Tools for Medical Education Scholarship: From Curricular Development to Educational Research.

The development of successful educational scholarship, either curricula or medical education research, is vital in ensuring that the field of medical education continues to evolve. Fostering the skills of medical educators in conducting high-quality educational research is essential to this process because publishing such research helps to disseminate best educational practices to the medical community at large. Unfortunately, developing rigorous medical education research can be challenging for pediatric hospitalists within busy clinical settings. In this article, we aim to discuss key principles and frameworks for curricular development as well as offer guidance in transforming a curriculum into a scholarly medical education research product for pediatric hospital medicine providers.

Medical Student H&Ps: Do You Have to Observe Them All At Once?

OBJECTIVES: Direct observation of medical students' history and physical examination (H&P) skills by attendings is essential in ensuring trainees' competence. This study compared whether partial observations by multiple pediatric attendings across various clinical encounters versus a full observation by one attending affected students' performance on the pediatric Objective Structured Clinical Examination (OSCE) and the Year 3 Clinical Performance Examination (CPX3). METHODS: For the 2013-2014 and 2014-2015 academic years, 323 medical students submitted either H&P checklists completed by one attending observing an entire H&P (full observations) versus multiple attendings observing portions of the H&P (partial observations). The full and partial observation groups were compared by their pediatric OSCE and CPX3 performance. RESULTS: Students submitting full observations (n = 185) versus partial observations (n = 138) revealed no difference in OSCE (3.10 vs 3.10, P = 0.98) or CPX3 scores (74.49 vs 75.31, P = 0.18). Students submitting checklists by clerkship midpoint performed better on the OSCE (3.11 vs 2.88, P = 0.001) and CPX3 (75.00 vs 72.25, P = 0.03). CONCLUSIONS: Partial versus full observations of students' H&P skills have no effect on standardized clinical examination performance, and clerkships should consider using partial observations of students for efficient assessments. Promptness of checklist submission also may be an indicator of examination performance.

4-D ICE: A 2-D Array Transducer With Integrated ASIC in a 10-Fr Catheter for Real-Time 3-D Intracardiac Echocardiography.

We developed a 2.5 ×6.6 mm 2 2 -D array transducer with integrated transmit/receive application-specific integrated circuit (ASIC) for real-time 3-D intracardiac echocardiography (4-D ICE) applications. The ASIC and transducer design were optimized so that the high-voltage transmit, low-voltage time-gain control and preamp, subaperture beamformer, and digital control circuits for each transducer element all fit within the 0.019-mm 2 area of the element. The transducer assembly was deployed in a 10-Fr (3.3-mm diameter) catheter, integrated with a GE Vivid E9 ultrasound imaging system, and evaluated in three preclinical studies. The 2-D image quality and imaging modes were comparable to commercial 2-D ICE catheters. The 4-D field of view was at least 90 ° ×60 ° ×8 cm and could be imaged at 30 vol/s, sufficient to visualize cardiac anatomy and other diagnostic and therapy catheters. 4-D ICE should significantly reduce X-ray fluoroscopy use and dose during electrophysiology ablation procedures. 4-D ICE may be able to replace transesophageal echocardiography (TEE), and the associated risks and costs of general anesthesia, for guidance of some structural heart procedures.

Toward Quantitative Assessment of Rheumatoid Arthritis Using Volumetric Ultrasound.

