Commentary on Ultrasound Instruction in Undergraduate Medical Education: Perspective from Two Students.

Background: Ultrasound integration in undergraduate medical education (UME) has been a focused endeavor in recent years. According to the American Institute of Ultrasound in Medicine, more than a third of all US medical schools have adopted a focused ultrasound training program for medical students. Medical student perspectives on best practices in ultrasound education are lacking in the literature. Curricula Experiences: Two students' reflections are presented regarding two different didactic approaches, flipped classroom and self-study learning models, to teaching ultrasound in the pre-clinical medical education curriculum. Students present reflections on these didactic approaches to facilitate further improvement in ultrasound education curricula. Discussion: The self-directed learning model enabled students to learn foundational ultrasound exam techniques efficiently in a low-stress environment and subsequently optimized the efficiency of later faculty-led learning events. However, we noted that in both the flipped classroom and self-study learning models of education, the training on basic physical properties of ultrasound, tissue characteristics, and probe manipulation was limited. Conclusion: A self-study learning model ultrasound curricula improves perceived learning efficiency and student confidence, especially when followed by faculty-guided didactics and scanning opportunities. We suggest a framework for ultrasound education curricula that includes components of both formats of ultrasound education alongside faculty-led sessions as an ideal model of ultrasound education. Further, we propose the added benefit of inanimate object scanning to optimize students' knowledge of waveform physics (image acquisition and physical properties of materials) early in the ultrasound education process.

Impact of kidney transplant on post-operative morbidity and mortality in patients with pre-operative cardiac dysfunction.

BACKGROUND: Several studies show an increase in complications, both cardiac and non-cardiac, and a higher mortality in patients with preexisting cardiac disease when they undergo elective surgery. Due to the high incidence of cardiac dysfunction in patients with concomitant chronic kidney disease, we wanted to determine if the same negative impact is demonstrated in patients undergoing kidney transplantation. METHODS: A retrospective analysis was done on 582 patients who underwent kidney transplant from a single transplant center between 2014 and 2019. Participants for this study were divided into two groups based on cardiac ejection fraction: normal EF (≥40%) (n = 540) and low EF (<40%) (n = 33); exclusion criteria included patients undergoing multi-organ transplants (n = 9). Characteristics and outcomes of patients were compared before and after transplant using chi-square tests for categorical measures, and either Kruskal-Wallis or paired Student's t tests for continuous measures. Overall survival (OS) between groups was assessed using the Kaplan-Meier test. We compared outcomes between the normal EF and low EF groups using logistic regression in raw data, and propensity score matched sample and inverse-probability-weighting to mitigate selection bias. RESULTS: There was no significant difference in survival between patients in the low EF and normal EF groups (p = .33). Among patients with low EF, mean EF after transplant significantly improved (mean: 55.83% ± 5.75%) compared to mean EF before transplant (38.28% ± 7.35%), (p = < .0001). Of the patients with a low EF before transplant, 1 in 5 had a history of CAD, compared to only 1 in 10 among those patients with a normal EF, p = .0657. Post-transplant complications were comparable between the groups. CONCLUSION: Patients undergoing kidney transplantation with a low ejection fraction do not demonstrate an increased incidence of morbidity or mortality in the peri- and post-transplant follow-up compared with patients with a normal ejection fraction. Cardiac events post-transplantation is also comparable between the two groups. Of note, patients with a low EF have a significantly improved EF after kidney transplant which is likely a function of improvement in their physiologic state after the kidney transplant.

Small Group Tutorial Curriculum During Third Year Surgical Clerkship and Identification of Surgical Role Models.

Identification of surgical mentors is associated with medical student interest in surgical careers. Small group learning has been a fundamental component of the surgical clerkship at the University of North Carolina (UNC) School of Medicine for 14 years. The curriculum was standardized on 2018 and has long been hypothesized to facilitate mentoring relationships. In this brief report, we administered a survey that assessed the relationship between students and surgical faculty serving as small group tutors. Analysis was performed by descriptive statistics and chi-square analysis. The survey yielded an 18.8% response rate. Greater than 50% of students identified their tutor as a surgical role model. Greater than 60% of students affirmed that their tutor at least somewhat influenced their interest in surgery. Larger longitudinal studies with higher response rates are needed to assess relationships over time, and if these relationships ultimately correlate with applications made to surgical residency programs.

