Preclinical obesity curriculum: audit, implementation, and evaluation.

BACKGROUND: This study aimed to (1) evaluate the current status of obesity education at Case Western Reserve University School of Medicine (CWRU) (2), introduce a comprehensive first-year curriculum on obesity, and (3) assess the impact of the curriculum on self-reported attitudes and knowledge regarding obesity among first-year medical students. METHODS: The preclinical curriculum at CWRU was reviewed to determine the degree of coverage of Obesity Medicine Education Collaborative (OMEC) competencies for healthcare professionals, and recommendations were provided for revising the curriculum to better adhere to these evidence-based competencies. A survey on obesity attitudes and knowledge was given before and after the implementation of the new curriculum to measure intervention-related changes. Changes in obesity attitudes and knowledge were compared (1) before and after the intervention for the class of 2025 and (2) after the intervention for the class of 2025 to a historical cohort that did not receive the intervention. RESULTS: Among the 27 competencies examined in the audit, 55% were unmet and 41% were partially met. Of 186 first-year medical students (M1s), 29 (16%) completed the baseline survey and 26 (14%) completed the post-intervention survey. Following the intervention, there was a notable improvement in attitudes and knowledge regarding obesity. Specifically, there was a significant decrease in the belief that obesity is caused by poor personal choices, and knowledge of obesity in fourteen out of fifteen areas showed significant improvement from pre- to post-intervention. Additionally, obesity attitudes and knowledge were significantly better post-intervention when compared to the historical cohort. CONCLUSIONS: The improvements made to the preclinical curriculum through this project improved obesity attitudes and knowledge among first-year medical students. This method provides a practical approach for evaluating and enhancing obesity education in medical school curricula.

Towards sustainable and humane dairy farming: A low-cost electrochemical sensor for on-site diagnosis of milk fever.

Milk fever is a metabolic disorder that predominantly affects dairy animals during the periparturient period and within four weeks of calving. Milk fever is primarily attributed to a decrease in the animal's serum Ca2+ levels. Clinical milk fever occurs when Ca2+ concentration drops below 1.5 mM (6 mg/dL). Without prompt intervention, clinical milk fever leads to noticeable physical symptoms and health complications including coma and fatality. Subclinical milk fever is characterized by Ca2+ levels between 1.5 and 2.12 mM (6-8.48 mg/dL). Approximately 50% of multiparous dairy cows suffer from subclinical milk fever during the transition to lactation. The economic impact of milk fever, both direct and indirect, is substantial, posing challenges for farmers. To address this issue, we developed a low-cost electrochemical sensor that can measure bovine serum calcium levels on-site, providing an opportunity for early detection of subclinical and clinical milk fever and early intervention. This calcium sensor is a scalable solid contact ion sensing platform that incorporates a polymeric calcium-selective membrane and ionic liquid-based reference membrane into laser-induced graphene (LIG) electrodes. Our sensing platform demonstrates a sensitivity close to the theoretical Nernstian value (29.6 mV/dec) with a limit of detection of 15.6 µM and selectivity against the species in bovine serum. Moreover, our sensor can detect Ca2+ in bovine serum with 91% recovery.

Obesity preclinical elective: a qualitative thematic analysis of student feedback.

BACKGROUND: Education about the prevalent chronic disease of obesity is still minimal and variable in medical school curricula. In a student-led effort with faculty support, the authors designed and implemented an obesity medicine elective at Case Western Reserve University School of Medicine (CWRU). The 10-week elective, taught by seven physicians and one dietitian, was offered in January 2023 to medical students and included: weekly lectures, an interactive session with a patient, shadowing in obesity medicine practices, attendance at a distance-learning intensive behavioral lifestyle program, student presentations, and a final written reflection. The purpose of this study was to analyze the elective reflections and identify themes about the elective's value and areas to improve. METHODS: The authors analyzed reflections from the 20 medical students that completed the elective via qualitative thematic analysis. The analysis was performed using the Braun and Clarke six-phase framework: (1) become familiar with the data, (2) generate initial codes, (3) search for themes, (4) review themes, (5) define themes, and (6) write-up. RESULTS: The themes identified were improved: (1) understanding of obesity as a chronic disease, (2) knowledge about treatment options for obesity (3) confidence in compassionate obesity counseling skills, and (4) skills to confront weight bias. Theme (5) consisted of highlights (hearing from experts, practicing evidence-based medicine, and interacting with patients), and areas to improve (session length, presentation format, more peer-to-peer interaction, and more diverse patient interactions). CONCLUSIONS: Medical student assessments of a new obesity medicine elective described improved attitudes, knowledge, and skills to address obesity and obesity bias. Students were very satisfied and contributed ideas for improvements. This elective structure and evaluation method is a feasible model to provide medical students with meaningful experiences related to obesity.

