Educational Scholarship and Technology: Resources for a Changing Undergraduate Medical Education Curriculum.

Returning to the original emphasis of higher education, universities have increasingly recognized the value and scholarship of teaching, and medical schools have been part of this educational scholarship movement. At the same time, the preferred learning styles of a new generation of medical students and advancements in technology have driven a need to incorporate technology into psychiatry undergraduate medical education (UGME). Educators need to understand how to find, access, and utilize such educational technology. This article provides a brief historical context for the return to education as scholarship, along with a discussion of some of the advantages to this approach, as well as several recent examples. Next, the educational needs of the current generation of medical students, particularly their preference to have technology incorporated into their education, will be discussed. Following this, we briefly review the educational scholarship of two newer approaches to psychiatry UGME that incorporate technology. We also offer the reader some resources for accessing up-to-date educational scholarship for psychiatry UGME, many of which take advantage of technology themselves. We conclude by discussing the need for promotion of educational scholarship.

Advancements in Undergraduate Medical Education: Meeting the Challenges of an Evolving World of Education, Healthcare, and Technology.

Restructuring of undergraduate medical education (UGME) has occurred from time to time over the past century. Many influences, including the persuasive report of Abraham Flexner in 1910, acted to reorganize medical education in the early twentieth century [1, 2]. In his report, Flexner called on American medical schools to enact higher graduation standards and to stringently adhere to the protocols of mainstream science in their teaching. Prior to this report, UGME had changed little over the previous century but over the last several decades, reform within medical education has become routine. This increasing rate of change has been challenging for those within the realm of undergraduate medical education and can be frustrating to those outside this sphere. Today, the Association of American Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME) are typically the driving forces behind such changes, along with acceleration of advances in medical care and technology. The number of changes in the last decade is significant and warrants review by those interested or involved in education of medical students. This article aims to provide a summary of recent changes within UGME. Within the article, changes in both the pre-clerkship (1st and 2nd years) and clinical years (3rd and 4th) will be discussed. Finally, this review will attempt to clarify new terminology and concepts such as the recently released Core Entrustable Professional Activities (EPAs). The goal of these UGME changes, as with Flexner's reform, is to ensure future physicians are better prepared for patient care.

Accrediting Graduate Medical Education in Psychiatry: Past, Present, and Future.

The current terminology, goals, and general competency framework systematically utilized in the education of residents regardless of specialty is almost unrecognizable and quite foreign to those who trained before 2010. For example, the clinical and professional expectations for physicians-in-training have been placed onto a developmental framework of milestones. The expectations required during training have been expanded to include leadership and team participation skills, proficiency in the use of information technology, systems-based knowledge including respect of resources and cost of care, patient safety, quality improvement, population health and sensitivity to diversity for both individual and populations of patients. With these additions to physician training, the Accreditation Council for Graduate Medical Education (ACGME) hopes to remain accountable to the social contract between medicine and the public. With a focus on psychiatric practice, this article provides a general background and overview of the major overhaul of the accreditation process and educational goals for graduate medical education and briefly highlights possibilities for the future.

Training Psychiatry Residents in Professionalism in the Digital World.

Professionalism is an abstract concept which makes it difficult to define, assess and teach. An additional layer of complexity is added when discussing professionalism in the context of digital technology, the internet and social media - the digital world. Current physicians-in-training (residents and fellows) are digital natives having been raised in a digital, media saturated world. Consequently, their use of digital technology and social media has been unconstrained - a reflection of it being integral to their social construct and identity. Cultivating the professional identity and therefore professionalism is the charge of residency training programs. Residents have shown negative and hostile attitudes to formalized professionalism curricula in training. Approaches to these curricula need to consider the learning style of Millennials and incorporate more active learning techniques that utilize technology. Reviewing landmark position papers, guidelines and scholarly work can therefore be augmented with use of vignettes and technology that are available to residency training programs for use with their Millennial learners.

Microsatellites behaving badly: empirical evaluation of genotyping errors and subsequent impacts on population studies.