A case report on ultrasound evaluation of pediatric post-operative abdominal pain.

Pediatric post-operative abdominal pain can present a unique diagnostic challenge. The case presented here describes a 9-year-old female who presented with fever and worsening abdominal pain 4 days after laparoscopic resection of a benign ovarian teratoma. Computed tomography failed to provide adequate diagnostic imaging. Ultrasound was subsequently used to rule-out a major post-operative complication and ultimately led to a successful non-operative approach while avoiding repeat radiation exposure. Thin body habitus, increased radiosensitivity of pediatric organs, and increased lifetime risk of cancer complicate the use of computed tomography in the pediatric population. Ultrasound, when correlated to clinical findings, has unique advantages over CT such as detailed delineation of soft tissue structures and dynamic assessment of anatomy that make it advantageous in the pediatric post-operative setting.

Teaching Thoracic Surgery in a Low-Resource Setting:: Creation of a Simulation Curriculum in Rwanda.

Surgical education and global health partnerships have evolved over the years. There is growing recognition of the importance of in-country training of surgeons and surgeon specialists in low-resource settings to support the local health care system. There are numerous ways in which high-income partners can support local training programs. The Human Resources for Health program was initiated in 2012 to advance in-country training of health care professionals in Rwanda. As there was a limited in-country operative experience for teaching general thoracic surgery, simulation models were developed, influenced by a prior course developed for American cardiothoracic trainees. Local Rwandan faculty were engaged. Adaptations from the American version included constructing models from inexpensive materials to make the simulation more feasible in the Rwanda setting.

Mental health burden of empty nose syndrome compared to chronic rhinosinusitis and chronic rhinitis.

BACKGROUND: Empty nose syndrome (ENS) is characterized by the paradoxical perception of nasal obstruction despite patent sinonasal anatomy after surgery. We investigated the relationship between ENS, and anxiety, depression, obsessive-compulsive disorder, and somatic symptom disorder (SSD) compared to individuals with chronic rhinitis (CR) and chronic rhinosinusitis (CRS). METHODS: This cross-sectional survey study compared ENS and CR and CRS patients. A total of 116 patients participated: 58 ENS patients from digital support groups, and 58 CRS and CR patients from tertiary rhinology clinics. Study participants completed four validated surveys: (1) Empty Nose Syndrome 6-Item Questionnaire, (2) Rhinosinusitis Disability Index (RSDI), (3) Obsessive Compulsive Inventory - Revised (OCI-R), and (4) PRIME MD Patient Health Questionnaire (PHQ). RESULTS: ENS patients exhibited a mean RSDI of 78.6, 95% confidence interval [CI] 72.8-84.5, compared to 25.2, 95% CI 18.6-31.8 for CRS/CR patients (p < 0.0001). This difference was seen across all subdomains. Using the PHQ, 53% of ENS patients met diagnostic thresholds for SSD compared to 14% of CRS patients (p < 0.0001). In relation to obsessive compulsive disorder (OCD), 18.37% of ENS patients compared to 8.62% of CRS/CR patients scored above the diagnostic threshold (>21) on the OCI-R questionnaire (p = 0.159). CONCLUSION: ENS patients had diminished sinonasal quality of life and a higher prevalence of comorbid anxiety and depression, compared to CR and CRS. ENS patients were more likely to exceed thresholds for OCD and SSD compared to controls. Future studies are needed to assess the role of SSD in ENS to help optimize treatment for these complex patients.

Pharmacokinetic-based failure of a detergent virucidal for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) nasal infections: A preclinical study and randomized controlled trial.

