Role Modeling Kindness at the Bedside.

Compassion and kindness are interchangeable attitudes and behaviors in society. As evidence shows the importance of compassion and kindness in healthcare, there has been a push to nurture and teach compassion through experiential learning in medical schools. However, there is not much evidence of educating learners on the importance of kindness as the complement or foundation of compassion and empathy. Kindness is the ability to act positively and appropriately and can be provided without emotion, judgment, or expecting anything in return. Kindness does not require the receiver to be in severe distress or suffering. Acts of kindness can be random acts done to anyone, anytime, with or without illness or suffering. Research shows that kindness elevates the healthcare profession for both clinicians and patients. Compassion and kindness must be taught through the integrated approach of role modeling, observation, practice, experience, and reflection in the classroom and in the clinical environment. It is vital that medical schools and healthcare institutions' faculty and staff make kindness to patients, families, and staff a key behavior, along with compassion and empathy. There is more that can be done to encourage acts of kindness through everyday actions; educators can display kindness toward colleagues and medical students in their learning. Kindness can improve conversations with patients and improve the emotional and social well-being of learners. Displaying kindness during bedside or classroom teaching would engrain its importance in the professional identity formation of future generations of physicians.

We are our history: Baylor University Medical Center and Black physicians in Dallas.

The Texas Baptist Memorial Sanatorium, the hospital that later became known as Baylor University Medical Center, dates back to 1904. With this long-lived history comes the truths that affected all hospitals during the Jim Crow era: segregation and inequality. This paper attempts to place Baylor University Medical Center, which aimed (and continues to aim) to be a "great humanitarian hospital," in its historical context. Understanding this history may help explain and combat the inequities we continue to see in health care today.

A focused report on progestogen hypersensitivity.

INTRODUCTION: Progestogen Hypersensitivity (PH) is caused by increased sensitivity to either exogenous or endogenous progestogens. It is characterized by recurrent cutaneous eruptions including erythema multiforme, eczema, urticaria, and angioedema, which may be associated with systemic symptoms including asthma and anaphylaxis. AREAS COVERED: Symptoms may be persistent or cyclical, coinciding with progestogen levels. With increased use of oral contraceptives and hormonal treatments for fertility, the prevalence of PH is expected to continuously increase. Several proposed immunological mechanisms, diagnostics, and treatment modalities have been proposed. Most treatments focus on suppressing ovulation and progesterone secretion or inducing tolerance through progesterone desensitization. EXPERT OPINION: Although there has been increased recognition both clinically and in the medical literature, there is still a general lack of knowledge of PH and its clinical features in the medical community. An improved understanding of the underlying pathophysiology as well as more available commercial testis, such as ELISA that accurately measures specific IgE to progesterone, are expected to broaden and improve opportunities for disease recognition and symptom control. It is essential for physicians across specialties to recognize how to diagnose PH and either manage this condition or refer these patients to a specialist with experience treating PH.

The Florida Clinical Skills Collaborative: A New Regional Consortium for the Assessment of Clinical Skills.

Discontinuation of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 2 Performance Evaluation (2-PE) raised questions about the ability of medical schools to ensure the clinical skills competence of graduating students. In February 2021, representatives from all Florida, United States, allopathic and osteopathic schools initiated a collaboration to address this critically important issue in the evolving landscape of medical education. A 5-point Likert scale survey of all members (n=18/20 individuals representing 10/10 institutions) reveals that initial interest in joining the collaboration was high among both individuals (mean 4.78, SD 0.43) and institutions (mean 4.69, SD 0.48). Most individuals (mean 4.78, SD 0.55) and institutions (mean 4.53, SD 0.72) are highly satisfied with their decision to join. Members most commonly cited a "desire to establish a shared assessment in place of Step 2 CS/2-PE" as their most important reason for joining. Experienced benefits of membership were ranked as the following: 1) Networking, 2) Shared resources for curriculum implementation, 3) Scholarship, and 4) Work towards a shared assessment in place of Step 2 CS/2-PE. Challenges of membership were ranked as the following: 1) Logistics such as scheduling and technology, 2) Agreement on common goals, 3) Total time commitment, and 4) Large group size. Members cited the "administration of a joint assessment pilot" as the highest priority for the coming year. Florida has successfully launched a regional consortium for the assessment of clinical skills competency with high levels of member satisfaction which may serve as a model for future regional consortia.