GOAL: Rheumatoid arthritis (RA) is characterized by inflammation within the joint space as well as erosion or destruction of the bone surface. We believe that volumetric (3-D) ultrasound imaging of the joints in conjunction with automated image-analysis tools for segmenting and quantifying the regions of interest can lead to improved RA assessment. METHODS: In this paper, we describe our proposed algorithms for segmenting 1) the 3 -D bone surface and 2) the 3-D joint capsule region. We improve and extend previous 2-D bone extraction methods to 3-D and make our algorithm more robust to the intensity loss due to surface normals facing away from incident acoustic beams. The extracted bone surfaces coupled with a joint-specific anatomical model are used to initialize a coarse localization of the joint capsule region. The joint capsule segmentation is refined iteratively utilizing a probabilistic speckle model. RESULTS: We apply our methods on 51 volumes from 8 subjects, and validate segmentation results with expert annotations. We also provide the quantitative comparison of our bone detection with magnetic resonance imaging. These automated methods have achieved average sensitivity/precision rates of 94%/93% for bone surface detection, and 87%/83% for joint capsule segmentation. Segmentations of normal and inflamed joints are compared to demonstrate the potential of using proposed tools to assess RA pathology at the joint level. CONCLUSION: The proposed image-analysis methods showed encouraging results as compared to expert annotations. SIGNIFICANCE: These computer-assisted tools can be used to help visualize 3-D anatomy in joints and help develop quantitative measurements toward RA assessment.

4-D spatiotemporal analysis of ultrasound contrast agent dispersion for prostate cancer localization: a feasibility study.

Currently, nonradical treatment for prostate cancer is hampered by the lack of reliable diagnostics. Contrastultrasound dispersion imaging (CUDI) has recently shown great potential as a prostate cancer imaging technique. CUDI estimates the local dispersion of intravenously injected contrast agents, imaged by transrectal dynamic contrast-enhanced ultrasound (DCE-US), to detect angiogenic processes related to tumor growth. The best CUDI results have so far been obtained by similarity analysis of the contrast kinetics in neighboring pixels. To date, CUDI has been investigated in 2-D only. In this paper, an implementation of 3-D CUDI based on spatiotemporal similarity analysis of 4-D DCE-US is described. Different from 2-D methods, 3-D CUDI permits analysis of the entire prostate using a single injection of contrast agent. To perform 3-D CUDI, a new strategy was designed to estimate the similarity in the contrast kinetics at each voxel, and data processing steps were adjusted to the characteristics of 4-D DCE-US images. The technical feasibility of 4-D DCE-US in 3-D CUDI was assessed and confirmed. Additionally, in a preliminary validation in two patients, dispersion maps by 3-D CUDI were quantitatively compared with those by 2-D CUDI and with 12-core systematic biopsies with promising results.

Simulation training as a mechanism for procedural and resuscitation education for pediatric residents: a systematic review.

BACKGROUND: Pediatric residents often finish their training lacking sufficient procedural proficiency and resuscitation experience in the care of critically ill children. Simulation is gaining favor in pediatric residency programs as a modality for procedural and resuscitation education. We reviewed the literature assessing simulation and its role in pediatric resident training. METHODS: We conducted a Medline and PubMed search of simulation training in pediatric resident education from January 2007 to July 2012. RESULTS: Eight studies were included and divided into simulated procedural assessments and simulated resuscitation scenario assessments. The studies varied widely in their approach and analysis, and they yielded mixed results. CONCLUSIONS: Although some studies show the merits of simulation in the procedural and resuscitation training of pediatric residents, more research is needed to assess the effectiveness of simulation as an educational tool. Goals of future simulation research should include creation of validated assessment tools and applying skills learned to patient care outcomes.

High-fidelity simulation enhances pediatric residents' retention, knowledge, procedural proficiency, group resuscitation performance, and experience in pediatric resuscitation.

