Preference of Young Adult Cancer Survivors for In-Person Versus Telemedicine Cancer Survivorship Visits.

Young adult (YA) cancer survivors face barriers to follow-up care, which can be exacerbated by living in a rural location. Telemedicine may mitigate these barriers, but little is known about the preferences of YA survivors for telemedicine or in-person survivorship visits. We surveyed 57 YA cancer survivors in a rural state to assess their preference for survivorship visits. Forty-six percent of respondents preferred an in-person visit while 16% preferred telemedicine. The remaining 39% reported "it depends" or were undecided. In-person visits were preferred when stratified by rural versus urban location. This work can be used to inform survivorship delivery systems.

Equity Lens Protocol: Reflecting on Harms From the COVID-19 Response and Mitigation Strategies Implemented in a Local Public Health System.

This report describes an Equity Lens Protocol and its use to guide partners' systematic reflection on harms and mitigation strategies of the COVID-19 response in a local public health system. This process evaluation tool is based on the Guidance document for assuring an equitable response to COVID-19 prepared by the Pan American Health Organization. We used a participatory approach to engage public health partners in systematically reflecting on harms, mitigation strategies, and lessons learned and implications for practice. Outputs from using this tool included identified: (a) specific harms (e.g., loss of income and challenges to learning) related to particular COVID-19 response measures (e.g., home confinement and school closure) and (b) mitigation strategies implemented to reduce harms. In response to the protocol's guiding questions, partners also identified lessons learned and practice recommendations for strengthening equity work in public health responses (e.g., an equitable response requires an investment in people, structures, and relationships before a crisis). This report-and accompanying protocol-illustrates use of a practical method for systematic reflection on public health responses through an equity lens.

Validation of Panoramic Ultrasound Measurement of the Cross-Sectional Area of the Vastus Medialis.

ABSTRACT: Minnehan, KS, Dexter, WW, Holt, CT, Scharnetzki, L, Alex, JP, Chin, KE, and Kokmeyer, DJ. Validation of panoramic ultrasound measurement of the cross-sectional area of the vastus medialis. J Strength Cond Res 37(1): 41-45, 2023-The cross-sectional area (CSA) of the vastus medialis (VM) is an independent predictor of important clinical outcomes in musculoskeletal conditions of the knee, such as pain and long-term function. Previous studies validated ultrasound (US) to measure larger muscles of the thigh, but this approach has limited accuracy in measuring smaller muscles, such as the VM. In this study, we aimed to validate panoramic US measurements of the CSA of the VM and compare the results with those from the gold standard of magnetic resonance imaging (MRI) (significance set p ≤ 0.05). In this retrospective, single-center study, we compared pairs of US and MRIs taken of 25 adults who participated in a 10-week study of non-weight-bearing activity at a National Aeronautics and Space Administration facility. Images were acquired from various locations on the right thigh at multiple time points. Two researchers independently analyzed the US and MRI pairs by outlining the intermuscular border of the VM in the most distal image. We found excellent agreement between the US and MRI measurements of the CSA of the VM analyzed by researcher 1 (interclass correlation coefficient [ICC]: 0.997) and researcher 2 (ICC: 0.980). We also found excellent agreement for interrater reliability for MRI (ICC: 0.988) and US (ICC: 0.982) and intrarater reliability for US for researcher 1 (ICC: 0.999) and researcher 2 (ICC: 0.996). Our findings demonstrate that US is a valid and reliable tool for measuring the CSA of the VM compared with MRI.

Assessment and management of allergy history with a novel mRNA vaccine.