Microsatellites are useful tools for ecological studies because they can be used to discern population structure, dispersal patterns and genetic relationships among individuals. However, they can also yield inaccurate genotypes that, in turn, bias results, promote biological misinterpretations, and create repercussions for population management and conservation programs. We used empirical data from a large-scale microsatellite DNA study of white-tailed deer (Odocoileus virginianus) to identify sources of genotyping error, evaluate corrective measures, and provide recommendations to prevent bias in population studies. We detected unreported mutations that led to erroneous genotypes in five of 13 previously evaluated microsatellites. Of the five problematic markers, two contained mutations that resulted in null alleles, and three contained mutations that resulted in imperfect repeats. These five microsatellites had error rates that were four times greater on average than those observed in the remaining eight. Methodological corrections, such as primer redesign, reduced errors up to 5-fold in two problematic loci, although analytical corrections (computational adjustment for errors) were unable to fully prevent bias and, consequently, measures of genetic differentiation and kinship were negatively impacted. Our results demonstrate the importance of error evaluation during all stages of population studies, and emphasize the need to standardize procedures for microsatellite analyses. This study facilitates the application of microsatellite technology in population studies by examining common sources of genotyping error, identifying unreported problems with microsatellites, and offering solutions to prevent error and bias in population studies.

Activation of E-prostanoid4 and E-prostanoid2 receptors inhibits TNF-alpha release from human alveolar macrophages.

Prostaglandin (PG)E(2) has been shown to inhibit mediator release from human alveolar macrophages (AMs), but the prostanoid receptor(s) mediating this response have not yet been documented. To investigate this, the present authors conducted a range of pharmacological and expression-based studies in monocyte-derived macrophages (MDMs) and AMs. MDMs were obtained by in vitro differentiation of monocytes from the peripheral blood of healthy human volunteers. Human AMs were obtained by perfusion of lung tissue from carcinoma resection patients. In MDMs, PGE(2) potently inhibited lipopolysaccharide-induced tumour necrosis factor (TNF)-alpha release (p[A](50) 8.51+/-0.11, maximum inhibition 95.9+/-4.8%). In human AMs, PGE(2) also inhibited TNF-alpha release but the observed concentration-effect curve was very flat and inhibition was incomplete. The shape of the PGE(2) curve in AMs suggested that its effects were mediated by activation of a heterogeneous receptor population. Expression studies combined with the use of various E-prostanoid (EP) receptor agonists and a selective EP(4)-receptor antagonist (Ono-AE2-227) confirmed that the inhibitory effects of PGE(2) in both AMs and MDMs were mediated by activation of EP(4) and EP(2) receptors. These data indicate that both E-prostanoid(4) and E-prostanoid(2) selective agonists may have anti-inflammatory properties in lung diseases where macrophages play a role.

Reversal of a hallmark of brain ageing: lipofuscin accumulation.

The prospect of removing cellular deposits of lipofuscin is of considerable interest because they may contribute to age related functional decline and disease. Here, we use a decapod crustacean model to circumvent a number of problems inherent in previous studies on lipofuscin loss. We employ (a) validated lipofuscin quantification methods, (b) an in vivo context, (c) essentially natural environmental conditions and (d) a situation without accelerated production of residual material or (e) application of pharmacological compounds. We use a novel CNS biopsy technique that produces both an anti-ageing effect and also permits longitudinal sampling of individuals, thus (f) avoiding conventional purely cross-sectional population data that may suffer from selective mortality biases. We quantitatively demonstrate that lipofuscin, accrued through normal ageing, can be lost from neural tissue. The mechanism of loss probably involves exocytosis and possibly blood transport. If non-disruptive ways to accelerate lipofuscin removal can be found, our results suggest that therapeutic reversal of this most universal manifestation of cellular ageing may be possible.

The effects of a collaborative model of primary care on the mortality and hospital use of community-dwelling older adults.

BACKGROUND: This study evaluates the ability of a model of collaborative primary care practice to reduce mortality and hospital use in community-dwelling elderly persons. METHODS: Four rural and four urban clinic sites in east central Illinois were randomized to form treatment and comparison clinics from which patients were enrolled and followed prospectively for 2 years. Patients from the practices of participating physicians were eligible if they were aged 65 and older, were living in the community, and had at least one risk factor as determined prior to the study. Medicare hospital data were obtained from the Health Care Financing Administration. Demographic and health status measures were obtained by telephone interview every 12 months throughout the study. RESULTS: The treatment group experienced a 49% reduction in all-cause mortality during the second year of the study (odds ratio, 0.51, 95% confidence interval, 0.29-0.91, p = .02). There were no significant differences between treatment and comparison patients in percentage of persons hospitalized, hospital length of stay, or Medicare payments. Although measures of health status indicated that the treatment group was significantly sicker at baseline at the end of 1 year, these differences disappeared by the end of 2 years. CONCLUSIONS: The collaborative primary care model evaluated in this study significantly reduced mortality in the second year, without increasing hospital use. These findings suggest that a collaborative primary care team that enhances primary care practice can result in better patient outcomes.

