In paroxysmal AF, first-line catheter ablation vs. antiarrhythmic drugs reduces atrial arrhythmia recurrence.

SOURCE CITATION: Imberti JF, Ding WY, Kotalczyk A, et al. Catheter ablation as first-line treatment for paroxysmal atrial fibrillation: a systematic review and meta-analysis. Heart. 2021;107:1630-6. 34261737.

Impact of Required Versus Self-Directed Use of Virtual Patient Cases on Clerkship Performance: A Mixed-Methods Study.

PURPOSE: To explore how students use and benefit from virtual patient cases (VPCs). METHOD: In academic years 2013-2014 and 2014-2015, cohorts of students in pediatrics (Peds), family medicine (FM), and internal medicine (IM) clerkships were allocated to either core required use (CRU) or self-directed use (SU) of MedU VPCs. Outcomes included number and time of case review, student perception of learning from VPCs, National Board of Medical Examiners (NBME) subject examination scores, and summative clinical ratings for medical knowledge and differential diagnoses/problem solving. Focus groups were conducted each year. Mean differences were compared by t test. RESULTS: A total of 255 students participated in the study. Mean number of cases completed by the CRU group was significantly higher than that by the SU group (13.9 vs. 3.1 for FM, 16.1 vs. 3.9 for Peds, and 10.4 vs. 1.2 for IM) (P < .001). Student-perceived value ratings of VPCs were similar between groups. Students described VPCs as time consuming but useful for supplementing clinical conditions not seen in person. Mean scores on NBME subject examinations for CRU versus SU groups were not different between groups in any clerkship, nor were there significant differences in the summative clinical ratings for medical knowledge or differential diagnosis/clinical reasoning. CONCLUSIONS: Although VPCs continue to serve an important role in exposing students to clinical conditions not seen in person, the optimal employment of this technology in clerkship pedagogy requires further exploration.

CRISPR/Cas9 Editing of the Codling Moth (Lepidoptera: Tortricidae) CpomOR1 Gene Affects Egg Production and Viability.

The codling moth, Cydia pomonella (L.) (Lepidoptera: Tortricidae), is a major pest of pome fruit worldwide. Incorporation of semiochemicals, including the main sex pheromone (codlemone), into codling moth IPM programs has drastically reduced the amount of chemical insecticides needed to control this orchard pest. Odorant receptors located in sensory neuron membranes in the antennae are key sensors in the detection of semiochemicals and trigger downstream signaling events leading to a behavioral response. CpomOR1 is an odorant receptor belonging to the pheromone receptor subfamily in codling moth, and is a prime candidate for being a codlemone receptor based on its high expression levels in male antennae. In this study, the CpomOR1 gene was targeted using CRISPR/Cas9 genome editing to knockdown functional OR1 protein production to determine physiological function(s). By injecting early stage eggs, mutations were successfully introduced, including both deletions and insertions. When attempting to create stable populations of codling moth through mating of males with females containing mutations of the CpomOR1 gene, it was found that fecundity and fertility were affected, with edited females producing nonviable eggs. The role of CpomOR1 in fecundity and fertility in codling moth is unknown and will be the focus of future studies.

Implementation of a Mini-CEX Requirement Across All Third-Year Clerkships.

