. CONCLUSIONS: Social integration remains an important determinant of mortality risk in the United States independent of neighborhood poverty.

Assessing Emotional Suffering in Palliative Care: Use of a Structured Note Template to Improve Documentation.

CONTEXT: Documentation of the emotional or psychological needs of seriously ill patients receiving specialty palliative care is endorsed by the "Measuring What Matters" project as a quality performance metric and recommended for use by hospice and palliative care programs for program improvement. OBJECTIVES: The aim of this study was to increase the proportion of inpatient palliative care team encounters in which emotional or psychological needs of patients and family members were documented and to qualitatively enrich the nature of this documentation. METHODS: This is a mixed-methods retrospective study of 200 patient charts reviewed before and after implementation of a structured note template (SmartPhrase) for palliative care encounters. Patterns of documentation of emotional needs pre- and post-implementation were assessed quantitatively and qualitatively using thematic analysis. RESULTS: A total of 158 of 200 pre-intervention charts and 185 of 200 post-intervention charts included at least one note from the palliative care team. Documentation of emotional assessment increased after SmartPhrase implementation (63.9% [101 of 158] vs. 74.6% [138 of 185]; P < 0.03). Qualitative analysis revealed a post-intervention reduction in the use of generic phrases ("emotional support provided") and an increase in the breadth and depth of emotion-related documentation. CONCLUSION: A structured note template with a prompt for emotional assessment increases the overall quantity and richness of documentation related to patient and family emotions. However, this documentation remains mostly descriptive. Additional prompting for documentation of recommendations to address identified emotional needs, and the use of screening tools for depression and anxiety, when appropriate, may be necessary for clinically meaningful quality improvements in patient care.

Drug-Based Lead Discovery: The Novel Ablative Antiretroviral Profile of Deferiprone in HIV-1-Infected Cells and in HIV-Infected Treatment-Naive Subjects of a Double-Blind, Placebo-Controlled, Randomized Exploratory Trial.

UNLABELLED: Antiretrovirals suppress HIV-1 production yet spare the sites of HIV-1 production, the HIV-1 DNA-harboring cells that evade immune detection and enable viral resistance on-drug and viral rebound off-drug. Therapeutic ablation of pathogenic cells markedly improves the outcome of many diseases. We extend this strategy to HIV-1 infection. Using drug-based lead discovery, we report the concentration threshold-dependent antiretroviral action of the medicinal chelator deferiprone and validate preclinical findings by a proof-of-concept double-blind trial. In isolate-infected primary cultures, supra-threshold concentrations during deferiprone monotherapy caused decline of HIV-1 RNA and HIV-1 DNA; did not allow viral breakthrough for up to 35 days on-drug, indicating resiliency against viral resistance; and prevented, for at least 87 days off-drug, viral rebound. Displaying a steep dose-effect curve, deferiprone produced infection-independent deficiency of hydroxylated hypusyl-eIF5A. However, unhydroxylated deoxyhypusyl-eIF5A accumulated particularly in HIV-infected cells; they preferentially underwent apoptotic DNA fragmentation. Since the threshold, ascertained at about 150 µM, is achievable in deferiprone-treated patients, we proceeded from cell culture directly to an exploratory trial. HIV-1 RNA was measured after 7 days on-drug and after 28 and 56 days off-drug. Subjects who attained supra-threshold concentrations in serum and completed the protocol of 17 oral doses, experienced a zidovudine-like decline of HIV-1 RNA on-drug that was maintained off-drug without statistically significant rebound for 8 weeks, over 670 times the drug's half-life and thus clearance from circulation. The uniform deferiprone threshold is in agreement with mapping of, and crystallographic 3D-data on, the active site of deoxyhypusyl hydroxylase (DOHH), the eIF5A-hydroxylating enzyme. We propose that deficiency of hypusine-containing eIF5A impedes the translation of mRNAs encoding proline cluster ('polyproline')-containing proteins, exemplified by Gag/p24, and facilitated by the excess of deoxyhypusine-containing eIF5A, releases the innate apoptotic defense of HIV-infected cells from viral blockade, thus depleting the cellular reservoir of HIV-1 DNA that drives breakthrough and rebound. TRIAL REGISTRATION: ClinicalTrial.gov NCT02191657.

Impact of an emergency medicine clerkship on students' perceptions of emergency medicine.

PURPOSE: To determine the impact of an emergency medicine (EM) clerkship on senior (4th year) medical students' perceptions of the EM specialty. SUBJECTS AND METHODS: This was a pre/posttest observational study in a mandatory 4-week EM clerkship. Students were anonymously surveyed pre- and postclerkship regarding perceptions of EM. The survey used 24 statements grouped across four domains: 1) student EM clerkship expectations/experiences, 2) perceptions regarding EM physicians, 3) perceptions regarding patients in the emergency department (ED), and 4) EM as a desirable career. Data were analyzed using paired-sample t-tests, and comparisons made using McNemar's χ (2) test. RESULTS: A total of 385 of 407 students (94.6%) completed the pre- and postclerkship survey. There was no significant difference between mean ratings before and after related to perceptions regarding EM physicians (3.71 versus 3.71), ED patients (3.80 versus 3.76), or EM as a desirable career (3.88 versus 3.84). However, ratings regarding clerkship expectations/experiences decreased (3.88 versus 3.56, P=0.001). Of the 292 students that ranked their top three specialties in both pre- and postclerkship surveys, 46 (16%) included EM as a top choice preclerkship, with 31 of these maintaining this interest postclerkship. Conversely, 12 students (5%) became interested in EM postclerkship. Some survey-statement ratings were influenced and varied by urban versus community clerkship-rotation site. CONCLUSION: A mandatory senior EM clerkship did not significantly change overall students' perceptions regarding EM. Students with an interest in EM rated domains higher than those not interested, though there may have been an overall decline in perceptions related to clerkship expectations and experiences. Larger, multisite studies may help identify aspects of the field or EM clerkship that influence a student's ultimate career choice.

Characteristics of Children With Primary Congenital Glaucoma Receiving Trabeculotomy and Goniotomy.

PURPOSE: To describe the groups of patients who received trabeculotomy or goniotomy for the treatment of primary congenital glaucoma (PCG) regarding age at treatment, intraocular pressure (IOP) outcome, and medication burden. METHODS: A retrospective chart review of patients with PCG seen at Rutgers New Jersey Medical School, Newark, New Jersey, from 1998 to 2012 was conducted. Inclusion criteria were patients who received trabeculotomy or goniotomy with at least 9 months of follow-up. Presenting examination, surgical intervention, IOP, and number of medications at 1 and 2 years postoperatively were recorded. Absolute and qualified success, defined as IOP greater than 5 and less than 21 mm Hg without and with medications, respectively, was determined. RESULTS: Fifty eyes of 29 patients were diagnosed as having PCG. Of those, 25 eyes received trabeculotomy or goniotomy, with 19 fulfilling inclusion criteria. Average age at the time of trabeculotomy was 8 months versus 21 months for patients undergoing goniotomy. Mean IOP was significantly reduced (P < .001) for both trabeculotomy and goniotomy by 29.5% at 1 year and 33.3% at 2 years. There was no significant difference in IOP control between trabeculotomy and goniotomy groups. Patients in the goniotomy group were treated with significantly more medications before and after surgery compared to patients receiving trabeculotomy (P < .01), resulting in a greater rate of absolute success in trabeculotomy at 1 and 2 years. CONCLUSIONS: Patients with PCG who underwent trabeculotomy had higher IOP and were treated at an earlier age than those who had goniotomy. Both effectively lowered IOP up to 2 years with greater medication burden in patients receiving goniotomy.