Defining Advising, Coaching, and Mentoring for Student Development in Medical Education.

Medical school curricula integrate classroom academic teaching, hands-on clinical training, longitudinal professional development, and identity formation to prepare students to enter the healthcare workforce as residents. Mentorship, coaching, and advising are well-recognized approaches used by educators to help young learners accomplish their personal and professional goals and objectives. However, undergraduate medical education literature has not clearly articulated the distinctions between the roles and core responsibilities of each guidance approach. Attempts to describe each role and responsibility have generated ambiguity and steered institutions towards implementing their own role-specific functions. The purpose of this paper is to establish a functional framework that may be used to differentiate the principal duties of a mentor, coach, and advisor in the context of undergraduate medical education (UME). Four key components are necessary to achieve this goal: (1) adopting a singular definition for each form of guidance; (2) characterizing each role based on unique skills; (3) describing the interplay between learner needs and educator capabilities; (4) training educators on how to effectively distinguish each form of guidance. Creating clear distinctions between mentors, coaches, and advisors in medical education will bolster students' academic experience and improve the educator-learner relationship. These definitions may also benefit faculty members by providing a clear framework for their responsibilities, which can be used for evaluations or determining future promotions.

A woman with temporal pain.

Giant cell arteritis (GCA) is a difficult diagnosis to make in the emergency department, requiring a temporal artery biopsy to confirm the disease. Here, we present a case of GCA diagnosed on bedside ultrasound in a patient with left-sided temporal pain, left-sided blurry vision, and a normal erythrocyte sedimentation rate. Of note, this patient was on anticoagulation for atrial fibrillation, which delayed a biopsy from being performed, making the ultrasound findings even more significant. This case study suggests that bedside ultrasound can be utilized in the diagnosis of GCA, offering a quick, easy, and safe imaging modality that is available in many emergency departments.

Advanced Placement Courses for Medical School: A Novel AMed Track to Reduce Financial Burden and Attract Nontraditional Students.

Medical school admissions have become increasingly competitive, creating a pool of nontraditional applicants that seek postbaccalaureate training in biomedical sciences. Several postbaccalaureate and graduate programs developed curricula that, except for learning clinical skills, mirror the learning objectives of the foundational science curricula in medical schools. This education structure provides applicants with a competitive advantage when applying to medical schools. However, basic science curriculum assessments in medical schools have changed to pass/fail scoring systems. As a result, students that participate in preparatory postbaccalaureate and graduate programs cannot show their superior level of knowledge and may find some core foundational science subjects redundant during their pre-clerkship medical education. The aim of this article is to propose an innovative system for matriculation into medical school through the AdvancedMed (AMed) Track, a three-year accelerated medical curriculum in which graduate curricula adopt an advanced placement course called AMed courses. This system would mirror the structure of the high school Advanced Placement (AP) system; therefore, students would take AMed courses similar in rigor to medical school basic science courses. These courses include Anatomy, Histology, Physiology, Cellular Biology, Biochemistry, Genetics, Microbiology, Immunology, Biostatistics, and Epidemiology. All courses would require a scored national standardized test to receive medical school credit toward a three-year accelerated track curriculum. Nontraditional students could choose to study independently and take the AMed standardized examination for credit to enter the AMed Track. Medical schools have the incentive to start an AMed Track because its implementation could lessen the financial burden, reduce time spent in medical school, and increase the participation of nontraditional medical students.

Atopic endotypes as a modulating factor for SARS-CoV-2 infection: mechanisms and implications.

PURPOSE OF REVIEW: Asthma patients are typically at increased risk for severe outcomes from viral respiratory infections. However, asthma and atopy do not appear to be overrepresented comorbidities in COVID-19 patients, and hypotheses attempt to explain this observation. As COVID-19 continues to spread globally, it is imperative to understand how disease outcomes may be influenced in this population to guide patient care. RECENT FINDINGS: Angiotensin converting enzyme 2 (ACE2) is the principal host cell receptor for SARS-CoV-2 entry and Transmembrane Protease Serine 2 (TMRSS2) is the main priming protease. Models have linked atopic endotypes to reductions in ACE2 and increases in TMRSS2 on respiratory epithelia. Epidemiologic and experimental findings imply alterations in ACE2 expression correlate with clinical COVID-19 disease, but limitations restrict the ability to draw direct conclusions. SUMMARY: There is reasonable evidence to assert atopic endotypes modulate COVID-19 susceptibility, but it remains premature to classify this association as protective or deleterious. Asthma is a heterogeneous disease and epidemiologic studies should focus on investigating COVID-19 outcomes by underlying endotype. Direct experimental and clinical evidence is needed to draw definitive conclusions on how the complex interplay of ACE2 and TMRSS2 affect viral entry. VIDEO ABSTRACT: https://www.dropbox.com/sh/9sfwqhz2h78sio3/AAB0JYd4MFzM5JjDFcYwz4CXa?dl=0.