Caregivers' utilization of health services: results from the Medicare Alzheimer's Disease Demonstration, Illinois site.

OBJECTIVES: The purpose of this study is to examine the effect of the Medicare Alzheimer's Disease Demonstration and Evaluation (MADDE) conducted in Illinois on the use of health services and Medicare expenditures by caregivers of persons with dementia. DESIGN: Prospective randomized clinical trial. SETTING: The MADDE (1989-1994), Illinois site. PARTICIPANTS: A cohort of 412 Medicare-eligible caregivers of persons with dementia. MEASUREMENTS: Medicare claims files provided data on the number of hospitalizations, hospital bed days, emergency department visits, and total Medicare Part A expenditures. RESULTS: After adjustment for baseline variables, the caregivers in the treatment group, when compared with those in the comparison group, had a lower likelihood of any hospitalization during the study period (odds ratio 0.58 (95% confidence interval (CI)=0.35-0.97), P= .037) and a reduced, but not significant, likelihood of emergency department use (odds ratio 0.66 (95% CI=0.40-1.08), P= .095). For those who were hospitalized, there were no significant differences between the treatment and comparison group caregivers in the number of hospitalizations, hospital length of stay, or Medicare payments. CONCLUSION: These results suggest that enhanced chronic illness case management directed at persons with dementia and their caregivers can reduce the need for acute hospital care.

Integrated risk assessment and feedback reporting for clinical decision making in a Medicare Risk plan.

The challenge of tapping into the rich resource of population-based, aggregated data to inform and guide clinical processes remains one of the largely unrealized potentials of managed care. This article describes a multifaceted approach of using health-related data to support providers in clinical decision making as an adjunct to case management and primary care delivery. The goal is to provide data that can be used for clinical decision making that is population based, yet individualized for specific patient care situations. Information reporting holds great potential in the clinical care of patients because it can be used to identify persons who could benefit from early detection, intervention, or treatment. It has been suggested that one of the keys to success in managed Medicare is the timely use of information that is detailed, comprehensive, and real-time describing key parameters of clinical encounters.

Relationship of dorsoventral eyeshine distributions to habitat depth and animal size in mesopelagic decapods.

Eyeshine distribution patterns recorded from the eyes of 19 mesopelagic decapod species were examined and related to the depths at which the species are found. For most species examined, eyeshine was found to be brighter ventrally than dorsally. Deep-water decapod species that do not undergo diel vertical migrations had brighter dorsal eyeshine than migratory species. Eyeshine intensity increased with body size in five of the species examined and decreased in two. These changes in eyeshine intensity may be an adaptation to variations in depth distributions that occur with increasing body size. It is suggested that the depth and size-related changes reflect the importance of remaining camouflaged in the mesopelagic realm and are an example of ecologically functional development.

Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth.

PURPOSE: This study was performed to retrospectively evaluate treatment of deep caries in primary molars with formocresol pulpotomy (FP) and indirect pulp therapy (IPT). METHODS: 133 primary molars with deep caries approaching the pulp were treated with FP (N = 78) or IPT (N = 55) and followed 2-7 years. All IPTs received immediate stainless steel crowns (SSCs); 61 FPs got an immediate SSC, 13 an intermediate restorative material (IRM), and 4 amalgam. Thirteen IPTs and 25 FPs had pre-operative pain compatible with a diagnosis of reversible pulpitis. Treatment notes and radiographs were independently assessed. RESULTS: Overall IPT success was 93% (51/55) versus 74% (58/78) for FP. Molars with pain compatible with a diagnosis of reversible pulpitis were successfully treated by IPT 85% (11/13) versus 76% (19/25) for FP. FP-treated molars exhibited earlier exfoliation 38% (30/78), while all IPT molars exhibited normal exfoliation. FPs receiving immediate SSCs had 50/61 (82%) succeed; FPs restored with an IRM temporary succeeded 5/13 (39%), amalgam 3/4 (75%). CONCLUSIONS: IPT success was significantly higher than FP (P = 0.01) in the treatment of deep caries. Both IPT and FP were successful in treating teeth with pain compatible with the diagnosis of reversible pulpitis. FP significantly hastened the exfoliation of pulpotomized primary molars (P = 0.001). IPT in primary teeth can be successfully used in a one step procedure. SSCs placed immediately after FP significantly increased FP success vs. FP followed by IRM temporary (P = 0.01).

Assessing medication appropriateness in the elderly: a review of available measures.