Context: Tertiary care hospital provided onsite COVID-19 vaccine roll out as a work benefit for all care team members with medically supervised waiting period at the time of the distribution of the first round of the novel mRNA COVID-19 vaccines. Little was known about the immediate hypersensivity reactions or what might predispose to cross reactivity. Objective: We developed a working protocol to continuously track the vaccines administered, the patient history of allergy and hypersensistivity, the reactions observed and the care plan developed (determination of allergy to mRNA vaccines or normal vaccine response). Continuous process improvement allowed us to change protocols as the CDC developed guidance. Every patient was observed for at least 15 minutes and every reaction was reviewed by a physician supervising the waiting area. We aimed to determine if there were predictors of adverse, immediate reaction to the vaccine and to assess prevalence of risk factors (history of allergy to polyethylene Glycol or polysorbate; allergy to other injectable medication or vaccines; hypersensitivity to multiple substances). Study Design: Cohort study of all employees who received a first mRNA COVID-19 vaccine between December 16 and January 7th. Descriptive statistics were developed with demographic and medical history recorded, reactions noted and treatment given. Setting or Dataset: Tertiary care hospital in urban area. Population Studied: Employees who received an mRNA COVID-19 vaccine. Intervention/Instrument: Clinical records from employee vaccine clinic. Outcome Measures: Record of immediate response, determination of allergy. Results: We served over 7000 individuals with approximately 10% having a history of anaphylactic reaction. We had fewer with history of anaphylaxis to medications or vaccines. We delivered these vaccines safely, and observed three cases of immediate anaphylaxis on first dose of mRNA and over 50 cases of immediate allergic hypersensitivity. We did not see any patterns that predicted these reactions (gender, age or medical history). Expected Outcomes: We used this data to inform our employee health vaccination campaign and to inform the health system as strategies and safety protocols for vaccination of the population were developed.

Injury Trends in Special Olympics Athletes From the 2018 USA Games.

OBJECTIVE: To categorize injury types and occurrence among athletes participating in the Special Olympics (SO). DESIGN: Retrospective cross-sectional cohort study. SETTING: 2018 SO USA Games. PARTICIPANTS: Athletes participating in 14 sports at the 2018 SO USA Games (n = 2251). INDEPENDENT VARIABLES: Individual and team sports. MAIN OUTCOME MEASURES: Percentage of athletes injured per individual sport, percentage of injury type by sport, rate of injuries per 1000 exposures, and number of injuries per game in team sports. RESULTS: In individual sports, the percentage of athletes injured ranged from 38.5% in gymnastics to 12.9% in golf. Musculoskeletal (MSK) injuries occurred in 53.3% of gymnastics injuries and 58.6% of tennis injuries. For stand-up paddleboard, most injuries were non-MSK (66.7%). The highest rate of MSK injuries occurred in gymnastics (25.6/1000 exposures), whereas the highest rates of non-MSK injuries (95.2/1000 exposures) and minor injuries (47.6/1000 exposures) were among stand-up paddleboard athletes. In team sports, the highest number of injuries per game occurred in softball (1.9 per game). CONCLUSIONS: A high percentage of injuries occurred at the 2018 SO USA Games. The high rate of non-MSK injuries is unique to the SO and should be considered when planning medical coverage for future events.

Participatory Monitoring and Evaluation of the COVID-19 Response in a Local Public Health System.

The coronavirus disease 2019 (COVID-19) pandemic tested the capacity of local health systems to understand and respond to changing conditions. Although data on new cases of COVID-19 were widely shared in communities, there was less information on the multisector response activities and factors associated with implementation. To address this gap, this empirical case study examined (a) the pattern of implementation of COVID-19 response activities and (b) the factors and critical events associated with both the pattern of new cases and the implementation of the local COVID-19 response. We used a participatory monitoring and evaluation system to capture, code, characterize, and communicate 580 COVID-19 response activities implemented in the city of Lawrence and Douglas County, Kansas. Collaboration across sectors including public health, medical services, city/county government, businesses, social services, public schools, and universities enabled the local public health system's response effort. Documentation results showed the varying pattern of new COVID-19 cases and response activities over time and the factors identified as enabling or impeding the response and related new cases. Similar participatory monitoring and evaluation methods can be used by local health systems to help understand and respond to the changing conditions of COVID-19 response and recovery.

Reduction of High School Ice Hockey Injuries With Implementation of New Checking/Boarding Rules.

