Impact of COVID-19 Policies on Hospitalists' Psychological Safety.

OBJECTIVES: The coronavirus disease 2019 pandemic brought about many changes in work environment and interpersonal interactions to prevent the spread of infection. Policies such as ubiquitous masking, virtual meetings, physician distancing, and decreased communal eating changed the inpatient work environment. This study aims to look at the impact of these changes on hospitalists' psychological safety. METHODS: We surveyed hospitalists on how these changes affected their well-being and feelings of psychological safety. RESULTS: Masking, virtual meetings, and fewer opportunities to eat together decreased connection with colleagues. Virtual meetings and social distancing decreased some aspects of psychological safety. CONCLUSIONS: This study highlights the importance of finding ways to foster connection and decrease burnout while continuing to prevent the spread of infection.

AP-3 complex subunit delta gene, ap3d1, regulates melanogenesis and melanophore survival via autophagy in zebrafish (Danio rerio).

Zebrafish are an emerging model organism to study the syndromic albinism disorder, Hermansky-Pudlak syndrome (HPS), due to visible pigment development at 24 hours postfertilization, and conserved melanogenesis mechanisms. We describe crasher, a novel HPS type 10 (HPS10) zebrafish model, with a mutation in AP-3 complex subunit delta gene, ap3d1. Exon 14 of ap3d1 is overexpressed in crasher mutants, while the expression of ap3d1 as a whole is reduced. ap3d1 knockout in *AB zebrafish recapitulates the mutant crasher phenotype. We show ap3d1 loss-of-function mutations cause significant expression changes in the melanogenesis genes, dopachrome tautomerase (dct) and tyrosinase-related protein 1b (tyrp1b), but not tyrosinase (tyr). Last, Generally Applicable Gene-set Enrichment (GAGE) analysis suggests autophagy pathway genes are upregulated together in crasher. Treatment with autophagy-inhibitor, bafilomycin A1, significantly decreases melanophore number in crasher, suggesting ap3d1 promotes melanophore survival by limiting excessive autophagy. crasher is a valuable model to explore the regulation of melanogenesis gene expression and pigmentation disease.

Zebrafish Syndromic Albinism Models as Tools for Understanding and Treating Pigment Cell Disease in Humans.

Melanin is the pigment that protects DNA from ultraviolet (UV) damage by absorbing excess energy. Melanin is produced in a process called melanogenesis. When melanogenesis is altered, diseases such as albinism result. Albinism can result in an increased skin cancer risk. Conversely, black pigment cell (melanocyte) development pathways can be misregulated, causing excessive melanocyte growth that leads to melanoma (cancer of melanocytes). Zebrafish is an emerging model organism used to study pigment disorders due to their high fecundity, visible melanin development in melanophores (melanocytes in mammals) from 24 h post-fertilization, and conserved melanogenesis pathways. Here, we reviewed the conserved developmental pathways in zebrafish melanophores and mammalian melanocytes. Additionally, we summarized the progress made in understanding pigment cell disease and evidence supporting the strong potential for using zebrafish to find novel treatment options for albinism.

Leveraging Podcasts to Introduce Medical Students to the Broader Community of Health Care Professionals.

INTRODUCTION: Safe, patient-centered, and cost-effective care requires effective collaboration within interprofessional teams. Education programs for health care professionals are often siloed, providing students with limited interprofessional education (IPE) opportunities to learn from, with, and about other professions. Podcasts offer a novel approach to facilitate IPE, allowing for asynchronous conversations with interprofessional colleagues. METHODS: We developed four podcasts with various health care professionals for 135 preclinical medical students preparing to transition into clinical rotations. The podcasts were coupled with an hour-long interactive session with the podcast interviewees conducted via videoconference. The curriculum explored the distinct education paths, roles, and responsibilities of various health care disciplines. Strategies for communicating effectively with and learning from interprofessional team members were emphasized. RESULTS: There were 197 unique downloads of the podcasts, and 95 students attended the interactive session. Most students reported that the podcasts and follow-up live session enhanced their learning (100% and 98% of students who completed the postcurriculum survey, respectively). Responses to the postcurriculum survey revealed students learned strategies for engaging in productive interprofessional conversations, the importance of leveraging the distinct roles and responsibilities of diverse health professionals, the value of learning from other health professionals, and the use of respectful language. DISCUSSION: This IPE curriculum built around podcasts enhances medical student learning and represents an innovative approach to improving access to IPE in a virtual learning environment. This modality can be adapted to meet the needs of a wide spectrum of learners and can be coupled with in-person learning.