The disproportionate use of medications, combined with age-related pharmacokinetic and pharmacodynamic changes, places older adults at high risk for medication related problems (MRPs). MRPs demonstrate significant morbidity, mortality and economic impact among healthcare systems. The negative outcomes associated with MRPs emphasise the need for more careful and thorough assessments of drug therapy among older adults. In the 1990s a number of methods and instruments were developed to assist in the assessment of medication appropriateness. These tools may be categorised by criteria as: implicit, explicit or one utilising a combination of implicit and explicit criteria. This article reviews these available tools and outlines the advantages and disadvantages of each. In conclusion, those instruments considered to be comprised of both implicit and explicit criteria offer a more thorough assessment of medication appropriateness.

Hyperventilation associated with quetiapine.

OBJECTIVE: To describe a case of hyperventilation associated with the administration of quetiapine. CASE SUMMARY: A 69-year-old African-American woman admitted to a psychiatric hospital for treatment of major depression with psychotic features was treated and successfully discharged with quetiapine, along with metronidazole and miconazole to treat bacterial/monilial vaginitis. Three days after discharge, the patient presented to a community hospital with shortness of breath and hyperventilation. The patient was admitted and treated for tachypnea and acute respiratory alkalosis. During this hospitalization, the patient was noted to have increased respiratory rate following the administration of quetiapine. DISCUSSION: Hyperventilation was reported during the clinical trials of quetiapine; however, this is the first published report to date. Serotonin is involved both centrally and peripherally in the regulation of respiration. A contributing factor in this case may have been the concomitant administration of metronidazole, which inhibits the cytochrome P450 enzyme (CYP3A4) also responsible for the metabolism of quetiapine. CONCLUSIONS: The development of hyperventilation and respiratory alkalosis was associated with the administration of quetiapine.

Image compression and chest radiograph interpretation: image perception comparison between uncompressed chest radiographs and chest radiographs stored using 10:1 JPEG compression.

We have assessed the effect of 10:1 lossy (JPEG) compression on six board-certified radiologists' ability to detect three commonly seen abnormalities on chest radiographs. The study radiographs included 150 chest radiographs with one of four diagnoses: normal (n = 101), pulmonary nodule (n = 19), interstitial lung disease (n = 19), and pneumothorax (n = 11). Before compression, these images were printed on laser film and interpreted in a blinded fashion by six radiologists. Following an 8-week interval, the images were reinterpreted on an image display workstation after undergoing 10:1 lossy compression. The results for the compressed images were compared with those of the uncompressed images using receiver operating characteristic (ROC) analyses. For five of six readers, the diagnostic accuracy was higher for the uncompressed images than for the compressed images, but the difference was not significant (P > .1111). Combined readings for the uncompressed images were also more accurate when compared with the compressed images, but this difference was also not significant (P = .1430). The sensitivity, specificity, and accuracy values were 81.5%, 89.2%, and 86.7% for the compressed images, respectively, as compared with 78.9%, 94.5%, and 89.3% for the uncompressed images. There was no correlation between the readers' accuracy and their experience with soft-copy interpretation; the extent of radiographic interpretation experience had no correlation with overall interpretation accuracy. In conclusion, five of six radiologists had a higher diagnostic accuracy when interpreting uncompressed chest radiographs versus the same images modified by 10:1 lossy compression, but this difference was not statistically significant.

Sensory discrimination capabilities in patients with focal hand dystonia.

To explore the concept that dystonia may result from dysfunction of the sensory system, 14 patients with focal hand dystonia were tested during two somatosensory discrimination tasks. Compared with controls, patients had a higher threshold in a task involving discrimination of two electric stimuli closely related temporally, an abnormality that correlated with the degree of severity of dystonia. There was no significant difference in a single-touch, gross localization task. The possible relevance of these findings to the pathogenesis of dystonia is discussed.

The community assessment risk screen (CARS): identifying elderly persons at risk for hospitalization or emergency department visit.

OBJECTIVE: To develop and validate an instrument for identifying community dwelling elderly patients at increased risk for hospitalizations or emergency department (ED) encounters. STUDY DESIGN: Prospective cohort study. PATIENTS AND METHODS: The development cohort consisted of 411 Medicare fee-for-service patients and the validation cohort consisted of 1054 individuals enrolled in a Medicare Risk Demonstration. Baseline demographic, health status, and utilization measures were obtained from telephone interviews and mailed questionnaires. Service utilization data for the development cohort were obtained from Medicare claims files. Utilization and cost data for the validation cohort were obtained from submitted claims. RESULTS: Logistic regression identified 3 characteristics that were predictors of hospitalizations or ED visits during the following year in the development cohort: having 2 or more comorbidities, taking 5 or more prescription medications, and having had a hospitalization or ED encounter in the previous 12 months. A scoring system (range 0 to 9) was developed for each predictor variable and patients in the validation cohort were assigned to low (0 to 3) and high (4 to 9) risk categories. When compared with the low-risk group, the high-risk group was significantly (P < .01) more likely to be hospitalized (33% versus 14%), to have an ED visit (34% versus 15%), and to have higher per-member-per-month (PMPM) charges ($977 versus $445) during the following 12 months. CONCLUSION: The Community Assessment Risk Screen (CARS) is a simple instrument that can be used to identify elderly patients who are at higher risk for health service use and increased costs.