OBJECTIVE: Evaluate whether rule changes by the National Federation of State High School Associations (NFHS) were associated with reduced injury rates in US high school ice hockey players. DESIGN: We compared injury rates for the 3 seasons before the rule changes (2011-2012, 2012-2013, and 2013-2014) with the 2 subsequent seasons (2014-2015 and 2015-2016) using data from the High School Reporting Information Online (RIO) database. SETTING: Convenience sample of US high schools. PARTICIPANTS: High school ice hockey athletes. INTERVENTIONS: The sports injury surveillance system that supplied the data for this study was funded in part by the Centers for Disease Control and Prevention (grant Nos. R49/CE000674-01, R49/CE001172-01, and R49/CE002106-01) as well as research funding contributions of the NFHS, National Operating Committee on Standards for Athletic Equipment (NOCSAE), DonJoy Orthotics, and EyeBlack. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or any other funding agency. In the 2014 to 2015 ice hockey season, the NFHS increased the penalty for boarding (illegally causing opponent to be thrown violently into the boards) and for checking from behind. MAIN OUTCOME MEASURES: Injury rates and mechanism of injury. RESULTS: There was a statistically significant 40% reduction in rates of injury attributed to being checked in the 2 seasons after the rule changes (5.0 injuries per 10 000 athlete exposures) compared with the 3 previous seasons (8.3) (rate ratio = 0.60, P = 0.002). There were no significant differences in overall injury rates (P = 0.12) or injury rates due to checking (P = 0.27), contact with the boards (P = 0.31), or contact with another player (P = 0.55). CONCLUSIONS: Among US high school ice hockey athletes, implementation of stricter penalties for boarding and checking from behind was associated with a significant decrease in injury rate due to being checked. Rates of injury due to other mechanisms were not significantly altered, suggesting the rule changes achieved their targeted effect.

An Asynchronous Curriculum to Address Substance Use Disorder Training Needs for Medical and Surgical Residents.

Developing substance use (SU) skills in medical training remains a challenge. Residents in teaching hospitals bear a large burden in managing SU sequelae and often lack support. Preventive and addiction medicine faculty defined broadly applicable core knowledge and skills for residents across specialties in a tertiary care center. Three 1-hour online modules were developed and delivered asynchronously to interns, followed by a live skills session at orientation. Topics were (1) Unhealthy SU Screening, Detection, and Intervention; (2) Bias and Communication; and (3) Safer Prescribing in Acute Pain. All 68 interns completed the curriculum. Pre/posttesting showed increased knowledge (52%-83% correct, P < .001) and perceived confidence (10-12.9, maximum 16, P < .001). Attitudes were unchanged (18.4-18.7, maximum 20, P = .07). This process identified and improved core knowledge and skills for SU prevention and treatment in medical and surgical trainees.

Proxy Finnegan Component Scores for Eat, Sleep, Console in a Cohort of Opioid-Exposed Neonates.

OBJECTIVES: The Finnegan Neonatal Abstinence Score (FNAS) monitors infants with neonatal abstinence syndrome (NAS), but it has been criticized for being time consuming and subjective. Many institutions have transitioned to a more straightforward screening tool, Eat, Sleep, Console (ESC), an assessment based on 3 simple observations with a focus on maximizing nonpharmacologic therapies. We aimed to compare the sensitivity and specificity of the ESC with that of the FNAS to determine if infants who needed pharmacologic therapy could potentially be missed when assessed by using ESC. METHODS: A retrospective cohort study of infants identified by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision billing codes for NAS. FNAS scores were recorded every 4 hours for the entire hospitalization. ESC proxy scores were created by using components of the FNAS that referenced eating, sleeping, and consoling. Detailed demographic and clinical data were manually extracted regarding opioid exposures and pharmacologic treatment of NAS. RESULTS: From 2013 to 2016, 423 infants ≥37 weeks' gestation had a total of 33 115 FNAS scores over 921 days of observation. In total, 287 (68%) were exposed to buprenorphine, 100 (23.7%) were exposed to methadone, and 165 (39%) were pharmacologically treated. The FNAS was 94.8% sensitive and 63.5% specific for pharmacologic treatment, and the ESC proxy variables were 99.4% sensitive and 40.2% specific (P < .01). CONCLUSIONS: ESC proxy variables have slightly higher sensitivity compared with FNAS, suggesting that ESC use is unlikely to miss infants requiring treatment who would have been identified by FNAS. Transitioning from FNAS to ESC is not likely to impair the care of infants with NAS.