Functional coordination of non-myocytes plays a key role in adult zebrafish heart regeneration.

Cardiac regeneration occurs primarily through proliferation of existing cardiomyocytes, but also involves complex interactions between distinct cardiac cell types including non-cardiomyocytes (non-CMs). However, the subpopulations, distinguishing molecular features, cellular functions, and intercellular interactions of non-CMs in heart regeneration remain largely unexplored. Using the LIGER algorithm, we assemble an atlas of cell states from 61,977 individual non-CM scRNA-seq profiles isolated at multiple time points during regeneration. This analysis reveals extensive non-CM cell diversity, including multiple macrophage (MC), fibroblast (FB), and endothelial cell (EC) subpopulations with unique spatiotemporal distributions, and suggests an important role for MC in inducing the activated FB and EC subpopulations. Indeed, pharmacological perturbation of MC function compromises the induction of the unique FB and EC subpopulations. Furthermore, we developed computational algorithm Topologizer to map the topological relationships and dynamic transitions between functional states. We uncover dynamic transitions between MC functional states and identify factors involved in mRNA processing and transcriptional regulation associated with the transition. Together, our single-cell transcriptomic analysis of non-CMs during cardiac regeneration provides a blueprint for interrogating the molecular and cellular basis of this process.

The Kind Care Bundle: A Curriculum to Teach Medical Students the Behaviors of Kind, Compassionate Care.

Introduction: Patients' hospital experiences can be adversely affected by clinicians' negative behaviors. Simple positive behaviors, however, can have a dramatic impact on patient-clinician relationships. Medical students starting clinical training are ideal educational targets for learning good behavioral habits that promote kind, compassionate care. Methods: We developed the Kind Care Bundle, a collection of concrete verbal and nonverbal behaviors for showing compassion in patient interactions. The curriculum was taught in 3-hour small-group interactive sessions to first-year students. Students reflected on personal experiences of compassionate care and role-played the use of the Kind Care Bundle. In pairs, students interviewed patients about their experiences of kind, compassionate care while practicing the Kind Care Bundle. Students completed a postsession evaluation with Likert scales and free-text responses. Results: Thirty-seven of 40 students (92%) completed postsession evaluation forms. Session organization was considered excellent (27 of 37 students, 73%) or very good (nine of 37, 27%). Session relevance was rated as excellent by 30 of 37 students (81%) and very good by six of 37 students (16%). Students believed the bundle filled an educational gap. Qualitative themes included appreciation of concrete behaviors in the bundle, importance of empathy, and opportunity to reflect on one's own experience of compassion. Discussion: Students appreciated learning about specific behaviors for improving patient interactions. Targeting preclinical medical students has the potential to promote kinder and more compassionate patient interactions during subsequent clinical training. The long-term impact on students' behavior and on their personal and professional development requires further study.

A description of novel variants and review of phenotypic spectrum in UBA5-related early epileptic encephalopathy.

Early infantile epileptic encephalopathy-44 (EIEE44, MIM: 617132) is a previously described condition resulting from biallelic variants in UBA5, a gene involved in a ubiquitin-like post-translational modification system called UFMylation. Here we report five children from four families with biallelic pathogenic variants in UBA5 All five children presented with global developmental delay, epilepsy, axial hypotonia, appendicular hypertonia, and a movement disorder, including dystonia in four. Affected individuals in all four families have compound heterozygous pathogenic variants in UBA5 All have the recurrent mild c.1111G > A (p.Ala371Thr) variant in trans with a second UBA5 variant. One patient has the previously described c.562C > T (p. Arg188*) variant, two other unrelated patients have a novel missense variant, c.907T > C (p.Cys303Arg), and the two siblings have a novel missense variant, c.761T > C (p.Leu254Pro). Functional analyses demonstrate that both the p.Cys303Arg variant and the p.Leu254Pro variants result in a significant decrease in protein function. We also review the phenotypes and genotypes of all 15 previously reported families with biallelic UBA5 variants, of which two families have presented with distinct phenotypes, and we describe evidence for some limited genotype-phenotype correlation. The overlap of motor and developmental phenotypes noted in our cohort and literature review adds to the increasing understanding of genetic syndromes with movement disorders-epilepsy.

