Beyond Competency: A Student Perspective on Growth Through Clerkship Feedback.

This article proposes a paradigm shift from the competency-based model of clerkship feedback using checklists to a coaching-based, action plan-oriented process that centers on individualized student-oriented goals. Using a student perspective, the authors examine the feedback literature and put forward a proposal to use an impact model whose emphasis is to improve the learning climate for students. Several techniques are reviewed which include goal generation and creation of dynamic action plans. By intentionally focusing on coaching relationships as a platform for feedback, the learners and mentors share goals and the result of feedback becomes action-based behaviors which may help negate personal attribution and bias in the feedback process.

Use of biologics for treatment of autoimmune inner ear disease.

OBJECTIVE: Biologic medications are novel therapeutics in the treatment of Autoimmune Inner Ear Disease (AIED), an etiology of Sensorineural Hearing Loss (SNHL). The goal of this study is to review the currently available literature on the efficacy of biologic medications on autoimmune-mediated hearing loss and associated symptomology among patients with AIED. METHODS: A systematic review of Pubmed, Scopus, Cochrane, and Web of Science databases was conducted to identify studies investigating the impact of biologic medications on hearing outcomes. Bias assessment was independently conducted by three authors and studies were stratified based on risk of bias. RESULTS: Of 174 unique abstracts screened, 12 articles met inclusion criteria for formal review. One randomized control trial, seven prospective cohort studies, and four retrospective cohort studies were included. Seven biologic medications, Etanercept, Infliximab, Adalimumab, Golimumab, Rituximab, Anakinra, and Canakinumab, were identified targeting three unique molecular targets, TNF-α, CD20, and IL-1. CONCLUSION: The effects of biologic medications in treating SNHL was highly variable without clear efficacy of a drug or drug category, likely due to rarity of disease, multifactorial etiologies of AIED, and cohort heterogeneity. However, several medications alleviate symptoms associated with AIED, such as vertigo and tinnitus. While biologic medications may be promising therapeutics in AIED patients, the evidence is currently inconclusive. Large-scale randomized control trials and prospective cohort reviews are required to establish the efficacy of biologic medications in treating hearing loss.

The ubiquitin ligase Cul5 regulates CD4+ T cell fate choice and allergic inflammation.

Antigen encounter directs CD4+ T cells to differentiate into T helper or regulatory cells. This process focuses the immune response on the invading pathogen and limits tissue damage. Mechanisms that govern T helper cell versus T regulatory cell fate remain poorly understood. Here, we show that the E3 ubiquitin ligase Cul5 determines fate selection in CD4+ T cells by regulating IL-4 receptor signaling. Mice lacking Cul5 in T cells develop Th2 and Th9 inflammation and show pathophysiological features of atopic asthma. Following T cell activation, Cul5 forms a complex with CIS and pJak1. Cul5 deletion reduces ubiquitination and subsequent degradation of pJak1, leading to an increase in pJak1 and pSTAT6 levels and reducing the threshold of IL-4 receptor signaling. As a consequence, Cul5 deficient CD4+ T cells deviate from Treg to Th9 differentiation in low IL-4 conditions. These data support the notion that Cul5 promotes a tolerogenic T cell fate choice and reduces susceptibility to allergic asthma.

The Prevalence of Esophageal Disorders Among Voice Patients With Laryngopharyngeal Reflux-A Retrospective Study.

OBJECTIVE: The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry. METHODS: A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed. RESULTS: The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively). CONCLUSION: Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

Cannabis use and medication nonadherence in bipolar disorder: A nationwide inpatient sample database analysis.

BACKGROUND: Medication nonadherence among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cannabis use disorder (CUD) association with medication noncompliance in hospitalized BD patients. METHODS: Using data on 266,303 BD hospitalizations between 2010 and 2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and CUD. Logistic regression was used to evaluate factors associated with medication noncompliance. RESULTS: Overall mean age, the prevalence of CUD, and medication nonadherence were 41.58 (± 0.11) years, 15.0% and 16.1%, respectively. There were 56.6% females in the overall population. There was a significant difference in the characteristics of those in the medication nonadherence vs adherence groups, including age, sex, race, comorbid substance use, income, insurance type, hospital region, and hospital teaching status (p < 0.001). After adjusting for other variables using multivariate analysis, there remained a statistically significant association of medication nonadherence in BD hospitalization and CUD (OR 1.42, 95% CI 1.36-1.48). LIMITATION: Confounding multiple substance use could not be accounted for, and the retrospective nature of the database which includes only inpatients is prone to possible selection and reporting bias. CONCLUSION: CUD statistically predicts increased rates of medication nonadherence among patients with BD. Given the possible association of CUD with medication nonadherence among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of patients with BD and comorbid CUD.

Bullous Pemphigoid and Other Pemphigoid Dermatoses.