BACKGROUND: The nose is the portal for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection, suggesting the nose as a target for topical antiviral therapies. The purpose of this study was to assess both the in vivo and in vitro efficacy of a detergent-based virucidal agent, Johnson and Johnson's Baby Shampoo (J&J), in SARS-CoV-2-infected subjects. METHODS: Subjects were randomized into three treatment groups: (1) twice daily nasal irrigation with J&J in hypertonic saline, (2) hypertonic saline alone, and (3) no intervention. Complementary in vitro experiments were performed in cultured human nasal epithelia. The primary outcome measure in the clinical trial was change in SARS-CoV-2 viral load over 21 days. Secondary outcomes included symptom scores and change in daily temperature. Outcome measures for in vitro studies included change in viral titers. RESULTS: Seventy-two subjects completed the clinical study (n = 24 per group). Despite demonstrated safety and robust efficacy in in vitro virucidal assays, J&J irrigations had no impact on viral titers or symptom scores in treated subjects relative to controls. Similar findings were observed administering J&J to infected cultured human airway epithelia using protocols mimicking the clinical trial regimen. Additional studies of cultured human nasal epithelia demonstrated that lack of efficacy reflected pharmacokinetic failure, with the most virucidal J&J detergent components rapidly absorbed from nasal surfaces. CONCLUSION: In this randomized clinical trial of subjects with SARS-CoV-2 infection, a topical detergent-based virucidal agent had no effect on viral load or symptom scores. Complementary in vitro studies confirmed a lack of efficacy, reflective of pharmacokinetic failure and rapid absorption from nasal surfaces.

A longitudinal study of olfactory dysfunction and parosmia in mild COVID-19 cases.

Background: COVID-19-related olfactory dysfunction (OD) can persist long after patients recover from acute infection, yet few studies have investigated the long-term progression of this complication. Moreover, existing studies are focused on hyposmia/anosmia but parosmia is becoming an increasingly recognized long-term symptom. Methods: We completed a longitudinal study about OD in individuals with mild cases of COVID-19. Participants completed a questionnaire and Brief Smell Identification Test (BSIT) one week, one month and one year after diagnosis. At one-year, participants completed an additional survey about parosmia. Results: We obtained questionnaires and psychophysical olfactory testing information from participants at one week (n=45), one month (n=38), and one year (n=33) post COVID-19 diagnosis. At one-year, 15.2% of participants had persistent OD and 66.7% of participants reported experiencing parosmia at some point following COVID-19 diagnosis. The mean onset of parosmia was 1.3 weeks (SD: 1.9 weeks) after diagnosis, although two patients reported delayed onset (>4 weeks after diagnosis). Eight patients (24.2%) reported ongoing parosmia one year after diagnosis. Of the patients whose parosmia resolved, the mean duration of symptoms was 7.2 weeks (SD: 7.3 weeks). Conclusion: Decreased sense of smell associated with COVID-19 infection has received significant recognition in both the media and in the medical literature. Symptoms of OD and parosmia were common in our patients with COVID-19. Hyposmia, anosmia, and parosmia, all decrease quality of life, necessitating continued research to understand the pathogenesis, course of symptoms, and possible treatment for these complications.

Granulomatous mastitis: An underdiagnosed inflammatory disease afflicting minority women.

Granulomatous mastitis (GM) is an underdiagnosed and understudied benign inflammatory disease of the breast whose accurate diagnosis is confounded by mimicry of other breast pathologies (infectious mastitis and abscess, malignancy) and limited clinician knowledge of the disease. GM disproportionately affects minority women, furthering health disparities for a demographic already disadvantaged in the care of breast diseases. The first step in diagnosis is ultrasound followed by core needle biopsy yielding granulomatous inflammation. To far lesser degree, mammography, and MRI may play a role in narrowing the differential. A high index of clinical suspicion and multidisciplinary approach is required. The presence of Corynebacterium kroppensteddti may indicate one subtype of granulomatous mastitis called cystic neutrophilic granulomatous mastitis; disease stratification, and individualized therapy are on the horizon.

Creating an Ultrasound Scholarly Concentration Program for Medical Students.

