Impact of a stroke interprofessional simulation on health professional students.

INTRODUCTION: The objective was to describe the interprofessional stroke simulation delivered across three campuses with seven types of health professions students and the impact the activity had on the students. METHODS: An interprofessional stroke simulation event was completed with pharmacy, medical, nursing, physician assistant, occupational therapy, physical therapy, and speech pathology students across a multi-site campus. Pre-activity, demographic information was requested including age, gender, discipline, year in respective program, number of experiences in prior interprofessional events, and comfort working with other health care professionals. The survey was repeated after the session and gathered free-text responses on whether learners gained information on working together, if they learned about the roles of other health care workers, and if they found the session useful. RESULTS: A total of 1820 health care professional students completed the simulation activity over four years. Of those students, 1035 (57%) completed the pre-survey, and 884 (49%) completed the post-survey. From the post-survey results, 91.5% of participants felt that they learned how health care disciplines can work together. Also, 87% of participants felt more comfortable working with learners from other professions. Most participants agreed the session was useful (77.1%) and rated it as moderately to extremely effective (81.8%). CONCLUSIONS: Interprofessional sessions with health care professional students are beneficial for learning new information about other professions and enhancing comfort levels in working with interprofessional groups. The interprofessional simulation improved the comfort level of students working with other health care professional students and should be considered in professional student curricula.

Speaking up: using OSTEs to understand how medical students address professionalism lapses.

BACKGROUND: Objective-structured teaching encounters (OSTEs) are used across many disciplines to assess teaching ability. The OSTE detailed in this paper assesses 191 fourth-year medical students' (M4) ability to identify and address lapses in professionalism based on Association of American Medical Colleges' professionalism competencies. The research questions addressed are How frequently do M4s address professionalism lapses observed during an OSTE? What factors influence whether M4s provide feedback when they observe professionalism lapses in an OSTE? METHODS: Standardized patients (SPs) and standardized learners (SLs) were recruited and trained to participate in a standardized encounter with specific cognitive, social, and behavioral errors, including professionalism lapses. M4s viewed this encounter and then offered feedback to the SL, while remotely observed by faculty. Post-encounter, the SL and faculty completed identical checklists to assess both teaching readiness and ability to address professionalism concerns. RESULTS: An analysis of frequencies showed that six of the Association of American Medical Colleges' nine professional competencies were addressed in the checklist and/or discussed in the focus group. Analysis of transcribed debriefing sessions confirmed that M4s did not consistently address professionalism lapses by their peers. CONCLUSIONS: In focus groups, M4s indicated that, while they noticed professionalism issues, they were uncomfortable discussing them with the SLs. Findings of the current study suggest how medical educators might support learners' ability to address lapses in professionalism as well as topics for future research.

Respiratory infections: community-acquired pneumonia.

Pneumonia causes substantial morbidity and mortality. Older age, suppressed immune function, and certain drugs increase the risk of community-acquired pneumonia (CAP), whereas adequate dental care and high socioeconomic status decrease the risk. For patients without other significant cardiopulmonary disease, the diagnosis of pneumonia can be straightforward. Common symptoms include fever, chills, pleuritic chest pain, and a cough with mucopurulent sputum. Bacterial and viral infections are the most common etiologies. Fungal and parasitic etiologies are less common. Illness severity scores and new diagnostic methods, including procalcitonin, proadrenomedullin, and bacterial diagnostic testing, are being used increasingly for CAP diagnosis. Antibiotic selection and treatment duration for CAP have become more standardized to decrease rates of bacterial antibiotic resistance. Still, CAP causes significant expense in human life and cost expenditures worldwide.

Respiratory infections: pulmonary tuberculosis.

Family physicians can prevent mortality and disability due to pulmonary tuberculosis (TB) by identifying high-risk patients. Recognition of symptoms (eg, cough for 3 weeks or longer) helps prevent overlooked diagnoses because results of tuberculin skin tests and interferon-gamma release assays are negative in up to 25% and 21%, respectively, of severe acute cases. The typical x-ray findings of cavities, infiltrates, and lymphadenopathy are minimal among immunosuppressed patients. Cases of active TB must be reported to local or state health departments within 24 hours of diagnosis. Sputum acid-fast bacillus tests provide results within hours and help quantify bacterial load but are not highly sensitive, and infection with nontuberculous mycobacteria can cause positive test results. Sputum cultures are adequately sensitive, identify mycobacterial species, and provide organisms for antibiotic susceptibility testing but require weeks for results. Molecular detection of Mycobacterium tuberculosis and of antibiotic-resistant mutations can expedite diagnosis and management of drug-resistant TB. Management of active TB should include directly observed therapy. Standard 6-month therapy with rifampin, isoniazid, pyrazinamide, and ethambutol resolves infection in nearly all immunocompetent adults with pansensitive TB. Multidrug-resistant TB requires second-line antibiotics (eg, fluoroquinolones, linezolid) in individualized regimens lasting 2 years. Management of latent TB infection prevents progression to active TB disease, particularly if management is completed within 2 years of infection.

Respiratory infections: fungal infections.