Team-Based Learning Intervention to Improve Obesity Education in Medical School.

Introduction: Obesity is a multifactorial chronic disease and a major contributor to numerous health conditions. Despite the high prevalence, costs, and health effects of obesity, physicians are largely unprepared to treat it. Most medical students and residents lack sufficient training in obesity and obesity management. Methods: We evaluated a two-part team-based learning seminar (TBL) on obesity pathogenesis and treatment for first-year medical students at Case Western Reserve University School of Medicine (CWRU SOM). A questionnaire on attitudes toward obesity and self-perceived knowledge of obesity was administered before and after the TBL, utilizing Likert scales. Results: Of 183 medical students who attended both TBLs, 155 (85%) completed the baseline questionnaire, and 127 (69%) completed the postintervention questionnaire. Confidence in treating obesity increased significantly from preintervention (M = 2.7, SD = 1.0) to postintervention (M = 3.7, SD = 0.8). The attitude that obesity is caused by poor personal choices decreased significantly from preintervention (M = 2.8, SD = 0.9) to postintervention (M = 2.1, SD = 0.9). Self-perceived knowledge of obesity in all nine areas-epidemiology, energy homeostasis, etiologies, nutrition, physical activity, behavior, pharmacology, surgery, and language-increased significantly. Discussion: Despite obesity being one of the most prevalent health concerns, obesity education in medical school is scant. This TBL resulted in improved attitudes toward obesity and self-perceived knowledge of obesity among first-year medical students at CWRU SOM and offers a practical mechanism to introduce more obesity education into undergraduate medical curricula.

Clinical and Sociodemographic Characteristics Associated with Emergency Peripartum Hysterectomy due to Puerperal Sepsis in Malawi.

Background and Objective: In Malawi, emergency peripartum hysterectomy continues to be routine for the management of puerperal sepsis. While the hysterectomy may be life-saving for the mother, it carries with it life-altering permanent sterility. The surgeon is left with a difficult dilemma: remove the infection source (uterus) to preserve the life of the patient at the cost of her fertility, or preserve the uterus and fertility but risk worsening infection and possible death for the patient. The objective of this study was to (1) identify characteristics associated with mortality post-laparotomy due to puerperal sepsis and (2) identify characteristics associated with emergency peripartum hysterectomy in the management of puerperal sepsis. Methods: In this retrospective chart review, we obtained medical records of patients who underwent laparotomy secondary to puerperal sepsis at a tertiary hospital in Lilongwe, Malawi. Data collected included demographic information and clinical findings. These data were compared between women with and without adverse outcomes. Chi-squared tests were used to determine if there were significant relationships between variables and outcomes. Results: Fifty-eight patient records met inclusion criteria. The following characteristics were significantly associated with mortality: age greater than 30, multiparity, vaginal delivery, and intensive care unit admission. Cesarean delivery and an intraoperative finding of necrosis were significantly associated with hysterectomy. Conclusion and Global Health Implications: Emergency peripartum hysterectomy in the setting of puerperal sepsis is a significant source of maternal morbidity and mortality. To prevent emergency peripartum hysterectomy, it is important to have prompt recognition and treatment of puerperal sepsis, to have access to adequate antibiotics, and to have standards to guide the role of hysterectomy as the definitive and necessary treatment for puerperal sepsis.

Neutrophil DREAM promotes neutrophil recruitment in vascular inflammation.

The interaction between neutrophils and endothelial cells is critical for the pathogenesis of vascular inflammation. However, the regulation of neutrophil adhesive function remains not fully understood. Intravital microscopy demonstrates that neutrophil DREAM promotes neutrophil recruitment to sites of inflammation induced by TNF-α but not MIP-2 or fMLP. We observe that neutrophil DREAM represses expression of A20, a negative regulator of NF-κB activity, and enhances expression of pro-inflammatory molecules and phosphorylation of IκB kinase (IKK) after TNF-α stimulation. Studies using genetic and pharmacologic approaches reveal that DREAM deficiency and IKKß inhibition significantly diminish the ligand-binding activity of ß2 integrins in TNF-α-stimulated neutrophils or neutrophil-like HL-60 cells. Neutrophil DREAM promotes degranulation through IKKß-mediated SNAP-23 phosphorylation. Using sickle cell disease mice lacking DREAM, we show that hematopoietic DREAM promotes vaso-occlusive events in microvessels following TNF-α challenge. Our study provides evidence that targeting DREAM might be a novel therapeutic strategy to reduce excessive neutrophil recruitment in inflammatory diseases.