INTRODUCTION: Point of care ultrasound (POCUS) is increasingly prevalent and standardized in undergraduate medical education (UME); however, roughly 25% of United States medical schools lack an ultrasound curriculum. One of the commonly cited barriers to ultrasound training in UME is faculty time resources. Here, we describe an ultrasound scholarly concentration program (SCP) designed to provide medical students with ultrasound opportunities in clinical and scholarly domains, while reducing the need for extensive faculty resources. METHODS: SCPs at the University of North Carolina School of Medicine have 3 requirements: an elective course, a longitudinal portfolio, and a final scholarly project. Thus, the ultrasound SCP was designed to comprise an introductory clinical elective to ultrasound, development of a longitudinal scan portfolio, and a final scholarly project in ultrasound related research or educational innovation. A review of the literature and search of the top 50 US medical schools by US News & World Report was performed to assess the novelty of the ultrasound SCP. RESULTS: To the best of our knowledge, the ultrasound SCP is the first scholarly concentration, track or pathway offered to medical students in the United States. It is the first description of a student designed and student led curriculum focused on providing meaningful ultrasound opportunities to students without necessitating unavailable faculty resources and educational infrastructure. CONCLUSION: A novel ultrasound SCP is described which has clinical aims to expose students to clinical ultrasound as well as scholarly aims to facilitate ultrasound related research and educational innovation. It is designed to enable students to make ultrasound a defining characteristic of their medical school experience. The SCP relies on motivated student involvement and near-peer teaching in a way that is self-sustaining and self-improving.

COVID-19 related olfactory dysfunction prevalence and natural history in ambulatory patients.

BACKGROUND: Evidence regarding prevalence of COVID-19 related Olfactory dysfunction (OD) among ambulatory patients is highly variable due to heterogeneity in study population and measurement methods. Relatively few studies have longitudinally investigated OD in ambulatory patients with objective methods. METHODS: We performed a longitudinal study to investigate OD among COVID-19 ambulatory patients compared to symptomatic controls who test negative. Out of 81 patients enrolled, 45 COVID-19 positive patients and an age- and sex-matched symptomatic control group completed the BSIT and a questionnaire about smell, taste and nasal symptoms. These were repeated at 1 month for all COVID-19 positive patients, and again at 3 months for those who exhibited persistent OD. Analysis was performed by mixed-effects linear and logistic regression. RESULTS: 46.7% of COVID-19 patients compared to 3.8% of symptomatic controls exhibited OD at 1-week post diagnosis (p<0.001). At 1 month, 16.7%, (6 of 36), of COVID-19 patients had persistent OD. Mean improvement in BSIT score in COVID-19 patients between 1-week BSIT and 1 month follow-up was 2.0 (95% CI 1.00 - 3.00, p<0.001). OD did not correlate with nasal congestion (r= -0.25, 95% CI, -0.52 to 0.06, p=0.12). CONCLUSIONS: Ambulatory COVID-19 patients exhibited OD significantly more frequently than symptomatic controls. Most patients regained normal olfaction by 1 month. The BSIT is a simple validated and objective test to investigate the prevalence of OD in ambulatory patients. OD did not correlate with nasal congestion which suggests a congestion-independent mechanism of OD.

Sleep quality, depressive symptoms, and transplant outcomes: Follow-up analyses from the ADAPT prospective pilot study.