OBJECTIVE: The goal of this study was to assess the effect of high-fidelity simulation (HFS) pediatric resuscitation training on resident performance and self-reported experience compared with historical controls. METHODS: In this case-control study, pediatric residents at a tertiary academic children's hospital participated in a 16-hour HFS resuscitation curriculum. Primary outcome measures included cognitive knowledge, procedural proficiency, retention, and self-reported comfort and procedural experience. The intervention group was compared with matched-pair historical controls. RESULTS: Forty-one residents participated in HFS training with 32 matched controls. The HFS group displayed significant initial and overall improvement in knowledge (P < .01), procedural proficiency (P < .05), and group resuscitation performance (P < .01). Significant skill decay occurred in all performance measures (P < .01) with the exception of endotracheal intubation. Compared with controls, the HFS group reported not only greater comfort with most procedures but also performed more than twice the number of successful real-life pediatric intubations (median: 6 vs 3; P = .03). CONCLUSIONS: Despite significant skill decay, HFS pediatric resuscitation training improved pediatric resident cognitive knowledge, procedural proficiency, and comfort. Residents who completed the course were not only more proficient than historical controls but also reported increased real-life resuscitation experiences and related procedures.

Pilot randomized trial on mindfulness training for smokers in young adult binge drinkers.

BACKGROUND: We report results of a pilot study designed to test a novel smoking cessation intervention, Mindfulness Training for Smokers (MTS), in smokers age 18-29 years with regular episodes of binge drinking. Mindfulness is a cognitive skill of applying close moment-to-moment attention to experience with a mental posture of acceptance and non-reactivity. The MTS intervention consisted of six weekly classes that provided instruction on how to use mindfulness to manage known precursors of smoking relapse including smoking triggers, strong emotions, stressful situations, addictive thoughts, urges, and withdrawal symptoms. METHODS: The MTS intervention was compared to Interactive Learning for Smokers (ILS), a time/intensity matched control group using daily non-directed walking instead of mindfulness meditation. Recruitment was conducted primarily at local technical colleges. Primary outcome measures included biochemically-confirmed smoking abstinence and reduction in alcohol use at the end of treatment (2-weeks post-quit attempt). RESULTS: The sample (N = 55) was 70.9% male, with a mean age of 21.9 years, and a mean of 11.76 alcoholic drinks consumed per week. Intent-to-treat analysis showed biochemically-confirmed 7-day point prevalence abstinence rates at 2-weeks post-quit for MTS = 20.0% and ILS = 4.0%, p = .08. Secondary analysis showed number of drinks per week in the first 2-weeks post-quit correlated with smoking relapse at 2-weeks post-quit (p < .01). CONCLUSIONS: This pilot study demonstrated that Mindfulness Training for Smokers shows promise for smoking cessation and alcohol use reduction in treating young adult smokers with alcohol abuse. Results suggest the need for a study with larger sample size and methods that reduce attrition. TRIAL REGISTRATION: ClnicalTrial.gov, NCT01679236.

Packaging and modular assembly of large-area and fine-pitch 2-D ultrasonic transducer arrays.

A promising transducer architecture for largearea arrays employs 2-D capacitive micromachined ultrasound transducer (CMUT) devices with backside trench-frame pillar interconnects. Reconfigurable array (RA) application-specified integrated circuits (ASICs) can provide efficient interfacing between these high-element-count transducer arrays and standard ultrasound systems. Standard electronic assembly techniques such as flip-chip and ball grid array (BGA) attachment, along with organic laminate substrate carriers, can be leveraged to create large-area arrays composed of tiled modules of CMUT chips and interface ASICs. A large-scale, fully populated and integrated 2-D CMUT array with 32 by 192 elements was developed and demonstrates the feasibility of these techniques to yield future large-area arrays. This study demonstrates a flexible and reliable integration approach by successfully combining a simple under-bump metallization (UBM) process and a stacked CMUT/interposer/ASIC module architecture. The results show high shear strength of the UBM (26.5 g for 70-µm balls), high interconnect yield, and excellent CMUT resonance uniformity (s = 0.02 MHz). A multi-row linear array was constructed using the new CMUT/interposer/ASIC process using acoustically active trench-frame CMUT devices and mechanical/ nonfunctional Si backside ASICs. Imaging results with the completed probe assembly demonstrate a functioning device based on the modular assembly architecture.

Volumetric ultrasound and computer-assisted analysis at the point-of-care: a musculoskeletal exemplar.

