Cultivating compassion in medicine: a toolkit for medical students to improve self-kindness and enhance clinical care.

BACKGROUND: Compassionate care lies at the foundation of good patient care and is a quality that patients and providers continue to value in the fast-paced setting of contemporary medicine. Compassion is often discussed superficially in medical school curricula, but the practical aspect of learning this skill is often not taught using a formal framework. In the present work, the authors present an 8-session curriculum with a mindfulness-based approach to compassion that addresses this need. It is hypothesized that students in this curriculum will improve in their levels of compassion based on validated scales. METHODS: The curriculum was delivered to fourth-year medical students at Renaissance School of Medicine at Stony Brook University who had just completed their clerkship year. It was developed as a customizable set of modules that could be delivered in various ways. The students were taught with evidence-based cognitive exercises followed by group discussions and written reflections based on compassion-focused thematic questions. All students completed a pre- and post-Self-Compassion Scale, Compassion Scale, and Toronto Mindfulness Scale. Students in this course were compared with students in different courses about non-clinical topics delivered at the same time. Wilcoxon Signed Rank tests and Mann Whitney U tests were used to assess potential associations between pre- and post-survey responses for the validated scales and subscales. RESULTS: 17 fourth-year medical students completed pre- and post-course tests, 11 participated in the compassion curriculum while 6 participated from the other courses. Before any of the courses began, all students performed similarly on the pre-test across all scales. The students in the compassion curriculum demonstrated a significant increase in their total Self-Compassion score by 8.7 [95% CI 4.3 to 13.2] points (p = 0.008), total Compassion score by 6.0 [95% CI 1.4 to 10.6] points (p = 0.012), and the curiosity component of the Toronto Mindfulness Scale by 4.4 [95% CI 1.0 to 7.7] points (p = 0.012). There was no statistically significant difference between pre- and post-tests among the non-compassion curriculum students in the aforementioned scales (p = 0.461, p = 0.144, p = 0.785, respectively). CONCLUSIONS: Our results indicate that the students in our course developed an enhanced ability to engage in self-compassion, to understand the shared human experience, and to be motivated to act to alleviate suffering. Regardless of a program's existing compassion education, this customizable model allows for easy integration into a medical student's crowded curriculum. Furthermore, although teaching compassion early and often in a clinician's training is desirable, our study that targeted fourth-year medical students suggests an additional benefit of rekindling the loss of compassion well described in a medical student's clinical years.

Case report: Metastatic metaplastic breast cancer with choriocarinomatous features: Targeting the choriocarcinoma component for cure.

Breast cancer with choriocarcinomatous features (BCCF) is a rare and aggressive breast cancer. BCCF carries a poor prognosis and there is unfortunately scant literature to guide treatment beyond surgical resection with most patients receiving standard regimens for breast cancer. In our case, we present a 42-year-old female with an initial hCG of 2,324 and two suspicious lesions of the right breast. On biopsy, each lesion had distinct histopathology with the larger lesion diagnosed as BCCF and the smaller lesion being an invasive ER/PR positive ductal carcinoma. The diagnosis of BCCF rather than metastatic choriocarcinoma was confirmed using DNA typing. Salvage chemotherapy targeting choriocarcinoma resulted in marked clinical and biomarker success including normalization of the hCG. After recurrent brain metastases were diagnosed, high dose chemotherapy with methotrexate was administered resulting in long term remission.

Regulation of the error-prone DNA polymerase Polκ by oncogenic signaling and its contribution to drug resistance.

The DNA polymerase Polκ plays a key role in translesion synthesis, an error-prone replication mechanism. Polκ is overexpressed in various tumor types. Here, we found that melanoma and lung and breast cancer cells experiencing stress from oncogene inhibition up-regulated the expression of Polκ and shifted its localization from the cytoplasm to the nucleus. This effect was phenocopied by inhibition of the kinase mTOR, by induction of ER stress, or by glucose deprivation. In unstressed cells, Polκ is continually transported out of the nucleus by exportin-1. Inhibiting exportin-1 or overexpressing Polκ increased the abundance of nuclear-localized Polκ, particularly in response to the BRAFV600E-targeted inhibitor vemurafenib, which decreased the cytotoxicity of the drug in BRAFV600E melanoma cells. These observations were analogous to how Escherichia coli encountering cell stress and nutrient deprivation can up-regulate and activate DinB/pol IV, the bacterial ortholog of Polκ, to induce mutagenesis that enables stress tolerance or escape. However, we found that the increased expression of Polκ was not excessively mutagenic, indicating that noncatalytic or other functions of Polκ could mediate its role in stress responses in mammalian cells. Repressing the expression or nuclear localization of Polκ might prevent drug resistance in some cancer cells.

Prescribing Patterns of Heart Failure-Exacerbating Medications Following a Heart Failure Hospitalization.

OBJECTIVES: This study sought to describe the patterns of heart failure (HF)-exacerbating medications used among older adults hospitalized for HF and to examine determinants of HF-exacerbating medication use. BACKGROUND: HF-exacerbating medications can potentially contribute to adverse outcomes and could represent an important target for future strategies to improve post-hospitalization outcomes. METHODS: Medicare beneficiaries ≥65 years of age with an adjudicated HF hospitalization between 2003 and 2014 were derived from the geographically diverse REGARDS (Reasons for Geographic and Racial Difference in Stroke) cohort study. Major HF-exacerbating medications, defined as those listed on the 2016 American Heart Association Scientific Statement listing medications that can precipitate or induce HF, were examined. Patterns of prescribing medications at hospital admission and at discharge were examined, as well as changes that occurred between admission and discharge; and a multivariable logistic regression analysis was conducted to identify determinants of harmful prescribing practices following HF hospitalization (defined as either the continuation of an HF-exacerbating medications or an increase in the number of HF-exacerbating medications between hospital admission and discharge). RESULTS: Among 558 unique individuals, 18% experienced a decrease in the number of HF-exacerbating medications between admission and discharge, 19% remained at the same number, and 12% experienced an increase. Multivariable logistic regression analysis revealed that diabetes (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.18 to 2.75]) and small hospital size (OR: 1.93; 95% CI: 1.18 to 3.16) were the strongest, independently associated determinants of harmful prescribing practices. CONCLUSIONS: HF-exacerbating medication regimens are often continued or started following an HF hospitalization. These findings highlight an ongoing need to develop strategies to improve safe prescribing practices in this vulnerable population.