BACKGROUND: Previous studies suggested that depressive symptoms and sleep quality may be important for long-term clinical outcomes following cardiothoracic transplant. Few studies, however, have systematically examined objective markers of these behavioral factors among ambulatory transplant recipients, or their association with clinical outcomes. METHODS: We examined sleep quality and depressive symptoms with subsequent clinical outcomes (hospitalizations and death) in a sample of 66 lung or heart transplant recipients using a single-center, prospective cohort study. Recipients were assessed at approximately 6 months post-transplant and completed one week of actigraphy assessment to examine sleep quality and self-report measures of mood (Centers for Epidemiologic Studies of Depression [CESD]). Recipients were followed for clinical outcomes. RESULTS: At 6-months following transplantation, recipients spent the majority of daytime activity at a sedentary level (61% of daily activity [SD = 10]) and elevated depressive symptoms were common (subclinical = 17%, mild = 12%, or moderate = 8%). Over a median follow-up of 4.5 years (IQR = 0.9, 5.1), 51 participants (77%) had at least one unplanned hospitalization and 11 (17%) participants died. In addition, sleep efficiency measurements suggested that a subset of participants exhibited suboptimal sleep (mean efficiency = 87% [SD = 7]). Poorer sleep quality, indexed by lower sleep efficiency and greater sleep fragmentation, was associated with greater depressive symptoms (r's = 0.37-0.50, P < .01). Better sleep quality at 6-months (HR = 0.75 [0.60, 0.95], P = .015), including sleep efficiency (HR = 0.74 [0.56, 0.99], P = .041) and sleep fragmentation (HR = 0.71 [0.53, 0.95], P = .020) were associated with lower risk of hospitalization or death. Compared with individuals without elevated depressive symptoms or sleep difficulties, individuals with either factor (HR = 1.72 [1.05, 2.81], P = .031) or both factors (HR = 2.37 [1.35, 4.18], P = .003) exhibited greater risk of clinical events in adjusted analyses. CONCLUSIONS: Sleep quality is associated with depressive symptoms among cardiothoracic transplant recipients and enhances the prognostic association between biobehavioral risk factors and clinical outcomes.

Pharmacokinetic-based failure of a detergent virucidal for SARS-COV-2 nasal infections.

The nose is the portal for SARS-CoV-2 infection, suggesting the nose as a target for topical antiviral therapies. Because detergents are virucidal, Johnson and Johnson's Baby Shampoo (J&J) was tested as a topical virucidal agent in SARS-CoV-2 infected subjects. Twice daily irrigation of J&J in hypertonic saline, hypertonic saline alone, or no intervention were compared (n = 24/group). Despite demonstrated safety and robust efficacy in in vitro virucidal assays, J&J irrigations had no impact on viral titers or symptom scores in treated subjects relative to controls. Similar findings were observed administering J&J to infected cultured human airway epithelia using protocols mimicking the clinical trial regimen. Additional studies of cultured human nasal epithelia demonstrated that lack of efficacy reflected pharmacokinetic failure, with the most virucidal J&J detergent components rapidly absorbed from nasal surfaces. This study emphasizes the need to assess the pharmacokinetic characteristics of virucidal agents on airway surfaces to guide clinical trials.

Retrospective review of the patient cases at a major trauma center in Nairobi, Kenya and implications for emergency care development.

INTRODUCTION: Low- and middle-income countries (LMICs) are continuing to experience a "triple burden" of disease - traumatic injury, non-communicable diseases (NCDs), and communicable disease with maternal and neonatal conditions (CD&Ms). The epidemiology of this triad is not well characterised and poses significant challenges to resource allocations, administration, and education of emergency care providers. The data collected in this study provide a comprehensive description of the emergency centre at Kenya's largest public tertiary care hospital. METHODS: This study is a retrospective chart review conducted at Kenyatta National Hospital of all patient encounters over a four-month period. Data were collected from financial and emergency centre triage records along with admission and mortality logbooks. Chief complaints and discharge diagnoses collected by specially trained research assistants were manually converted to standardised diagnoses using International Classification of Disease 10 (ICD-10) codes. ICD-10 codes were categorised into groups based on the ICD-10 classification system for presentation. RESULTS: A total of 23,941 patients presented to the emergency centre during the study period for an estimated annual census of 71,823. The majority of patients were aged 18-64 years (58%) with 50% of patients being male and only 3% of unknown sex. The majority of patients (61%) were treated in the emergency centre, observed, and discharged home. Admission was the next most common disposition (33%) followed by death (6%). Head injury was the overall most common diagnosis (11%) associated with admission. CONCLUSIONS: Trends toward NCDs and traumatic diseases have been described by this study and merit further investigation in both the urban and rural setting. Specifically, the significance of head injury on healthcare cost, utilisation, and patient death and disability points to the growing need of additional resources at Kenyatta National Hospital for acute care. It further demonstrates the mounting impact of trauma in Kenya and throughout the developing world.