Improving Internal Medicine Resident Comfort With Shoulder and Knee Joint Injections Using an Injection Workshop.

Introduction: Joint injections can be effective treatments for musculoskeletal issues. We examined whether a brief teaching session delivered to residents and faculty would significantly improve resident confidence in performing shoulder and knee joint injections. Methods: We implemented a 90-minute workshop instructed by two sports medicine providers. The objectives and content of the workshop included the topics of indications and contraindications, risks and benefits, supplies and setup, and injection techniques, all assessed on 5-point Likert scales. The workshop included a lecture, followed by residents practicing injections on simulation models and identifying key bony landmarks. Outpatient clinic faculty were given the same lecture and practiced on models. The postworkshop questionnaire was administered to the residents 4 months later. Results: Eighteen residents participated. Mean confidence for performing knee injections increased from 2.2 to 3.8 immediately postlecture (p = .006). Shoulder injection confidence increased from 1.6 to 3.8 immediately postlecture (p = .0002). Confidence in knowledge of the risks and benefits, supplies needed, and indications increased similarly. Four months postworkshop, confidence levels were sustained above pretesting levels for all areas studied. Faculty members appreciated their workshop since they had not often performed injections. Discussion: This brief workshop-style teaching session can provide meaningful, durable improvements in a trainee's confidence regarding performing shoulder or knee joint injections. The session requires few resources and fits into regular didactic sessions. Further development of this model could increase clinical performance and practice confidence and make these procedures more widely accessible to patients.

Osteopathic Manipulative Medicine Consultations for Hospitalized Patients.

CONTEXT: Although osteopathic manipulative treatment (OMT) is predominantly known for its benefits in improving musculoskeletal pain, many studies have examined the effects of OMT on hospitalized patients with a variety of conditions, showing improved outcomes in conditions such as pneumonia, postoperative and postpartum recovery, preterm newborn recovery, and newborn feeding dysfunction. OBJECTIVE: To determine the reasons osteopathic manipulative medicine (OMM) consultations are being ordered at a tertiary care teaching hospital. METHODS: This descriptive study was conducted at an academic medical center with a well-established electronic health record system. A retrospective review examined data on all OMM consultations between January 1, 2015, and June 30, 2015. Reasons for consultations in a free text field were grouped into categories of "primary reason for consult" by a single reviewer. Demographics and patient location were also assessed. RESULTS: Of 1310 total consultations included in the study, 620 (47.0%) listed a musculoskeletal complaint as the primary or only reason for a consultation, 231 (18.0%) of which were for back pain, followed by neck pain (69 [5.0%]) and headache (46 [4.0%]). The next most common reason for consultation was for newborn feeding difficulty (352 [27.0%]) or other newborn consultation (66 [5.0%]). A total of 272 consultations (21.0%) were not limited to musculoskeletal complaints and included general nonspecific discomfort (96 [7.0%]) or respiratory complaint (53 [4.0%]). A total of 209 (16.0%) consultations noted patients to be postoperative; 124 (9.5%) to be postpartum; 57 (4.4%) to have cystic fibrosis; and 21 (1.6%) to have constipation. CONCLUSION: The majority of inpatient OMM consultations were placed for musculoskeletal complaints, followed by newborn feeding problems. Although it is clear that some physicians think that OMT will help their patients for the aforementioned conditions, the number was still quite low, suggesting that many physicians may be unaware that OMT can help patients with conditions such as respiratory disorder, postoperative recovery, and constipation. There are many opportunities for treatment teams to be ordering OMM consultations as a way to reduce morbidity in their patients.

Using Controlled Substance Receipt Patterns to Predict Prescription Overdose Death.

BACKGROUND: This study evaluates complete state data from controlled substance prescribing trends in the prescription monitoring program (PMP) database and their association with the risk of prescription drug overdose death. SUMMARY: Maine PMP records of individuals who died of prescription overdose deaths between 2006 and 2010 were selected (n = 690). For each subject, an age, gender, and residence matched cohort of PMP users in a 50: 1 ratio was identified (n = 34,500). Key Messages: Prescription opioids contributed to 480 of 690 prescription deaths, many co-ingestions were noted, and OR for overdose death increased with milligram of morphine equivalent (MME)/day >100. The majority who were prescribed MME >100 per day received a prescription within 90 days of overdose matching the toxicology cause of death. CONCLUSIONS: Medication profiles available through state PMP can identify dosing of prescriptions associated with drug overdose death.