Fungal infections cause pneumonia but are less common than bacterial or viral etiologies; therefore, fungal infections often are diagnosed late and can be lethal in a small percentage of cases. Although traditionally thought to affect mostly individuals with impaired immunity, fungal infections also occur in immunocompetent individuals and can be severe, even in the latter group. Important advances in the diagnosis and management of fungal infections have occurred in the past decade. Obtaining a detailed history is critical because many fungal infections are associated with specific activities, geographic locations, and environmental exposures. Newer diagnostic methods such as galactomannan antigen testing, polymerase chain reaction, and breath testing are used increasingly in the diagnosis of fungal infections. Newer azole antibiotics also are available to manage these infections.

Respiratory infections: respiratory infections in immigrants to the United States.

Immigration has brought millions of individuals into the United States over the past decade. The Centers for Disease Control and Prevention and the US Public Health Service are charged with ensuring that immigrants who enter do not pose a public health risk. Health examinations and immunization regimens are required for individuals wishing to live in the United States. Many immigrants and refugees are exposed to communicable diseases not routinely encountered in the United States These include helminthic infections, tuberculosis, malaria, and other infections. Zoonotic infections, such as influenza A, and novel coronavirus infections also are of increasing concern because of population mobility.

Graves' disease and treatment effects on warfarin anticoagulation.

Background. Hyperthyroidism causes an increased hypoprothrombinemic response to warfarin anticoagulation. Previous studies have demonstrated that patients with hyperthyroidism require lower dosages of warfarin to achieve a therapeutic effect. As hyperthyroidism is treated and euthyroidism is approached, patients may require increasing warfarin dosages to maintain appropriate anticoagulation. We describe a patient's varying response to warfarin during treatment of Graves' disease. Case Presentation. A 48-year-old African American female presented to the emergency room with tachycardia, new onset bilateral lower extremity edema, gradual weight loss, palpable goiter, and generalized sweating over the prior 4 months. She was admitted with Graves' disease and new onset atrial fibrillation. Primary stroke prophylaxis was started using warfarin; the patient developed a markedly supratherapeutic INR likely due to hyperthyroidism. After starting methimazole, her free thyroxine approached euthyroid levels and the INR became subtherapeutic. She remained subtherapeutic over several months despite steadily increasing dosages of warfarin. Immediately following thyroid radioablation and discontinuation of methimazole, the patient's warfarin dose and INR stabilized. Conclusion. Clinicians should expect an increased response to warfarin in patients with hyperthyroidism and close monitoring of the INR is imperative to prevent adverse effects. As patients approach euthyroidism, insufficient anticoagulation is likely without vigilant follow-up, INR monitoring, and increasing warfarin dosages.

Adolescent bipolar disorder: a clinical vignette.

Adolescence is a vulnerable developmental phase marked by physical, psychological, and social changes that rapidly expose young people to a wide range of new stressors. When differentiating between bipolar disorder and teenage "acting out," a careful history is important. Adolescent bipolar disorder is a psychiatric illness characterized by fluctuating episodes of mood elevation and depression that is frequently neither recognized nor formally diagnosed. Adolescents with bipolar disorder often manifest a more nonepisodic, chronic course with continuous rapid-cycling patterns than do adults. Pharmacologic treatment of adolescent bipolar disorder is difficult and often requires combination therapy to address comorbidities like attention-deficit/hyperactivity disorder and anxiety disorder. Adjuncts to pharmacologic treatment of bipolar disorder can be beneficial. Psychosocial treatments include family education, enhanced parenting techniques, stress management, and the development of effective coping strategies.

Diagnosis and treatment of streptococcal pharyngitis.

Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy. Cough, coryza, and diarrhea are more common with viral pharyngitis. Available diagnostic tests include throat culture and rapid antigen detection testing. Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly. The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy. Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness. Amoxicillin is equally effective and more palatable. Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy. Increased group A beta-hemolytic streptococcus (GABHS) treatment failure with penicillin has been reported. Although current guidelines recommend first-generation cephalosporins for persons with penicillin allergy, some advocate the use of cephalosporins in all nonallergic patients because of better GABHS eradication and effectiveness against chronic GABHS carriage. Chronic GABHS colonization is common despite appropriate use of antibiotic therapy. Chronic carriers are at low risk of transmitting disease or developing invasive GABHS infections, and there is generally no need to treat carriers. Whether tonsillectomy or adenoidectomy decreases the incidence of GABHS pharyngitis is poorly understood. At this time, the benefits are too small to outweigh the associated costs and surgical risks.

Toilet training.

Toilet training is a developmental task that impacts families with small children. All healthy children are eventually toilet trained, and most complete the task without medical intervention. Most research on toilet training is descriptive, although some is evidence based. In the United States, the average age at which training begins has increased over the past four decades from earlier than 18 months of age to between 21 and 36 months of age. Newer studies suggest no benefit of intensive training before 27 months of age. Mastery of the developmental skills required for toilet training occurs after 24 months of age. Girls usually complete training earlier than boys. Numerous toilet-training methods are available. The Brazelton child-oriented approach uses physiologic maturity, ability to understand and respond to external feedback, and internal motivation to assess readiness. Dr. Spock's toilet-training approach is another popular method used by parents. The American Academy of Pediatrics incorporates components of the child-oriented approach into its guidelines for toilet training. "Toilet training in a day," a method by Azrin and Foxx, emphasizes operant conditioning and teaches specific toileting components. Because each family and child are unique, recommendations about the ideal time or optimal method must be customized. Family physicians should provide guidance about toilet-training methods and identify children who have difficulty reaching developmental milestones.