Influence of the Microbiome on Chronic Rhinosinusitis With and Without Polyps: An Evolving Discussion.

Chronic rhinosinusitis (CRS) is widely prevalent within the population and often leads to decreased quality of life, among other related health complications. CRS has classically been stratified by the presence of nasal polyps (CRSwNP) or the absence nasal polyps (CRSsNP). Management of these conditions remains a challenge as investigators continue to uncover potential etiologies and therapeutic targets. Recently, attention has been given to the sinunasal microbiota as both an inciting and protective influence of CRS development. The healthy sinunasal microbiologic environment is largely composed of bacteria, with the most frequent strains including Staphylococcus aureus, Streptococcus epidermidis, and Corynebacterium genera. Disruptions in this milieu, particularly increases in S. aureus concentration, have been hypothesized to perpetuate both Th1 and Th2 inflammatory changes within the nasal mucosa, leading to CRS exacerbation and potential polyp formation. Other contributors to the sinunasal microbiota include fungi, viruses, and bacteriophages which may directly contribute to underlying inflammation or impact bacterial prevalence. Modifiable risk factors, such as smoking, have also been linked to microbiota alterations. Research interest in CRS continues to expand, and thus the goal of this review is to provide clinicians and investigators alike with a current discussion on the microbiologic influence on CRS development, particularly with respect to the expression of various phenotypes. Although this subject is rapidly evolving, a greater understanding of these potential factors may lead to novel research and targeted therapies for this often difficult to treat condition.

The smile is stronger than the handshake.

This article was migrated. The article was marked as recommended. Healthcare providers struggle with the timing of handwashing and the handshake during the visit with patients, we question whether the handshake is even a necessary component of the modern introduction. The Physician-Patient relationship is strongest when built on trust, and typically begins with a traditional handshake. The importance of hand hygiene has become an integral part of the patient encounter. Taking a break for hand-hygiene interrupts the natural flow of the initial introduction and non-verbal body language to our patients. In current time constrained visits, we focus on handwashing instead of on continuous eye-contact with our patient. It is arguable that the elimination of the handshake may allow one to focus on more culturally acceptable universal verbal and non-verbal communication skills that help us to build essential trust with our patients.

Guideline of Chronic Urticaria Beyond.

Urticaria is a relatively common condition that if chronic can persist for weeks, months or years and affect quality of life significantly. The etiology is often difficult to determine, especially as it becomes chronic. Many cases of chronic urticaria are thought to be autoimmune, although there is no consensus that testing for autoimmunity alters the diagnostic or management strategies or outcomes. Many times, urticaria is easily managed with antihistamines and/or short courses of oral corticosteroids, but too often control is insufficient and additional therapies must be added. For years, immune modulating medications, such as cyclosporine and Mycophenolate Mofetil, have been used in cases refractory to antihistamines and oral corticosteroids, although the evidence supporting their efficacy and safety has been limited. Omalizumab was recently approved for the treatment of chronic urticaria unresponsive to H1-antagonists. This IgG anti-IgE monoclonal antibody has been well demonstrated to safely and effectively control chronic urticaria at least partially in approximately 2/3 of cases. However, the mechanism of action and duration of treatment for omalizumab is still unclear. It is hoped that as the pathobiology of chronic urticaria becomes better defined, future therapies that target specific mechanistic pathways will be developed that continue to improve the management of these often challenging patients.

Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines.

Urticaria can present acutely and be self-limiting or become chronic and persist for weeks, months, or years. In either case, the condition may have a significant impact on the patient's quality of life. Two major consensus groups, the EAACI/WAO and the AAAAI/ACAAI Joint Task Force, have written guidelines on the diagnosis and management of urticaria. While both agree on most points regarding the definition, general evaluation, and treatment, there are some differences which exist. The guidelines, which are written to assist both primary practitioners and specialists in managing their patients with urticaria, have been developed based on scientific evidence, and when insufficient evidence is available, then recommendations are based on expert consensus opinion. The majority of the differences between the two guidelines pertain to recommendations based on expert opinion because of weak scientific evidence. Within this document, we compare the recommendations of these two groups, highlighting the key similarities and differences.