Comparison of Physical Activity, Healthy Eating Habits, and Knowledge of Diabetes and Pre-diabetes in Rural Reservation and Off-reservation Communities.

INTRODUCTION: Residents in two small rural communities on the Northern Great Plains completed surveys to determine their community's needs for physical activity, healthy eating habits, and knowledge of diabetes/pre-diabetes. METHODS: One rural American Indian reservation (Community A) and one off-reservation (Community B) were selected for the study. Both communities had similar population size, medical clinic, pharmacy, grocery store and fitness center. Surveys were collected in-person during local community events. RESULTS: More respondents in Community A (41 percent) compared to Community B (18 percent) used the Fitness Center and had more vigorous physical activity (44 percent vs. 5 percent respectively). Compared to Community A, Community B respondents bought more fruits and vegetables (85 percent vs. 96 percent respectively). While a higher rate of diabetes (15.1 percent) in the American Indian population has been reported, this study did not find a significant difference when comparing these two rural communities. Fewer respondents with diabetes in Community A (25 percent), compared to Community B (85 percent) had attended diabetes education. More respondents in Community A (31 percent) than B (13 percent) had pre-diabetes. CONCLUSIONS: Community A's fitness center had personal trainers that provided education, motivation and encouraged individuals to exercise. The majority of respondents in Communities A (85 percent) and B (96 percent) purchased fruits and vegetables. Fruits and vegetables were readily available in the local grocery stores for both small rural communities. More individuals with diabetes (83 percent) in Community B had attended diabetes education classes. More Community A respondents had pre-diabetes; however, diabetes prevention education could reduce their risk of developing type 2 diabetes by 58 percent.

Reinventing the Pregnancy Wheel to Improve Pregnancy Dating and Antenatal Care Visits: A Pilot Randomized Trial in Malawi.

BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the feasibility of a customized, culturally sensitive pregnancy wheel given to pregnant women to improve gestational age dating accuracy at the time of delivery and to improve antenatal care attendance. METHODS: This was a pilot randomized trial involving pregnant women presenting to a regional hospital in Lilongwe, Malawi. The primary outcome was accuracy of gestational age at the time of presentation to the hospital in labor. The secondary outcome was the number of antenatal visits. RESULTS: At final analysis, 14 subjects were included in the pregnancy wheel (intervention) arm and 11 in the standard care arm. Fifty percent (n=7) of women in the intervention arm were accurately dated at the time of presentation for delivery, compared to only 9% (n=1) in the standard antenatal care arm (p=0.04). There was not a significant difference in the number of antenatal visits between the two study arms. No patients met the World Health Organization's recommended eight antenatal care visits for prenatal care. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: The customized pregnancy wheel given to patients could improve gestational age dating accuracy, and as a result, clinical decision making. However, the barriers to greater antenatal care access are more complex and likely require a more complex solution. Significant attrition in this pilot trial limited statistical power, suggesting the need for future larger interventions. Accurate gestational dating requires access to ultrasonography and early antenatal care initiation, both of which are inadequate in Malawi. Although the customized pregnancy wheel did not improve antenatal care attendance, it improved gestational age dating accuracy in a pilot study at a central hospital in Lilongwe, Malawi.

The Hope Health and Wellness Clinic: Outcomes of Individuals with Serious Mental Illness in a Bidirectional Integrated Care Clinic.

The integrated health home, the Hope Health and Wellness Clinic, provides comprehensive primary and behavioral health services to adult clients of a Community Mental Health Center in Aurora, Colorado. A program evaluation of the effectiveness of this clinic was conducted over a 4 year period. Physical health data (Body Mass Index BMI, HbA1c, cholesterol, blood pressure, and waist circumference measurements) and self-report data (social connectedness, everyday functioning, psychological distress, perceived health, satisfaction with services) were tracked across time. Individuals enrolled (N = 534) experienced significant improvements over time in LDL and total cholesterol, as well as self-reported social connectedness, everyday functioning, perceived health, and psychological distress. At risk individuals demonstrated significant improvements in HDL cholesterol, triglycerides, blood pressure, tobacco and alcohol use. Individuals with serious mental illness show improvements in physical health and self-reported health after being involved in bidirectional integrated care.