Spatial discrimination is abnormal in focal hand dystonia.

BACKGROUND: In patients with focal hand dystonia, abnormal digit representations in the primary somatosensory cortex (S1) could be the result of enlarged and overlapping receptor fields, as suggested by an animal model of dystonia. A possible clinical correlate of this S1 abnormality is a disturbed spatial discrimination capability. OBJECTIVE: To test the hypothesis that somatosensory spatial discrimination is abnormal in focal hand dystonia. METHODS: Seventeen patients with focal hand dystonia underwent a quantitative evaluation of somatosensory spatial frequency (gap detection, JVP domes, applied to the distal phalanx of the index finger) and single-touch localization (Von Frey monofilaments, applied to the middle phalanx of the index finger). RESULTS: Compared with control subjects, patients had a decreased performance in both the gap detection (p = 0.004) and the localization (p = 0.013) tasks. The extent of spatial frequency abnormality correlated with age in both groups. CONCLUSIONS: These findings, together with a previously shown temporal discrimination deficit, support a role for sensory dysfunction in the pathophysiology of dystonia.

Vitamin E in the treatment of tardive dyskinesia.

OBJECTIVE: To review the efficacy of vitamin E in the treatment of tardive dyskinesia (TD). DATA SOURCES: Published articles and abstracts in English were identified from January 1986 to March 1999 by MEDLINE and International Pharmaceutical Abstracts searches using the terms vitamin E, alpha-tocopherol, and tardive dyskinesia. Additional articles were identified from the references of the retrieved articles and cross- referencing selected articles. DATA EXTRACTION: All clinical trials evaluating the use of vitamin E in human subjects with TD were reviewed. Selected articles also included those considered to be helpful in providing a basic introduction to TD pathophysiology and management. DATA SYNTHESIS: TD occurs in approximately 20% of patients treated with neuroleptics. The resulting dyskinesias can be irreversible and are often psychologically and physically debilitating. Recent research suggests that TD may be a result of neuronal damage inflicted by free radicals generated from increased neurotransmitter turnover and metabolism. Vitamin E as a naturally occurring free radical scavenger has been evaluated in the treatment of TD. Eighteen completed trials are available either in completed or abstract form. Twelve of these trials have produced positive results with vitamin E in the treatment of TD. Patients who have had TD for less than five years appear to respond better than patients with long-standing TD. CONCLUSIONS: Research suggests that vitamin E offers benefit in the management of a subgroup of patients with TD. Further investigation is needed to ascertain continued efficacy with long-term use as well as the role of vitamin E in TD prophylaxis.

Estrogen for dementia-related aggression in elderly men.

OBJECTIVE: To report the use of conjugated estrogens for aggression in two elderly men with dementia and to review the available literature relating to estrogen use for aggression in the elderly. CASE SUMMARIES: Case 1. A 78-year-old white man had probable Alzheimer dementia and aggression (verbal and physical) that was nonresponsive to antipsychotic, antidepressant, and mood stabilizer therapy. However, conjugated estrogens 1.875 mg/d reduced his physical aggression, as evidenced by a 75% decline in aggressive episodes, per 24-hour nursing reports and progress notes. Case 2. A 78-year-old African-American man with vascular dementia, physical aggression, and sexual inappropriateness was unsuccessfully managed with several antipsychotic and benzodiazepine trials. He did, however, exhibit a decline in physical and sexual aggression by 80%, as well as a 55% reduction in sexual comments, after daily treatment with conjugated estrogens 0.625 mg. Estrogen was well tolerated by both patients. DATA SOURCES: MEDLINE (January 1966-May 1998) and PsychLit (January 1974-May 1998) database searches were performed to identify case reports, letters, or clinical trials discussing estrogen use in aggressive elderly patients. CONCLUSIONS: As with previous reports, these cases suggest that conjugated estrogens may be used to reduce physical and sexual aggression associated with dementia in elderly men. Additional study is needed to determine the exact role of this alternative pharmacologic intervention.