Unverifiable Academic Work by Applicants to Primary Care Sports Medicine Fellowship Programs in the United States.

BACKGROUND: In 2008, it was shown that 11% of applications to a primary care sports medicine program contained unverifiable citations for publications. In 2009, the American Medical Society for Sports Medicine changed the application requirements, requiring proof that all claimed citations (publications and presentations) be included with the fellowship application. OBJECTIVE: We determined the rate of unverifiable academic citations in applications to primary care sports medicine fellowship programs after proof of citations was required. METHODS: We retrospectively examined all applications submitted to 5 primary care sports medicine fellowship programs across the country for 3 academic years (2010-2013), out of 108 to 131 programs per year. For claimed citations that did not include proof of publication or presentation, we attempted to verify them using PubMed and Google Scholar searches, a medical librarian search, and finally directly contacting the publisher or sponsoring conference organization for verification. RESULTS: Fifteen of 311 applications contained at least 1 unverifiable citation. The total unverifiable rate was 4.8% (15 of 311) for publications and 11% (9 of 85) for presentations. These rates were lower than previously published within the same medical subspecialty. CONCLUSIONS: After requiring proof of publication and presentation citations within applications to primary care sports medicine fellowship programs, unverifiable citations persisted but were less than previously reported.

The Health and Libraries of Public Use Retrospective Study (HeLPURS).

BACKGROUND: Public libraries may promote health through literacy, education and social connections. OBJECTIVE: To conduct the first broad-based, quantitative exploration of health and public library patronage. METHODS: Retrospective cross-sectional study. All 2925 adult patients at a general practice clinic living in a small north-eastern U.S. city were invited by mail to participate; 243 consented. Clinical variables from the medical records were combined with library usage variables from the public library patron database. The authors analysed how patient health characteristics were associated with library cardholding, average card use or recency of use. RESULTS: Approximately 72% of participants held a library card; 40% of these had used it within the last month. Library cardholding was not associated with patient characteristics. Higher average card use was associated with pregnancy, having youth at home and depression severity. Lack of recent library usage was associated with current smoking (P = 0.01) and drug use (P = 0.01). Among ever-smokers, moderate/high card use and card use within six months were both associated with over two times the odds of quitting smoking. CONCLUSIONS: Public libraries and health appear to intersect around substance abuse and depression-anxiety disorders. Moderate or higher use of public libraries is strongly associated with tobacco cessation.

Prescription Monitoring Program Trends Among Individuals Arrested in Maine for Trafficking Prescription Drugs in 2014.

OBJECTIVE: To evaluate controlled substance prescribing trends available in the Maine Prescription Monitoring Program (PMP) among individuals arrested for prescription drug "trafficking." The demographic characteristics of the individuals who had matching prescription records in the PMP within 90 days of the arrest were identified. STUDY DESIGN: A population-based, retrospective cohort study using data from the Maine Diversion Alert Program (DAP) and the Maine PMP. The study population consisted of persons arrested for trafficking prescription drugs in Maine during the 2014 calendar year from January 1 to December 31. RESULTS: There were 594 trafficking arrests reported by the Maine DAP in 2014. The study population consisted of the 235 persons (40%) with arrests involving controlled prescription medications. The mean age of these persons was 33 years (range 18-77 yrs), and 156 (66%) were male. Arrests involved 154 prescription opioids (65%), seven stimulants (3%), seven benzodiazepines (3%), and 77 unspecified controlled prescription drugs (33%). A minority of individuals (n=57, 24%) had a prescription record in the PMP that matched the substance involved in the arrest. Only one person with matching PMP and arrest records utilized ≥ 5 prescribers, while none used ≥ 5 pharmacies within 90 days before the arrest. Payment methods for matching prescriptions were commercial insurance (n=28, 49%), Medicaid (n=19, 33%), Medicare (n=5, 9%), and cash (n=5, 9%). CONCLUSIONS: The majority (76%) of persons arrested for prescription drug trafficking did not have PMP records and did not directly obtain the diverted medication from a licensed pharmacy. Traditional red flags, like cash payment and using multiple prescribers or pharmacies, were uncommon. Therefore, arrest records for diversion and PMPs are distinct and complementary tools for identifying individuals at risk for substance misuse.