Everyday Resilience: Equipping Faculty With Practical Exercises to Promote Resilience Among Medical Students.

Introduction: Burnout is prevalent in health care. As professionals advocate to increase resilience training as a strategy to reduce burnout, few examples exist of practical resilience programs that equip faculty to help students build and sustain well-being over time. Method: We developed two straightforward, skills-based resilience exercises. Breaking Down Easy taught individuals to identify personal strengths. My Resilience Practice helped individuals identify strategies to cope with daily stressors. We taught these exercises to international faculty in a train-the-trainer workshop format, at two medical education conferences. Faculty applied the exercises, performed pair-share reflections, and discussed opportunities to introduce the exercises in their own institutions. Postsession surveys evaluated the workshop quality and the exercises' ease of use and applicability. Results: Thirty-five faculty and five students participated across two international conferences. Of participants, 83% (33 of 40) completed postsession surveys. On a 5-point Likert scale, participants rated the workshop on average 4.4 for usefulness, 4.6 for applicability, 4.4 for ease of instruction, 4.5 for clarity, and 4.8 for overall quality. Participants found the exercises to be straightforward to use and planned to use them at their institutions with students, residents, and faculty. Discussion: Participants found our workshop to be relevant and effective and shared their intention to incorporate these materials into their teaching with medical students, residents, and faculty. Implementing effective programs to build resilience is critical to increasing well-being and reducing burnout. This, in turn, may enhance patient safety and improve health system outcomes.

Gender-Based Discrimination and Sexual Harassment Among Academic Internal Medicine Hospitalists.

BACKGROUND: Gender-based discrimination and sexual harassment, both implicit and overt, have been reported in academic medicine. This study examines experiences of academic hospitalists regarding gender-based discrimination and sexual harassment. METHODS: A survey was distributed to Internal Medicine hospitalists at university-based academic institutions in the United States. Questions assessed experiences regarding gender-based discrimination and sexual harassment in their interactions with patients, as well as with other healthcare providers (HCPs). RESULTS: Eighteen institutions participated in the survey, resulting in 336 individual responses. Female hospitalists more frequently reported inappropriate touch, sexual remarks, gestures, and suggestive looks by patients compared with male peers both over their careers (P < .001) and in the last 30 days (P < .001). Similarly, females more frequently reported being referred to with inappropriate terms of endearment (eg, "dear," "honey," "sweetheart") by patients both over their careers (P < .001) and in the last 30 days (P < .001). Almost 100% of females reported being mistaken by patients for nonphysician HCPs over their careers, compared with 29% of males (P < .001) (76% vs 10%, in the last 30 days; P < .001). Similarly, females more frequently reported sexual harassment over their careers (P < .05) and being mistaken for nonphysician HCPs by colleagues both over their careers (P < .001) and in the last 30 days (P < .001). Females rated their sense of respect both by patients (P < .001) and colleagues (P < .001) lower than males (P < .001). More females than males reported that gender negatively impacted their career opportunities (P < .001). CONCLUSION: This survey demonstrates that gender-based discrimination and sexual harassment are commonly encountered by academic hospitalists, with a significantly higher number of females reporting these experiences.

Hierarchy, "Kreng Jai" and Feedback: A Grounded Theory Study Exploring Perspectives of Clinical Faculty and Medical Students in Thailand.