In this paper we motivate the hypothesis that the use of volumetric ultrasound imaging and automated image analysis tools would improve clinical workflows as well as outcomes at the point-of-care. To make our case, this paper presents results from a rheumatoid arthritis (RA) study where several image analysis techniques have been applied to volumetric ultrasound, highlighting anatomy of interest to better understand disease progression. Pathologies related to RA in joints, manifest themselves commonly as changes in the bone (e.g. erosions) and the region enclosed by the joint-capsule (e.g. synovitis). Automated tools for detecting and segmenting such structures would help significantly towards objective and quantitative assessment of RA in joints. Extracted bone coupled with a simple anatomical model of the joint provides a coarse localization of the joint-capsule region. A probabilistic speckle model is then used to iteratively refine the capsule segmentation. We illustrate the performance of proposed algorithms through quantitative comparisons with expert annotations as well as qualitative results on over 30 scans obtained from 11 subjects.

Intra-urban societal vulnerability to extreme heat: the role of heat exposure and the built environment, socioeconomics, and neighborhood stability.

Extreme heat is an important weather hazard associated with excess mortality and morbidity. We determine the relative importance of heat exposure and the built environment, socioeconomic vulnerability, and neighborhood stability for heat mortality (Philadelphia, PA, USA) or heat distress (Phoenix, AZ, USA), using an ecologic study design. We use spatial Generalized Linear and Mixed Models to account for non-independence (spatial autocorrelation) between neighboring census block groups. Failing to account for spatial autocorrelation can provide misleading statistical results. Phoenix neighborhoods with more heat exposure, Black, Hispanic, linguistically and socially isolated residents, and vacant households made more heat distress calls. Philadelphia heat mortality neighborhoods were more likely to have low housing values and a higher proportion of Black residents. Our methodology can identify important risk factors and geographic areas to target interventions.

Coordinate suppression of B cell lymphoma by PTEN and SHIP phosphatases.

The inositol phosphatases phosphatase and tensin homologue (PTEN) and Src homology 2 domain-containing inositol phosphatase (SHIP) negatively regulate phosphatidylinositol-3-kinase (PI3K)-mediated growth, survival, and proliferation of hematopoietic cells. Although deletion of PTEN in mouse T cells results in lethal T cell lymphomas, we find that animals lacking PTEN or SHIP in B cells show no evidence of malignancy. However, concomitant deletion of PTEN and SHIP (bPTEN/SHIP(-/-)) results in spontaneous and lethal mature B cell neoplasms consistent with marginal zone lymphoma or, less frequently, follicular or centroblastic lymphoma. bPTEN/SHIP(-/-) B cells exhibit enhanced survival and express more MCL1 and less Bim. These cells also express low amounts of p27(kip1) and high amounts of cyclin D3 and thus appear poised to undergo proliferative expansion. Unlike normal B cells, bPTEN/SHIP(-/-) B cells proliferate to the prosurvival factor B cell activating factor (BAFF). Interestingly, although BAFF availability may promote lymphoma progression, we demonstrate that BAFF is not required for the expansion of transferred bPTEN/SHIP(-/-) B cells. This study reveals that PTEN and SHIP act cooperatively to suppress B cell lymphoma and provides the first direct evidence that SHIP is a tumor suppressor. As such, assessment of both PTEN and SHIP function are relevant to understanding the etiology of human B cell malignancies that exhibit augmented activation of the PI3K pathway.

Central lower eyelid thinning with trichiasis: characterization and management of a unique subset of entropion in elderly patients.