PROBLEM: Direct observation of medical students performing clinical tasks, such as eliciting a patient history or examining a patient, and the provision of feedback, are foundational to student improvement but have been reported to occur infrequently. The mini clinical evaluation exercise (mini-CEX) is a tool that can facilitate direct observation and feedback. This study assessed the impact of a mini-CEX requirement across all 3rd-year clerkships on student report of direct observation by faculty and objectively measured clinical skills. INTERVENTION: A mini-CEX requirement across all 3rd-year clerkships was implemented in the 2012-2013 academic year. The impact of the mini-CEX requirement on student report of direct observation was assessed by end-of-clerkship surveys and Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) items on direct observation. The impact on students' clinical skills was assessed by a summative Objective Structured Clinical Examination (OSCE). Pre/post comparisons were assessed with chi-square and Fisher's exact tests. CONTEXT: A mini-CEX requirement had been in place for the internal medicine clerkship, and student reports of direct observation were historically higher for the internal medicine clerkship than for other clerkships. Faculty, residents, and students at each of the clinical sites across all 6 clerkships were oriented to the use of the mini-CEX; the feasibility of its use during usual patient interaction settings and the importance of direct observation and feedback for student improvement were emphasized during these sessions. OUTCOME: Adherence to the mini-CEX requirement was high: 92% of required forms were completed, and 78% of completed forms indicated that specific feedback was given. The proportion of students reporting direct observation of physical examination significantly increased in all clerkships, with the largest relative increase occurring in surgery (from 49% to 87%), χ2(1, N = 225) = 37.70, p < .0001. Significant increases were seen in faculty observation of history taking in pediatrics, surgery, and psychiatry. Direct observation rates also increased on the AAMC GQ items for history taking and physical exam for all clerkships. Failures on the summative OSCE decreased from 12% preintervention to 2% postintervention (p = .0046). LESSONS LEARNED: Institution of a mini-CEX requirement was feasible across all 3rd-year clerkships and was associated with a significant increase in student report of direct observation by faculty and a decrease in summative OSCE failure rates.

What Are We Telling Our Students? A National Survey of Clerkship Directors' Advice for Students Applying to Internal Medicine Residency.

BACKGROUND: Little is known about the advice fourth-year medical students receive from their advisors as they prepare to apply for residency training. OBJECTIVE: We collected information on recommendations given to medical students preparing to apply to internal medicine residencies regarding fourth-year schedules and application strategies. METHODS: Clerkship Directors in Internal Medicine conducted its annual member survey in June 2013. We analyzed responses on student advising using descriptive and comparative statistics, and free-text responses using content analysis. RESULTS: Of 124 members, 94 (76%) responded, and 83 (88%) advised fourth-year medical students. Nearly half (45%) advised an average of more than 20 students a year. Advisors encouraged students to take a medicine subinternship (Likert scale mean 4.84 [1, strongly discourage, to 5, strongly encourage], SD = 0.61); a critical care rotation (4.38, SD = 0.79); and a medicine specialty clinical rotation (4.01, SD = 0.80). Advisors reported they thought fourth-year students should spend a mean of 6.5 months doing clinical rotations (range 1-10, SD = 1.91). They recommended highest academic quartile students apply to a median of 10 programs (range 1-30) and lowest quartile students apply to 15 programs (range 3-100). Top recommendations involved maximizing student competitiveness, valuing program fit over reputation, and recognizing key decision points in the application process. CONCLUSIONS: Undergraduate medical advisors recommended specific strategies to enhance students' competitiveness in the Match and to prepare them for residency. The results can inform program directors and encourage dialogue between undergraduate medical education and graduate medical education on how to best utilize the fourth year.

Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.

The fourth year of medical school remains controversial, despite efforts to reform it. A committee from the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine examined transitions from medical school to internship with the goal of better academic advising for students. In 2013 and 2014, the committee examined published literature and the Web sites of 136 Liaison Committee on Medical Education-accredited schools for information on current course offerings for the fourth year of medical school. The authors summarized temporal trends and outcomes when available.Subinternships were required by 122 (90%) of the 136 schools and allow students to experience the intern's role. Capstone courses are increasingly used to fill curricular gaps. Revisiting basic sciences in fourth-year rotations helps to reinforce concepts from earlier years. Many schools require rotations in specific settings, like emergency departments, intensive care units, or ambulatory clinics. A growing number of schools require participation in research, including during the fourth year. Students traditionally take fourth-year clinical electives to improve skills, both within their chosen specialties and in other disciplines. Some students work with underserved populations or seek experiences that will be henceforth unavailable, whereas others use electives to "audition" at desired residency sites. Fourth-year requirements vary considerably among medical schools, reflecting different missions and varied student needs. Few objective outcomes data exist to guide students' choices. Nevertheless, both medical students and educators value the fourth year of medical school and feel it can fill diverse functions in preparing for residency.

Searching for answers to clinical questions using google versus evidence-based summary resources: a randomized controlled crossover study.