Phenomenon: Institutional learning culture influences how feedback is provided, accepted, and acted upon. The Thai societal culture, characterized by strict hierarchy and collectivism, may have a significant impact on the learning culture and, therefore, feedback conversations between teachers and learners. This study explored: common approaches used by faculty to provide feedback to students; and faculty and student perspectives regarding sociocultural factors that impact feedback seeking, provision, and acceptance. Approach: Using a constructivist paradigm, we explored perspectives of clinical faculty and medical students at an academic medical center in Thailand using focus groups (students) and a focus group and individual interviews (faculty). Sessions were audiotaped, transcribed, and de-identified prior to analysis. Constant comparative analysis was performed on transcripts, focusing on perceived cultural factors that impacted feedback conversations. Findings: Thirty faculty participated in the study, four participated in a focus group, and 27 participated in individual interviews. Twenty-two medical students participated in four focus groups. We identified the following key themes, which could be grouped under three categories: (1) Faculty approaches to providing feedback (1.1) Feedback should be initiated by faculty. (1.2) Feedback is initiated primarily for deficit identification and correction. (2) Factors impacting students' feedback seeking and acceptance. (2.1) Students are willing to accept harsh feedback when it provides suggestions for improvement. (2.2) Feedback is most credible when faculty have direct knowledge of the student's effort. (2.3) Feedback seeking is considered a burden on teachers. (3) Cultural factors that influence feedback (3.1) Societal hierarchy perpetuates unidirectional top-down feedback. (3.2) Kreng jai (the balance between consideration for others and self-interests) affects feedback seeking and provision. Insights: Though the value of feedback on learning was emphasized by all participants, the hierarchical culture of Thai society was perceived to have a significant influence on feedback seeking, provision, and acceptance. Identifying and addressing societal as well as institutional cultural factors would be key in designing growth-enhancing feedback initiatives relevant to the local context. One size feedback training does not fit all.

Enhancing the Formal Preclinical Curriculum to Improve Medical Student Perception of Surgery.

BACKGROUND: This study aims to determine the effect of formal, preclinical curricular interventions on medical students' perceptions of surgeons, surgical learning objectives, and concerns regarding the surgical clerkship. METHODS: Thirty-eight medical students underwent a newly required, formal introduction to surgery during the preclinical curriculum. Two months later, these students were given surveys regarding their perception of surgery before and after a bootcamp-style transitions to the wards workshop that immediately preceded their core clinical rotations. Student responses were compared to historical peers. RESULTS: Thirty-seven students participated in the study (97.4%). Relative to historical peers, students demonstrated improved overall perception of surgery (71.2 vs 66.6, p = 0.046). A smaller proportion of students indicated that they were worried about evaluation (18.9% in 2018 vs 55.3% in 2017, p = 0.001) and interactions with surgical educators (18.9% vs 50%, p = 0.005). Students' overall perception of surgery significantly improved after participation in the transition to the wards workshop (71.2 to 77.8, p ≤ 0.0001), as did student agreement with 9 of 21 specific items. Improvement in surgical perception across the bootcamp-style workshop was similar to that of a prior workshop (8.6 in 2018 vs 6.4 in 2017, p = 0.21). CONCLUSIONS: A preclinical introduction to surgery can have a positive impact on medical student perception of surgery prior to entry to the wards and may mitigate student fears regarding their surgical rotation.

Melanosome maturation proteins Oca2, Mitfa and Vps11 are differentially required for cisplatin resistance in zebrafish melanocytes.

Melanoma is the deadliest form of skin cancer, partially due to its inherent resistance to therapy. Here, we test in live larvae the hypothesis that mature melanosomes contribute to resistance to chemotherapeutic drug, cisplatin, via drug sequestration. We also compare three melanosome biogenesis proteins-microphthalmia-associated transcription factor (Mitfa), vacuolar protein sorting 11 (Vps11) and oculocutaneous albinism 2 (Oca2) to determine their respective contributions to chemoresistance. Melanocytes in zebrafish larvae harbouring loss-of-function mutations in the mitfa, vps11 or oca2 genes are more sensitive to cisplatin damage than wild-type larvae. As a comparison, we examined sensory hair cells of the lateral line, which are sensitive to cisplatin. Hair cells in oca2 and mitfa mutants do not show increased cisplatin sensitivity when compared to wild-type larvae, suggesting the increase in cisplatin sensitivity could be melanocyte specific. However, hair cells in vps11 mutants are more sensitive to cisplatin than their wild-type counterparts, suggesting that this mutation increases cisplatin susceptibility in multiple cell types. This is the first in vivo study to show an increase in chemotherapeutic drug sensitivity when melanosome maturation mutations are present. The proteins tested, especially Oca2, represent novel drug targets for increasing the efficiency of melanoma chemotherapy treatment.