PURPOSE: To characterize the clinical and pathologic features of central lower eyelid thinning with trichiasis and discuss the management of this unique subset of entropion in elderly patients. METHODS: Retrospective study of patients with central lower eyelid thinning with trichiasis who presented between July 1996 and March 2006. Evaluation of management, including surgical intervention, using a modified Quickert "4-snip" block excision combined with lower eyelid retractor plication. RESULTS: Forty-one lower eyelids in 25 patients (22 men, 3 women; age range, 65-92 years; mean age, 79.6 +/- 6.6 years). All lower eyelids had medialization of the lateral eyelashes progressing posteriorly to frank trichiasis in the thinnest central zone. Seventeen patients (68%) had blepharitis. Twenty lower eyelids (48.8%) were refractory to initial treatment or presented with more severe disease and required incisional surgery; 16 of these were considered to have a successful postoperative outcome. Pathology reports from the specimens obtained frequently revealed the absence of meibomian glands, subconjunctival fibrosis, and tarsal scarring. CONCLUSIONS: Central lower eyelid thinning with trichiasis is a distinct subset of entropion in elderly patients. Its management differs from the usual treatment for entropion in this age group. Surgeons should be aware of this unique condition to optimize diagnosis and treatment.

Ocular manifestations of long-term mascara use.

Mascara, a widely used cosmetic, is associated with eye pathology. The authors report 3 cases of eye problems secondary to long-term mascara use. Two patients had multiple pigmented conjunctival lesions; one of these had a history of melanoma of the hand. Conjunctival biopsy revealed nonmelanocytic pigment granules within conjunctival stroma cells in both cases. The other patient had a history of dry eye, and also showed pigment clumping around a punctal plug. The third patient had canalicular obstruction from a mascara-laden dacryolith ("dacryomascaralith"), the first such case reported. A literature review revealed cases of eyelid dermatitis, infectious keratitis, a conjunctival mass ("mascaroma"), and others. Ophthalmologists should be aware of mascara's associated eye problems. The physical findings combined with a high index of suspicion, especially in cases of heavy mascara use, may allow for an accurate diagnosis and spare the patient an otherwise unnecessary invasive procedure.

Wideband energy reflectance measurements of ossicular chain discontinuity and repair in human temporal bone.

OBJECTIVE: Recent studies have suggested the potential of wideband energy reflectance (ER) for the assessment of middle ear disorders. The purpose of this study was to examine the use of wideband ER in the evaluation of an ossicular discontinuity and its repair in human cadaver temporal bones. DESIGN: ER measurements at ambient pressure were made on five human cadaver ears in three conditions: (1) baseline with intact ossicular chain, (2) with the ossicular chain cut using an argon laser, and (3) with the ossicular chain repaired. Laser Doppler vibrometry measurements of stapes footplate velocity were also made in the three conditions to monitor the effect of the experimental manipulations on sound transfer through the middle ear. RESULTS: Disarticulating the ossicular chain resulted in the appearance of a deep notch in ER in each specimen ranging in center frequency from 561 to 841 Hz. The average reduction in ER was 31% at a frequency of 630 Hz. Laser Doppler vibrometry measurements confirmed the effect of the disarticulation and then repair using ionomeric cement. The low-frequency notch in ER was eliminated following repair of the ossicular chain. There was a small decrease in average high-frequency ER for both the cut and repaired conditions. A simple series impedance model of the middle ear was used to model the change in ER based on changes in middle ear impedance. The primary finding of the modeling was that the low-frequency notch in ER in the disarticulated ear occurs at the resonance frequency at which the reactance goes through zero consistent with the data. CONCLUSIONS: A disarticulation of the ossicular chain in human cadaver ears produces a low-frequency notch in ER that recovers with repair of the disarticulation. These results suggest that ER has the potential for use in the diagnosis of ossicular discontinuity and to monitor the status of the repaired ossicular chain. More data are needed to compare ER results from patients undergoing surgery for ossicular discontinuity with those of patients with other ossicular disorders such as otosclerosis.

Climate change, extreme weather events, and us health impacts: what can we say?