The pemphigoid family of dermatoses is characterized by autoimmune subepidermal blistering. The classic paradigm for pemphigoid, and the most common member, is bullous pemphigoid. Its variable clinical presentation, with or without frank bullae, is linked by significant pruritus afflicting the elderly. Mucous membrane pemphigoid is an umbrella term for a group of subepidermal blistering dermatoses that favor the mucosal membranes and can scar. Epidermolysis bullosa acquisita is a chronic blistering disorder characterized by skin fragility, sensitivity to trauma, and its treatment-refractory nature. Clinicians that encounter these pemphigoid disorders may benefit from an overview of their clinical presentation, diagnostic work-up, and therapeutic management, with an emphasis on the most frequently encountered pemphigoid disease, bullous pemphigoid.

Laryngeal Applications of Platelet Rich Plasma and Platelet Poor Plasma: A Systematic Review.

BACKGROUND: Platelet rich plasma (PRP) and platelet poor plasma (PPP) are regenerative therapies that offer the potential for improving care for disorders of the larynx. The laryngeal applications of these substances have been examined in both animals and humans. The goal of this systematic review is to examine the various applications of PRP and PPP in laryngology, assess the protocols for preparation and application of these substances and evaluate the outcomes and complications in both humans and animals. METHODS: A search of PUBMED was conducted in April 2021 using combinations of keywords of "platelet rich plasma" and "platelet poor plasma" with keywords such as "larynx," "vocal folds," "laryngology," and others. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines were followed. Articles were reviewed by two independent coauthors and included based on selection criteria pertinent to the goals of this study. The risk of bias in the included studies was assessed by two independent co-authors using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Randomized Controlled Trials and JBI Critical Appraisal Checklist for Quasi-Experimental Studies. Data regarding the pathologies treated using PRP and PPP, PRP, and PPP preparation protocols, application protocols, human voice outcomes, histopathological animal outcomes, and complications were extracted from each of the studies and presented in tables. RESULTS: Seven studies were included based on the selection criteria. PRP or PPP were used for vocal fold scar, sulcus, atrophy and palsy; acute vocal fold injury; glottic insufficiency, and graft healing. PRP or PPP were derived from autologous blood in a one- or two-step centrifugation process and administered via injection, soaking of cartilage grafts or topical application. Mean and median voice handicap index-10 (VHI-10) and voice handicap index (VHI) scores decreased following PRP or PPP injections in two human studies and one human study showed a similar VHI-10 score before and after PRP treatment. Videostroboscopy showed the absence of injection site reactions and at least temporary improvement in glottic gap or vibratory function following treatment in some patients. Other objective measures of voice outcomes in human studies showed improved phonatory function in the one-to-four-month period following PRP or PPP injections, with some patients experiencing a subjective decrease or return to baseline in phonatory function following the initial improvement period. Animal studies found elevated levels of growth factors, organized collagen deposition, decreased granulation tissue, increased vascularization, and increased cartilage proliferation in PRP treated laryngeal tissue. DISCUSSION: PRP and PPP might have the potential to be safely used in the larynx and at least temporarily influence wound healing and vocal function. Further study using comparable outcome measurement tools is required to assess their role and efficacy in treating acute vocal fold injury, chronic vocal fold pathologies, graft healing, and other laryngeal applications.

Voice Outcomes Following Colon Interposition.

SIGNIFICANCE STATEMENT: This case highlights the consequences of colon interposition on phonation and swallowing. Findings in this patient included laryngopharyngeal reflux, vocal fold paralysis, poor esophageal peristalsis, failed bolus transfers, and others. The mechanical and functional differences between the colon and the esophagus can impact bolus transfer, reflux, and phonation. Further research is required to identify the mechanisms by which colon interposition can impact voice and swallowing.

Naringenin inhibits α-glucosidase activity: a promising strategy for the regulation of postprandial hyperglycemia in high fat diet fed streptozotocin induced diabetic rats.

Obesity and the onset of diabetes are two closely linked medical complications prevalent globally. Postprandial hyperglycemia is one of the earliest abnormalities of glucose homeostasis associated with type 2 diabetes (T2D). Postprandial glucose levels can be regulated through α-glucosidase inhibition. The present study aims to demonstrate the potent inhibitory role of naringenin against α-glucosidase activity. The mode of inhibition of naringenin was examined by measuring enzyme activity in vitro with different concentrations of substrate using Lineweaver-Burk plot analysis. It shows competitive inhibition towards mammalian α-glucosidase thereby competing with α-limit dextrins and oligosaccharide residues for binding in the active site. Similar results have been obtained from the molecular docking analyses, where naringenin shows preferential binding for the active sites in each of the evaluated human intestinal α-glucosidase enzymes. Post-docking intramolecular hydrogen bonding analysis shows water molecule mediated hydrogen bonding for N-terminal maltase glucoamylase and N-terminal sucrase isomaltase. Naringenin's docked pose in the C-terminal maltase glucoamylase active site does not show any particular water mediated interaction similar to the co-crystallized acarbose. Further, our results suggest that naringenin (25 mg/kg) exerts significant inhibition of intestinal α-glucosidase activity in vivo thereby delaying the absorption of carbohydrates in T2D rats, thus resulting in significant lowering of postprandial blood glucose levels. Both in vitro and in vivo results were compared to the commercially available α-glucosidase inhibitor acarbose. Our findings clearly indicate that naringenin dampens postprandial glycemic response and offers a potential complementary approach in the management of T2D.