Factors Affecting Physicians' Intentions to Communicate Personalized Prognostic Information to Cancer Patients at the End of Life: An Experimental Vignette Study.

PURPOSE: To explore the effects of personalized prognostic information on physicians' intentions to communicate prognosis to cancer patients at the end of life, and to identify factors that moderate these effects. METHODS: A factorial experiment was conducted in which 93 family medicine physicians were presented with a hypothetical vignette depicting an end-stage gastric cancer patient seeking prognostic information. Physicians' intentions to communicate prognosis were assessed before and after provision of personalized prognostic information, while emotional distress of the patient and ambiguity (imprecision) of the prognostic estimate were varied between subjects. General linear models were used to test the effects of personalized prognostic information, patient distress, and ambiguity on prognostic communication intentions, and potential moderating effects of 1) perceived patient distress, 2) perceived credibility of prognostic models, 3) physician numeracy (objective and subjective), and 4) physician aversion to risk and ambiguity. RESULTS: Provision of personalized prognostic information increased prognostic communication intentions (P < 0.001, η(2) = 0.38), although experimentally manipulated patient distress and prognostic ambiguity had no effects. Greater change in communication intentions was positively associated with higher perceived credibility of prognostic models (P = 0.007, η(2) = 0.10), higher objective numeracy (P = 0.01, η(2) = 0.09), female sex (P = 0.01, η(2) = 0.08), and lower perceived patient distress (P = 0.02, η(2) = 0.07). Intentions to communicate available personalized prognostic information were positively associated with higher perceived credibility of prognostic models (P = 0.02, η(2) = 0.09), higher subjective numeracy (P = 0.02, η(2) = 0.08), and lower ambiguity aversion (P = 0.06, η(2) = 0.04). CONCLUSIONS: Provision of personalized prognostic information increases physicians' prognostic communication intentions to a hypothetical end-stage cancer patient, and situational and physician characteristics moderate this effect. More research is needed to confirm these findings and elucidate the determinants of prognostic communication at the end of life.

Weighty Problems: Predictors of Family Physicians Documenting Overweight and Obesity.

BACKGROUND AND OBJECTIVES: Documenting obesity on the problem list has been shown to promote action about obesity and overweight, yet a majority of primary care providers do not record obesity on the medical problem list. With this in mind, our objectives were to determine the proportion of physicians' documentation of overweight (OW) or obesity on the problem list in our primary care teaching practice and to identify predictors of physician documentation of OW/obesity. METHODS: De-identified health records of 6,195 adult patients with BMI ? 25 kg/m2 seen by a family physician over a 2-year period were included. Using multivariate logistic regression, patient age, BMI, gender, race, insurance, comorbidities, number of visits, physician gender or role, and practice site (suburban versus urban) were examined in relation to inclusion of OW/obesity on the medical problem list. RESULTS: Few (21.1%) patients had OW/obesity on their problem list. In the multivariate model, female PCPs were significantly more likely to document OW/obesity (OR=1.39, 95% CI=1.18--1.63) compared to male PCPs, and faculty were 26% more likely to document obesity (95% CI=1.07--1.48) compared to residents. Female patients, those with hypertension, diabetes, hyperlipidemia, and those with six or more visits were significantly more likely to have obesity on their problem lists, while patients with Medicaid were less likely to have obesity recorded. No significant difference was seen by race. CONCLUSIONS: Nearly 80% of OW and obese patients were not identified on the problem list. Patient gender, comorbidity, and number of visits were associated with documentation. Future research should examine automatic documentation of OW/obesity on the medical problem list.

Tolerability and Efficacy of 3 Approaches to Intra-articular Corticosteroid Injections of the Knee for Osteoarthritis: A Randomized Controlled Trial.