Update in Hospital Medicine: Practical Lessons from Current Literature.

BACKGROUND: Hospital medicine continues to grow in workforce, clinical scope, and academic inquiry. This article provides a summary of recent high-impact publications for busy clinicians who provide care to hospitalized adults. METHODS: Authors reviewed articles that were published between March 2017 and March 2018 for the Update in Hospital Medicine presentations at the 2018 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 29 articles presented were selected for this review based on quality and potential to influence practice. RESULTS: The following key insights were gained: (1) the perioperative continuation of aspirin in patients with previous percutaneous intervention is beneficial; (2) delaying hip fracture surgery beyond a 24-hour window increases complications; (3) oral antibiotics may be effective treatment for select bloodstream infections; (4) pulmonary embolism may not be as common a cause of syncope as previously suggested; (5) balanced intravenous fluids and normal saline are similar with respect to hospital-free days but a difference exists in renal events at 30 days favoring balanced crystalloids; (6) speaker introductions may reveal gender bias in academic medicine; (7) edoxaban is a reasonable choice for the treatment of venous thromboembolism in cancer; (8) high-flow nasal cannula reduces the need for intubation in respiratory failure when compared with usual oxygen therapy and noninvasive positive pressure ventilation; and (9) diagnostic errors in spinal epidural abscess lead to delays and morbidity. CONCLUSIONS: This research provides insight into how we can approach common medical problems in the care of hospitalized adults. The selected works have the potential to change or confirm current practices.

Medical students' perceptions and motivations prior to their surgery clerkship.

BACKGROUND: This study aims to determine the effect of a pre-clerkship workshop on medical students' perceptions of surgery and surgeons and to describe their concerns and learning goals. METHODS: Thirty-nine medical students completed surveys before and after a workshop preceding their surgery clerkship. Quantitative data and free responses that were inductively coded were used to assess effectiveness. RESULTS: Perceptions from 38 students (response rate = 97.4%) significantly improved for 11 of 21 items. At pre-workshop, the most frequently cited learning goals were improving technical skills (58%), surgical knowledge (53%), and understanding surgical culture and work (53%). Students' top concerns were meeting clerkship demands (68%) and being evaluated (55%). After the workshop, student learning objectives and concerns remained largely unchanged. CONCLUSIONS: A pre-clerkship workshop improved student perceptions of surgery and surgeons. Understanding students' intrinsic motivations may facilitate future clerkship curriculum improvement via better alignment of educator and student goals and objectives.

Protein Kinase A Signaling Inhibits Iridophore Differentiation in Zebrafish.

In zebrafish (Danio rerio), iridophores are specified from neural crest cells and represent a tractable system for examining mechanisms of cell fate and differentiation. Using this system, we have investigated the role of cAMP protein kinase A (PKA) signaling in pigment cell differentiation. Activation of PKA with the adenylyl cyclase activator forskolin reduces the number of differentiated iridophores in wildtype larvae, with insignificant changes to melanophore number. Inhibition of PKA with H89 significantly increases iridophore number, supporting a specific role for PKA during iridophore development. To determine the effects of altering PKA activity on iridophore and melanophore gene expression, we examined expression of iridophore marker pnp4a, melanophore marker mitfa, and the mitfa repressor foxd3. Consistent with our cell counts, forskolin significantly decreased pnp4a expression as detected by in situ hybridization and quantification of pnp4a+ cells. Forskolin had the opposite effect on mitfa and foxd3 gene activity, increasing the area of expression. As mitfa/nacre mutants have extra iridophores as compared to wildtype larvae, we examined the function of mitfa during PKA-sensitive iridophore development. Forskolin treatment of mitfa/nacre mutants did significantly reduce the number of iridophores but to a lesser extent than that observed in treated wildtype larvae. Taken together, our data suggests that PKA inhibits iridophore development in a subset of iridophore precursors, potentially via a foxd3-independent pathway.