Twelve Tips to Succeed as Health Profession Clinical Educator in Resource-Limited Settings.

Health professions education is one of the pillars of academic medicine; however, clinical educators often lack the appropriate resources to succeed in this field. Examples of these challenges include: lack of support for faculty development, mentorship, and high cost of resources, when available. In addition, challenges such as the Coronavirus disease (COVID-19) pandemic can affect healthcare personnel who are already struggling to provide adequate patient care while attempting to succeed in the role of educator and supervisor of trainees. Clinical educators face more challenges particularly in low-middle income countries as the limitations are more prominent and become key barriers to success. Similarly, due to COVID-19, these challenges can be far more evident in disadvantaged geographical, economic, and academic environments even in the United States. Herein, in this perspective paper, we define resource-limited settings in medical education, provide an overview of the most common barriers to career development as a clinical educator, and offer practical strategies to overcome some of these shortcomings.

Institutional Structures and Processes to Support Sepsis Care: A Multihospital Study.

OBJECTIVES: To identify opportunities for improving hospital-based sepsis care and to inform an ongoing statewide quality improvement initiative in Michigan. DESIGN: Surveys on hospital sepsis processes, including a self-assessment of practices using a 3-point Likert scale, were administered to 51 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan, at two time points (2020, 2022). Forty-eight hospitals also submitted sepsis protocols for structured review. SETTING: Multicenter quality improvement consortium. SUBJECTS: Fifty-one hospitals in Michigan. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the included hospitals, 92.2% (n = 47/51) were nonprofit, 88.2% (n = 45/51) urban, 11.8% (n = 6/51) rural, and 80.4% (n = 41/51) teaching hospitals. One hundred percent (n = 51/51) responded to the survey, and 94.1% (n = 48/51) provided a sepsis policy/protocol. All surveyed hospitals used at least one quality improvement approach, including audit/feedback (98.0%, n = 50/51) and/or clinician education (68.6%, n = 35/51). Protocols included the Sepsis-1 (18.8%, n = 9/48) or Sepsis-2 (31.3%, n = 15/48) definitions; none (n = 0/48) used Sepsis-3. All hospitals (n = 51/51) used at least one process to facilitate rapid sepsis treatment, including order sets (96.1%, n = 49/51) and/or stocking of commonly used antibiotics in at least one clinical setting (92.2%, n = 47/51). Treatment protocols included guidance on antimicrobial therapy (68.8%, n = 33/48), fluid resuscitation (70.8%, n = 34/48), and vasopressor administration (62.5%, n = 30/48). On self-assessment, hospitals reported the lowest scores for peridischarge practices, including screening for cognitive impairment (2.0%, n = 1/51 responded "we are good at this") and providing anticipatory guidance (3.9%, n = 2/51). There were no meaningful associations of the Centers for Medicare and Medicaid Services' Severe Sepsis and Septic Shock: Management Bundle performance with differences in hospital characteristics or sepsis policy document characteristics. CONCLUSIONS: Most hospitals used audit/feedback, order sets, and clinician education to facilitate sepsis care. Hospitals did not consistently incorporate organ dysfunction criteria into sepsis definitions. Existing processes focused on early recognition and treatment rather than recovery-based practices.

A Predictive Model for Acute Respiratory Distress Syndrome Mortality Using Red Cell Distribution Width.

METHODS: This observational retrospective cohort study includes 318 ARDS patients extracted from an ICU database between the years of 2001 and 2008. Clinical factors including age, gender, comorbidity score, Sequential Organ Failure Assessment (SOFA) score, and PaO2/FiO2 ratio were chosen for the base model to predict ICU mortality. The RDW value at the time of ARDS diagnosis was added to the base model to determine if it improved its predictive ability. RESULTS: 318 subjects were included; 113 (36%) died in the ICU. AUC for the base model without RDW was 0.76, and 0.78 following the addition of RDW [p=0.048]. The NRI was 0.46 (p=0.001), indicating that, in 46% of patients, the predictive probability of the model was improved by the inclusion of RDW. CONCLUSIONS: Adding RDW at time of ARDS diagnosis improved discrimination in a model using 4 clinical factors to predict ICU mortality.