Involvement of pharmacist-reviewed urine cultures and sexually transmitted infections in the emergency department reduces time to antimicrobial optimization.

PURPOSE: To streamline workflow of the culture review process in the emergency department (ED), a transition from a nurse-driven to a pharmacist-initiated process was implemented. METHODS: This was a single-center retrospective study conducted at an adult urban level 1 trauma academic medical center. The pharmacist-initiated culture review process was compared to the previous nurse-initiated process. The primary objective was time from final culture result to patient contact by an advanced practice provider. Secondary objectives included incidence of treatment failure and hospital admission within 30 days of ED visit. RESULTS: A total of 283 patients met inclusion criteria: 144 patients in the pre-intervention group and 139 patients in the postintervention group. Patients were contacted a median time of 15.7 hours (95% confidence interval [CI], 9.88-18.83) earlier for definitive urinary tract infection antibiotic therapy and 46.7 hours (95% CI, 33.34-61.62) earlier for definitive sexually transmitted infection therapy in the pharmacist-initiated workflow compared to the nurse-initiated workflow (P < 0.001). Treatment failure occurred in 0.01% of patients in the postintervention group and 6.3% in the pre-intervention group (P = 0.01). Hospital admission within 30 days of the ED visit occurred in 0% of patients in the postintervention group and 4.2% in the pre-intervention group (P = 0.03). CONCLUSION: Pharmacist-initiated culture review in the ED at an academic medical center reduced time from final culture to patient contact for optimal antibiotic therapy and decreased hospital admission and treatment failure rates. A change in the culture review workflow involving pharmacists appears to have a positive impact on clinical outcomes.

Non-adherence to labor guidelines in cesarean sections done for failed induction and arrest of dilation.

OBJECTIVES: In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes. METHODS: Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes. RESULTS: Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003). CONCLUSIONS: Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Association of weight loss with improved disease activity in patients with rheumatoid arthritis: A retrospective analysis using electronic medical record data.

OBJECTIVE: To evaluate the association between weight loss and rheumatoid arthritis (RA) disease activity. METHODS: We conducted a retrospective cohort study of RA patients seen at routine clinic visits at an academic medical center, 2012-2015. We included patients who had ≥2 clinical disease activity index (CDAI) measures. We identified visits during follow-up where the maximum and minimum weights occurred and defined weight change and CDAI change as the differences of these measures at these visits. We defined disease activity improvement as CDAI decrease of ≥5 and clinically relevant weight loss as ≥5 kg. We performed logistic regression analyses to establish the association between improved disease activity and weight loss and baseline BMI category (≥25 kg/m2 or <25 kg/m2). We built linear regression models to investigate the association between continuous weight loss and CDAI change among patients who were overweight/obese at baseline and who lost weight during follow-up. RESULTS: We analyzed data from 174 RA patients with a median follow-up of 1.9 years (IQR 1.3-2.4); 117 (67%) were overweight/obese at baseline, and 53 (31%) lost ≥5 kg during follow-up. Patients who were overweight/obese and lost ≥5 kg had three-fold increased odds of disease activity improvement compared to those who did not (OR 3.03, 95%CI 1.18-7.83). Among those who were overweight/obese at baseline, each kilogram weight loss was associated with CDAI improvement of 1.15 (95%CI 0.42-1.88). Our study was limited by using clinical data from a single center without fixed intervals for assessments. CONCLUSION: Clinically relevant weight loss (≥5 kg) was associated with improved RA disease activity in the routine clinical setting. Further studies are needed for replication and to evaluate the effect of prospective weight loss interventions on RA disease activity.

An exploration of lived religion in same-sex couples from Judeo-Christian traditions.

Religious involvement has been found to be associated with higher levels of commitment and relationship satisfaction among heterosexually married individuals (Mahoney et al., 1999). Little is known, however, about the religiosity of gay, lesbian, bisexual (GLB) individuals, and virtually nothing is known about religious involvement in same-sex couples. The purpose of this qualitative interview study was to examine couples' experiences of incorporating religious involvement into their committed relationships. In a sample of 14 same-sex couples, we found that couples used their spiritual/religious values to understand and undergird their relationships. In this process, they negotiated intra-couple differences in religious practices, involved themselves in activities that have religious or spiritual meaning to them, created religious social support for their relationships, and experienced some non-supportive or rejecting interpersonal interactions with religious family members, congregants, and strangers. These findings are instructive to therapists who work with same-sex couples and the family members of GLB individuals. We conclude with specific suggestions for practitioners.