OBJECTIVE: Address how climate change impacts on a group of extreme weather events could affect US public health. METHODS: A literature review summarizes arguments for, and evidence of, a climate change signal in select extreme weather event categories, projections for future events, and potential trends in adaptive capacity and vulnerability in the United States. RESULTS: Western US wildfires already exhibit a climate change signal. The variability within hurricane and extreme precipitation/flood data complicates identifying a similar climate change signal. CONCLUSIONS: Health impacts of extreme events are not equally distributed and are very sensitive to a subset of exceptional extreme events. Cumulative uncertainty in forecasting climate change driven characteristics of extreme events and adaptation prevents confidently projecting the future health impacts from hurricanes, wildfires, and extreme precipitation/floods in the United States attributable to climate change.

Posttraumatic cellulitis and ulcerative conjunctivitis caused by Yersinia enterocolitica O:8.

A 55-year-old white man presented with orbital cellulitis and suspicion of an intraorbital foreign body after ocular trauma. He underwent orbital exploration, but no intraorbital foreign bodies were identified. Intraoperative orbital and conjunctival cultures grew Yersinia enterocolitica O:8. The patient's signs and symptoms resolved with intravenous antibiotic treatment after this exploratory orbitotomy. This is the first case, to our knowledge, of human orbital cellulitis caused by Y. enterocolitica O:8. The single visible interpalpebral conjunctival ulceration was suspected to be an entry wound by the patient's primary physician, the emergency room physician, and the orbital surgeon prior to surgical investigation, at which time all the other ulcerations were identified. Therefore, the physical manifestations of this rare but important infection are presented because they may mislead clinicians in suspecting an intraorbital foreign body.

Cell-type specific and cytoplasmic targeting of PEGylated carbon nanotube-based nanoassemblies.

In this paper we report the fabrication of a multivalent, cell-type specific and cytoplasmic delivery system based on single-walled carbon nanotubes. The latter were functionalized through adsorption of phospholipids terminated by biotinylated PEG chains functionalized with fluorochrome-coupled neutravidin, and subsequently with antibodies (anti-CD3epsilon and anti-CD28) for T cell receptor post-signaling endocytosis and a synthetic fusogenic polymer for disruption of lysosomal compartments. The biomimetic nanoassemblies were composed by PEGylated individual/very small bundles of carbon nanotubes having an average length and a standard deviation of 176 nm and 77 nm, respectively. The nanoassemblies were stably dispersed under physiological conditions, visible by conventional optical and confocal microscopy and specifically targeted to T cells both in vitro and in living animals. The addition of a fusogenic polymer to the nanoassemblies did not affect the cellular uptake and allowed the release into the cytosol of the targeted cells both in vitro and in the animals. The present manuscript is the first report about the cytoplasmic delivery of carbon nanotubes in a specific cell type in intact animals and paves the way for their use as in vivo intracellular delivery systems.

Sneezing reflex associated with intravenous sedation and periocular anesthetic injection.

PURPOSE: To assess and compare the frequency of reflex sneezing occurring during periocular anesthetic injections with and without intravenous sedation. DESIGN: Retrospective, comparative case series. METHODS: Seven hundred and twenty-two patients undergoing oculoplastic surgical procedures were included in this study. Those who received a periocular anesthetic injection under intravenous sedation served as the test group of 381 subjects. Those who received a periocular anesthetic injection without intravenous sedation served as the control group of 341 subjects. The absence or presence of reflex sneezing in both groups was recorded and compared using Chi-square analysis. RESULTS: Of the 381 patients who received periocular anesthetic injections under intravenous sedation, 19 (5%) exhibited a vigorous sneeze. Conversely, none of the 341 patients who received periocular anesthetic injections without intravenous sedation sneezed (P < or = .001). CONCLUSIONS: Surgeons, anesthesia staff, and other operating room personnel should be aware of this unusual and potentially dangerous sneeze phenomenon when periocular anesthetic injections are delivered under intravenous sedation to reduce potential ocular complications.