A Chronic Fatigue Syndrome (CFS) severity score based on case designation criteria.

BACKGROUND: Chronic Fatigue Syndrome case designation criteria are scored as physicians' subjective, nominal interpretations of patient fatigue, pain (headaches, myalgia, arthralgia, sore throat and lymph nodes), cognitive dysfunction, sleep and exertional exhaustion. METHODS: Subjects self-reported symptoms using an anchored ordinal scale of 0 (no symptom), 1 (trivial complaints), 2 (mild), 3 (moderate), and 4 (severe). Fatigue of 3 or 4 distinguished "Fatigued" from "Not Fatigued" subjects. The sum of the 8(Sum8) ancillary criteria was tested as a proxy for fatigue. All subjects had history and physical examinations to exclude medical fatigue, and ensure categorization as healthy or CFS subjects. RESULTS: Fatigued subjects were divided into CFS with ≥4 symptoms or Chronic Idiopathic Fatigue (CIF) with ≤3 symptoms. ROC of Sum8 for CFS and Not Fatigued subjects generated a threshold of 14 (specificity=0.934; sensitivity=0.928). CFS (n=256) and CIF (n=55) criteria were refined to include Sum8≥14 and ≤13, respectively. Not Fatigued subjects had highly skewed Sum8 responses. Healthy Controls (HC; n=269) were defined by fatigue≤2 and Sum8≤13. Those with Sum8≥14 were defined as CFS-Like With Insufficient Fatigue Syndrome (CFSLWIFS; n=20). Sum8 and Fatigue were highly correlated (R(2)=0.977; Cronbach's alpha=0.924) indicating an intimate relationship between symptom constructs. Cluster analysis suggested 4 clades each in CFS and HC. Translational utility was inferred from the clustering of proteomics from cerebrospinal fluid. CONCLUSIONS: Plotting Fatigue severity versus Sum8 produced an internally consistent classifying system. This is a necessary step for translating symptom profiles into fatigue phenotypes and their pathophysiological mechanisms.

Dyspnea in Chronic Fatigue Syndrome (CFS): comparison of two prospective cross-sectional studies.

Chronic Fatigue Syndrome (CFS) subjects have many systemic complaints including shortness of breath. Dyspnea was compared in two CFS and control cohorts to characterize pathophysiology. Cohort 1 of 257 CFS and 456 control subjects were compared using the Medical Research Council chronic Dyspnea Scale (MRC Score; range 0-5). Cohort 2 of 106 CFS and 90 controls answered a Dyspnea Severity Score (range 0-20) adapted from the MRC Score. Subsets of both cohorts completed CFS Severity Scores, fatigue, and other questionnaires. A subset had pulmonary function and total lung capacity measurements. Results show MRC Scores were equivalent between sexes in Cohort 1 CFS (1.92 [1.72-2.16]; mean [95% C.I.]) and controls (0.31 [0.23-0.39]; p<0.0001). Receiver-operator curves identified 2 as the threshold for positive MRC Scores in Cohort 1. This indicated 54% of CFS, but only 3% of controls, had significant dyspnea. In Cohort 2, Dyspnea Score threshold of 4 indicated shortness of breath in 67% of CFS and 23% of controls. Cohort 2 Dyspnea Scores were higher for CFS (7.80 [6.60-9.00]) than controls (2.40 [1.60-3.20]; p<0.0001). CFS had significantly worse fatigue and other complaints compared to controls. Pulmonary function was normal in CFS, but Borg scores and sensations of chest pain and dizziness were significantly greater during testing than controls. General linear model of Cohort 2 CFS responses linked Dyspnea with rapid heart rate, chest pain and dizziness. In conclusion, sensory hypersensitivity without airflow limitation contributed to dyspnea in CFS. Correlates of dyspnea in controls were distinct from CFS suggesting different mechanisms.

Effect of fluticasone furoate on interleukin 6 secretion from adenoid tissues in children with obstructive sleep apnea.