BACKGROUND: Several studies have been performed suggesting that a superolateral approach to cortisone injections for symptomatic osteoarthritis of the knee is more accurate than anteromedial or anterolateral approaches, but there are little data to correlate clinical outcomes with these results. Additionally, there are minimal data to evaluate the pain of such procedures, and this consideration may impact physician preferences for a preferred approach to knee injection. PURPOSE: To determine the comparative efficacy and tolerability (patient comfort) of landmark-guided cortisone injections at 3 commonly used portals into the arthritic knee without effusion. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Adult, English-speaking patients presenting to a sports medicine clinic with knee pain attributed to radiographically proven grades I through III knee osteoarthritis were randomized to receive a cortisone injection via superolateral, anteromedial, or anterolateral approaches. Patients used a visual analog scale (VAS) to self-report comfort with the procedure. Western Ontario and McMaster Universities Arthritis Index (WOMAC) 3.1 VAS scores were used to establish baseline pain and dysfunction prior to the injection and at 1 and 4 weeks follow-up via mail. RESULTS: A total of 55 knees from 53 patients were randomized for injection using a superolateral approach (17 knees), an anteromedial approach (20 knees), and an anterolateral approach (18 knees). The mean VAS scores for procedural discomfort showed no significant differences between groups (superolateral, 39.1 ± 28.5; anteromedial, 32.9 ± 31.5; anterolateral, 33.1 ± 26.6; P = .78). WOMAC scores at baseline were similar between groups as well (superolateral, 1051 ± 686; anteromedial, 1450 ± 573; anterolateral, 1378 ± 673; P = .18). The WOMAC scores decreased at 1 and 4 weeks for all groups, with no significant differences in reduction between the 3 groups. CONCLUSION: Other studies have shown that the superolateral portal is the most accurate. This study did not assess accuracy, but it showed that all 3 knee injection sites studied have similar overall clinical benefit at 4-week follow-up. Procedural pain was not significantly different between groups.

Temporal changes in tolerance of uncertainty among medical students: insights from an exploratory study.

BACKGROUND: Physicians' tolerance of uncertainty (TU) is a trait potentially associated with desirable outcomes, and emerging evidence suggests it may change over time. Past studies of TU, however, have been cross-sectional and have not measured tolerance of the different, specific types of uncertainty that physicians confront. We addressed these limitations in a longitudinal exploratory study of medical students. METHODS: At the end of medical school (Doctor of Medicine degree) Years 1 and 4, a cohort of 26 students at a US medical school completed measures assessing tolerance of different types of uncertainty: 1) complexity (uncertainty arising from features of information that make it difficult to comprehend); 2) risk (uncertainty arising from the indeterminacy of future outcomes); and 3) ambiguity (uncertainty arising from limitations in the reliability, credibility, or adequacy of information). Change in uncertainty-specific TU was assessed using paired t-tests. RESULTS: Between Years 1 and 4, there was a significant decrease in tolerance of ambiguity (t=3.22, p=0.004), but no change in students' tolerance of complexity or risk. CONCLUSIONS: Tolerance of ambiguity--but not other types of uncertainty--decreases during medical school, suggesting that TU is a multidimensional, partially mutable state. Future studies should measure tolerance of different uncertainties and examine how TU might be improved.

Developing, evaluating and validating a scoring rubric for written case reports.

OBJECTIVE: The purpose of this study was to evaluate Family Medicine Clerkship students' writing skills using an anchored scoring rubric. In this study, we report on the assessment of a current scoring rubric (SR) used to grade written case description papers (CDP) for medical students, describe the development of a revised SR with examination of scoring consistency among faculty raters, and report on feedback from students regarding SR revisions and written CDP. METHODS: Five faculty members scored a total of eighty-three written CDP using both the Original SR (OSR) and the Revised SR1 (RSR1) during the 2009-2010 academic years. RESULTS: Overall increased faculty inter-rater reliability was obtained using the RSR1. Additionally, this subset analysis revealed that the five faculty using the Revised SR2 (RSR2) had a high measure of inter-rater reliability on their scoring of this subset of papers (as measured by intra-class correlation (ICC) with ICC = 0.93, p = 0.001. CONCLUSIONS: Findings from this research have implications for medical education, by highlighting the importance of the assessment and development of reliable evaluation tools for medical student writing projects.