Implementation of an educational intervention to improve medical student cost awareness: a prospective cohort study.

BACKGROUND: In the context of rising healthcare costs, formal education on treatment-related financial hardship is lacking in many medical schools, leaving future physicians undereducated and unprepared to engage in high-value care. METHOD: We performed a prospective cohort study to characterize medical student knowledge regarding treatment-related financial hardship from 2019 to 2020 and 2020-2021, with the latter cohort receiving a targeted educational intervention to increase cost awareness. Using Kirkpatrick's four-level training evaluation model, survey data was analyzed to characterize the acceptability of the intervention and the impact of the intervention on student knowledge, attitudes, and self-reported preparedness to engage in cost-conscious care. RESULTS: Overall, N = 142 medical students completed the study survey; 61 (47.3%) in the non-intervention arm and 81 (66.4%) in the intervention arm. Of the 81 who completed the baseline survey in the intervention arm, 65 (80.2%) completed the immediate post-intervention survey and 39 (48.1%) completed the two-month post-intervention survey. Following the educational intervention, students reported a significantly increased understanding of common financial terms, access to cost-related resources, and level of comfort and preparedness in engaging in discussions around cost compared to their pre-intervention responses. The majority of participants (97.4%) reported that they would recommend the intervention to future students. A greater proportion of financially stressed students reported considering patient costs when making treatment decisions compared to their non-financially stressed peers. CONCLUSIONS: Targeted educational interventions to increase cost awareness have the potential to improve both medical student knowledge and preparedness to engage in cost-conscious care. Student financial stress may impact high-value care practices. Robust curricula on high-value care, including treatment-related financial hardship, should be formalized and universal within medical school training.

Survival and tumor characteristics of patients presenting with single primary versus second primary melanoma lesions.

BACKGROUND: Patients with single primary melanomas have an increased risk of developing subsequent melanomas. Secondary tumors diagnosed within and after 3 months are termed "synchronous" and "asynchronous," respectively. OBJECTIVE: To compare tumor distributions and survival characteristics between patients with second primary melanomas and those with single primary melanomas. METHODS: Retrospective cohort study. Data were collected from an institutional database from 14,029 patients with a diagnosis of a primary melanoma seen between 1970 and 2004. RESULTS: The synchronous and asynchronous cohorts demonstrated significantly improved survival probabilities compared with the single primary cohort (P = .04 and .002, respectively). Single primary lesions (2.2 ± 2.3 mm) were significantly thicker than the first-identified synchronous (2.0 ± 1.7 mm) and asynchronous (1.7 ± 1.3 mm) lesions. Synchronous lesions were more likely to be anatomically concordant compared with asynchronous lesions (55.7% vs 38.2%, P < .001). LIMITATIONS: Single-center study design and incomplete records for second primary melanoma Breslow depth and histopathology. CONCLUSION: Patients with second primary melanomas demonstrated a significant survival advantage and thinner lesions compared with those with single primary melanomas. Our reported tumor distributions support the role of full body skin examinations, with attention to the region of initial diagnosis.

Atopic dermatitis leading to failure to thrive: A case report.

We present an infant with severe atopic dermatitis, protein loss, and subsequent failure to thrive. With proper management, the patient's laboratory findings normalized, and he gained weight appropriately. In this report, we highlight the impact that severe atopic dermatitis may have growth and development and review the genetic conditions that can result in a similar clinical presentation.

Racial and Ethnic Disparities in Surgical Outcomes after Postmastectomy Breast Reconstruction.

BACKGROUND: Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction. STUDY DESIGN: Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively. RESULTS: Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications. CONCLUSION: Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.

SARS-CoV-2 infections in patients with autoimmune blistering disorders: A case series and retrospective analysis.

BACKGROUND: Autoimmune blistering disorders (AIBDs) are rare, potentially life-threatening conditions often requiring immunosuppression. Throughout the SARS-CoV-2 pandemic, infection risk and mortality in patients with AIBDs are unknown. OBJECTIVE: We report the outcomes of SARS-CoV-2 infections in patients with AIBDs and determined if patients on rituximab have an increased risk of SARS-CoV-2 infection. METHODS: We examined clinical outcomes in 10 patients with AIBDs who developed SARS-CoV-2 infections at an American hospital. We performed a retrospective analysis of 132 patients with AIBDs enrolled in a clinical trial. RESULTS: Patients with severe SARS-CoV-2 (n = 4) or death (n = 2) trended to be older. These patients had higher mortality than the national average (20% vs 1.6%). Our cohort included 52 patients with a history of rituximab treatment, 35 of whom were immunosuppressed by rituximab during the pandemic, and 45 patients never treated with rituximab. We found no difference between the rates of SARS-CoV-2 positivity in patients with AIBDs immunosuppressed by rituximab and those not on rituximab (9.1% vs 12.1%). LIMITATIONS: Testing for SARS-CoV-2 was performed on demand rather than surveillance. Overall transmission varied over time, and outcomes depended on accepted treatments. The small sample size of our cohort limits the generalizability of our results. CONCLUSION: This study suggests that rituximab does not increase the risk of SARS-CoV-2 test positivity in patients with AIBDs. However, these results should be interpreted with caution due to our relatively small sample size.

Predictive factors of neoadjuvant immune checkpoint blockade in melanoma.

This review describes the current body of literature and ongoing clinical trials examining neoadjuvant immune checkpoint inhibitors (ICI) for patients with resectable stage III and IV melanoma. Based on prior success in treating metastatic melanoma and as adjuvant therapy, ICIs are being explored in the neoadjuvant setting. There have been initial trials and there are many ongoing trials examining neoadjuvant ICI. Herein, we will review the clinical feasibility and efficacy of various neoadjuvant ICI regimens, explore pathologic and cellular responses, and present factors associated with predictive tumor response.

Acute exertional compartment syndrome of the lumbar paraspinal muscles in a weightlifter. A case report.

BACKGROUND: Compartment syndrome (CS) is a well-known phenomenon in orthopaedics associated with traumatic injury to an extremity or over exertion which ultimately leads to prolonged and elevated intrafascial pressures. CS was initially described by Volkmann in 1881[1]. With any active muscle, there is a transient rise in intrafascial pressure from resting range of approximately 3 mmHg to 7.95 mmHg [2]. When this increase in pressure is too great or not transient, then a subsequent compartment syndrome develops. The consequences of such physiologic imbalance can induce muscle necrosis, nerve damage, vascular compromise, functional deficits, and potentially loss of limb[3,4]. Typical initial presentation of CS includes pain out of proportion to the severity of injury, which is intensified with passive motion of the muscle within the affected fascial compartment.[4] Non musculoskeletal manifestations of CS generally present themselves as the syndrome progresses and can include rhabdomyolysis, myoglobinuria, acute kidney injury, or acute tubular necrosis [4]. These non musculoskeletal manifestations of CS are potential etiologies causing patients to present for treatment [4]. PURPOSE: There have been approximately 20 previous case reports on paraspinal compartment syndrome with a combination of surgical and medical treatments in these patients. We will present a case of paraspinal CS in an avid weightlifter and discuss diagnostic and treatment options surrounding this syndrome. STUDY DESIGN: Case Report. PATIENT SAMPLE: This is a report of a single patient who presented to Duke University Medical Center. METHODS: We report the case of a 29 year old male with paraspinal compartment syndrome who was treated with fasciotomies. This was considered an IRB exempt study by our IRB as such informed consent was not obtained by the patient prior to publication. RESULTS: This patients had resolution of symptoms after surgical intervention which continued through follow up. CONCLUSION: Paraspinal compartment syndrome can be effectively treated with surgical fasciotomy.