Allergy to Prolene Sutures in a Dural Graft for Chiari Decompression.

Allergy to Prolene suture is exceedingly rare with only 5 cases reported in the literature. There have been no such cases associated with neurosurgical procedures. Diagnosis is nearly always delayed in spite of persistent symptomatology. A 27-year-old girl with suspected Ehlers-Danlos, connective tissue disorder, underwent posterior fossa decompression for Chiari Type 1 malformation. One year later, the patient presented with urticarial rash from the neck to chest. Cerebrospinal fluid and blood testing, magnetic resonance imaging, and intraoperative exploration did not suggest allergic reaction. Eventually skin testing proved specific Prolene allergy. After suture material was removed, the patient no longer complained of pruritus or rash. This single case highlights the important entity of allergic reaction to suture material, namely, Prolene, which can present in a delayed basis. Symptomatology can be vague but has typical allergic characteristics. Multidisciplinary approach is helpful with confirmatory skin testing as a vital part of the workup.

Ultrasound assessment of optic disc edema in patients with headache.

Point-of-care ocular ultrasonography is emerging as a powerful tool to evaluate emergency department (ED) patients at risk for ophthalmologic and intracranial pathology.We present cases of 3 patients in whom optic disc swelling was identified using ocular ultrasound. Causes for optic disc swelling in our patients included idiopathic intracranial hypertension, secondary syphilis, and malignant hypertension with associated hypertensive retinopathy. Because direct visualization of the optic disc may be challenging in an ED setting, ultrasound examination of the optic disc may represent an important adjunct to fundoscopy when assessing patients with headache or visual complaints.

A pilot study to assess candidacy for emergency contraception and interest in sexual health education in a pediatric emergency department population.

OBJECTIVES: The objective of the study was to assess potential candidacy for hormonal emergency contraception (EC) and desire for sexual health education among female adolescents presenting for care to a pediatric emergency department (ED). METHODS: We used an anonymous, cross-sectional, written survey of girls aged 15 to 19 years seeking care in an urban, children's hospital ED. The survey included questions about personal sexual history and desire for sexual health education about sexually transmitted infections and contraception options. RESULTS: One hundred thirty-four patients were eligible for participation; 77 (57%) consented and completed the survey. The mean age was 16.6 years. Fifty-six percent reported ever having had sexual intercourse. Of those, 6 (14%; confidence interval, 5%-28%) stated that they had unprotected sexual intercourse within the previous 5 days. When asked about their interest in sexual health education in the ED, 48% of all subjects wanted information about sexually transmitted infections, 36% wanted information about HIV, and 34% wanted information about preventing pregnancy. CONCLUSIONS: Among sexually active adolescents seeking care in an urban, children's hospital ED, a significant proportion could potentially utilize EC if they so chose. Furthermore, adolescents with and without a history of sexual activity expressed interest in learning about sexual health issues in the ED setting.

Aphthous ulcerations associated with trisomy 8-positive myelodysplastic syndrome.

The association of Behçet's disease with myelodysplastic syndromes has been established in the hematologic, gastrointestinal, and medical genetics literature; trisomy 8 is a feature present in 70% of these reports. Because trisomy 8 is ordinarily present in only 14% of patients with myelodysplastic syndrome, this is a significant overrepresentation. We describe a patient with recurrent aphthous stomatitis who was subsequently diagnosed with trisomy 8-positive myelodysplastic syndrome after an unexplained macrocytosis was further investigated.

Drug-associated lymphoma and pseudolymphoma: recognition and management.

This article discusses ways to recognize and manage lymphomas and pseudolymphomas associated with drug exposure. Over the last 30 years, the classification of pseudolymphomas and lymphomas has undergone significant change, especially following the application of sophisticated immunostaining and gene rearrangement analysis. The term cutaneous pseudolymphomas (CPL) is a nonspecific term for a heterogeneous group of benign reactive T- or B-cell lymphoproliferative processes that simulate cutaneous lymphomas clinically or histologically. While pseudolymphomas are relatively rare diseases, their clinical and histological heterogeneity has led to multiple systems of categorization based on immunological factors, causative agents, presentation, and clinical course.