PURPOSE: To compare the speed and accuracy of answering clinical questions using Google versus summary resources. METHOD: In 2011 and 2012, 48 internal medicine interns from two classes at Rutgers University Robert Wood Johnson Medical School, who had been trained to use three evidence-based summary resources, performed four-minute computer searches to answer 10 clinical questions. Half were randomized to initiate searches for answers to questions 1 to 5 using Google; the other half initiated searches using a summary resource. They then crossed over and used the other resource for questions 6 to 10. They documented the time spent searching and the resource where the answer was found. Time to correct response and percentage of correct responses were compared between groups using t test and general estimating equations. RESULTS: Of 480 questions administered, interns found answers for 393 (82%). Interns initiating searches in Google used a wider variety of resources than those starting with summary resources. No significant difference was found in mean time to correct response (138.5 seconds for Google versus 136.1 seconds for summary resource; P = .72). Mean correct response rate was 58.4% for Google versus 61.5% for summary resource (mean difference -3.1%; 95% CI -10.3% to 4.2%; P = .40). CONCLUSIONS: The authors found no significant differences in speed or accuracy between searches initiated using Google versus summary resources. Although summary resources are considered to provide the highest quality of evidence, improvements to allow for better speed and accuracy are needed.

Management of postoperative complications: anemia.

Anemia is extremely common following hip fracture. Consistent data from randomized trials show that transfusion of less blood, with a transfusion threshold around 8 g/dL hemoglobin concentration, is preferable to a traditional threshold of 10 g/dL. Adoption of a lower threshold leads to at least equivalent clinical outcomes, with much less exposure to transfusion costs and risks. The most common complication of transfusion is circulatory overload. Future research may elucidate the optimal transfusion threshold for these elderly patients and address the specific needs of subgroups of patients, including those with acute coronary syndrome or chronic kidney disease.

Pharmacist-led workshops to enhance pharmacotherapy knowledge for medical students.

BACKGROUND: Graduating medical students have reported concern regarding inadequate training in pharmacotherapy. Teaching by clinical pharmacists may improve medical students' pharmacotherapy knowledge. PURPOSE: To assess the impact of pharmacist led workshops on 4th year medical students' knowledge of pharmacotherapy and satisfaction. METHODS: Senior medical students enrolled in intensive care unit rotations at a US medical school were randomized to an intervention of pharmacist led case-based workshops or a control group without an explicit pharmacotherapy curriculum. Intervention group students attended four weekly 1-hour workshops that covered topics in pharmacokinetics, pharmacodynamics, drug interactions and toxicity. A multiple-choice test of clinical vignettes assessed students' knowledge of pharmacotherapy. An end of clerkship survey assessed student satisfaction with teaching. RESULTS: Of 176 medical students eligible, 148 agreed to participate and were randomized to the intervention (n = 63) or control groups (n = 85). Student satisfaction with pharmacist led workshops was high. End of clerkship performance on clinical vignettes (minimum score 0, maximum 100) was similar between the groups (mean score 47 (SD = 12.2) for intervention vs 44 (SD = 13.0) for control group, p = 0.16). On end of clerkship survey, only 8% of control group students agreed or strongly agreed that the standard curriculum provided sufficient teaching in pharmacotherapy. The majority of students (82%) felt that pharmacotherapy should be taught formally in the clinical years. CONCLUSION: Pharmacist led workshops on pharmacotherapy were well received by senior medical students but did not improve performance on a test of pharmacotherapy knowledge. Further study is needed to define optimal strategies for improving medical students' pharmacotherapy knowledge.

A trial of team-based versus small-group learning for second-year medical students: does the size of the small group make a difference?

BACKGROUND: Team-based learning is a large-group instructional modality intended to provide active learning with modest faculty resources. PURPOSE: The goal is to determine if team-based learning could be substituted for small-group learning in case sessions without compromising test performance or satisfaction. METHODS: One hundred and sixty-seven students were assigned to team-based or small-group learning for 6 case discussion sessions. Examination scores and student satisfaction were compared. RESULTS: Instruction modality had no meaningful effect on examination score, 81.7% team based versus 79.7% small-group, p=.56 after multivariate adjustment. Student satisfaction was lower with team-based learning, 2.45 versus 3.74 on a 5-point scale, p<.001. Survey responses suggested that the very small size (8-10 students) of our small groups influenced the preference for small-group learning. CONCLUSIONS: Team-based learning does not adversely affect examination performance. However, student satisfaction may be inferior, especially if compared to instruction in very small groups of 10 or fewer students.