Depressive symptoms, physical activity, and clinical events: The ADAPT prospective pilot study.

BACKGROUND: Physical inactivity and depressive symptoms following cardiothoracic transplantation are recognized as potentially modifiable psychosocial factors to improve clinical outcomes. However, few studies have prospectively assessed these in ambulatory, outpatient transplant recipients. METHODS: We conducted a prospective, single-center study examining actigraphy-assessed physical activity (PA) levels over a 1-week period in heart or lung transplant recipients recruited at 6 months (range 4-9) post-transplant. Depressive symptoms (Centers for Epidemiologic Study of Depression [CESD]), quality of life (QoL), and clinical events (transplant-related hospitalization and death) were collected. Clustered Cox proportional hazards models were used to examine the associations between PA, psychological measures, and clinical events. RESULTS: Among 105 potentially eligible participants, 66 (63%) met inclusion criteria and were enrolled between July, 2016 and May, 2017, including 42 lung and 24 heart transplant recipients. The mean age of the population was 53 years, 41% were women and 18% were black. Participants tended to be sedentary, with the majority of activity spent within the "sedentary" level (61%) and an average daily step count of 7188 (SD = 2595). In addition, participants tended to exhibit subclinical depressive symptoms, (mean CESD = 9.4 [SD = 8]) with only a subset exhibiting levels suggestive of clinical depression (22%). Over a median follow-up of 1.4 years (1.14, 1.62), 21 participants (32%) experienced at least one transplant-related hospitalization, including two deaths. In adjusted survival models, greater intensity of PA (HR = 0.45 [0.24, 0.84] per 0.2 METs, P = .012) was associated with a lower risk of clinical events, whereas greater depressive symptoms (HR = 2.11 [1.58, 2.82] per 9 CESD points, P < .001) at 6 months were associated a higher likelihood of subsequent transplant-related hospitalization and/or death. CONCLUSIONS: Physical inactivity and depressive symptoms at 6 months post-transplant were predictive of subsequent adverse clinical events among ambulatory cardiothoracic transplant recipients. Future studies should examine whether improving these potentially modifiable post-transplant risk factors improves clinical outcomes.

Retrospective review of the patient cases at a major trauma center in Nairobi, Kenya and implications for emergency care development

Introduction:Low- and middle-income countries (LMICs) are continuing to experience a "triple burden" of disease - traumatic injury, non-communicable diseases (NCDs), and communicable disease with maternal and neonatal conditions (CD&Ms). The epidemiology of this triad is not well characterised and poses significant challenges to resource allocations, administration, and education of emergency care providers. The data collected in this study provide a comprehensive description of the emergency centre at Kenya's largest public tertiary care hospital.Methods:This study is a retrospective chart review conducted at Kenyatta National Hospital of all patient encounters over a four-month period. Data were collected from financial and emergency centre triage records along with admission and mortality logbooks. Chief complaints and discharge diagnoses collected by specially trained research assistants were manually converted to standardised diagnoses using International Classification of Disease 10 (ICD-10) codes. ICD-10 codes were categorised into groups based on the ICD-10 classification system for presentation.Results:A total of 23,941 patients presented to the emergency centre during the study period for an estimated annual census of 71,823. The majority of patients were aged 18-64 years (58%) with 50% of patients being male and only 3% of unknown sex. The majority of patients (61%) were treated in the emergency centre, observed, and discharged home. Admission was the next most common disposition (33%) followed by death (6%). Head injury was the overall most common diagnosis (11%) associated with admission. Conclusions:Trends toward NCDs and traumatic diseases have been described by this study and merit further investigation in both the urban and rural setting. Specifically, the significance of head injury on healthcare cost, utilisation, and patient death and disability points to the growing need of additional resources at Kenyatta National Hospital for acute care. It further demonstrates the mounting impact of trauma in Kenya and throughout the developing world