OBJECTIVE: To determine the effect of intranasal corticosteroid therapy on T-regulatory cells and other inflammatory cytokines in adenoid tissues in children with obstructive sleep apnea syndrome. DESIGN: Randomized, prospective, exploratory study. SETTING: Academic pediatric otolaryngology practice in a tertiary care children's hospital. PATIENTS: Participants included 24 children between the ages of 2 and 12 years who were undergoing adenotonsillectomy for polysomnogram-documented obstructive sleep apnea syndrome. INTERVENTION: Children were randomized to either no treatment (n = 13) or treatment with fluticasone furoate nasal spray, 55 µg/nostril daily (n = 11), for 2 weeks before adenotonsillectomy. Adenoid tissue was obtained at the time of the procedure. MAIN OUTCOME MEASURES: The number of tissue T-regulatory cells, as determined by staining with FOXP3, CD4, and CD25, was the primary outcome measure. Staining for interleukin (IL)-10 and transforming growth factor-ß protein by immunohistochemistry, and adenoid mononuclear cell spontaneous and induced release of cytokines (IL-10, IL-6, IL-12, IL-13, tumor necrosis factor, and transforming growth factor ß) were secondary outcomes. RESULTS: Cells isolated from fluticasone furoate nasal spray-treated adenoid tissue released significantly less IL-6 spontaneously as well as upon stimulation with anti-CD3 monoclonal antibody (P = .05) compared with nontreated adenoid tissue. There were no significant differences in the number of CD4/FOXP3-, CD25/FOXP3-, or transforming growth factor ß-positive cells. Intensity of staining for IL-10 was also comparable between the groups. CONCLUSIONS: In this study, we show reduction of IL-6, a proinflammatory cytokine, in adenoid tissue obtained from children with obstructive sleep apnea syndrome treated with fluticasone furoate nasal spray. This reduction could contribute to the clinical efficacy of this class of medications in the treatment of childhood obstructive sleep apnea syndrome.

Effect of the addition of montelukast to fluticasone propionate for the treatment of perennial allergic rhinitis.

BACKGROUND: Guidelines for the treatment of patients with allergic rhinitis (AR) recommend intranasal corticosteroids as first-line therapy. In clinical trials, however, only 50% of patients obtain excellent symptom control. OBJECTIVE: To evaluate the effectiveness of montelukast add-on therapy in patients with perennial AR (PAR) who have incomplete relief of symptoms after 2 weeks of treatment with intranasal fluticasone propionate. METHODS: We performed a 4-week parallel, randomized, double-blind, placebo-controlled trial. One hundred two patients with a history of PAR and a positive skin test reaction to perennial allergens were recruited. They completed the Rhinitis Quality of Life Questionnaire (RQLQ) and were given intranasal fluticasone propionate, 200 microg daily. They were asked to complete symptom diary cards twice daily. After 2 weeks of treatment, patients with a mean total nasal symptom score of at least 4 during the past week (n = 54) were randomized to receive either montelukast (n = 28) or placebo (n = 26) in addition to the continued use of fluticasone propionate. At weeks 3 and 4, the RQLQ was completed again and symptom diary cards were collected. RESULTS: Compared with baseline, there were significant improvements in almost all domains of the RQLQ while taking fluticasone propionate (P < .001). A similar trend was observed for nasal symptom scores. After randomization to receive montelukast or placebo, there were no significant differences in RQLQ measures or nasal symptom scores between the groups during the 2 weeks of combination therapy. CONCLUSION: The addition of montelukast to an intranasal corticosteroid for the treatment of PAR with residual symptoms is no more effective than is placebo.

Vitamin D levels in children undergoing adenotonsillectomies.

OBJECTIVE: Because of the recent data supporting an immunoregulatory role for vitamin D, we evaluated levels of vitamin D in children undergoing adenotonsillectomies (T&A) and controls. METHODS: We prospectively collected data from 47 children undergoing T&As and 15 undergoing unrelated elective procedures at a tertiary care children's hospital. Demographic and disease specific data was obtained in addition to a blood sample for the measurement of 25-hydroxy (OH)-vitamin D. RESULTS: There were no differences in vitamin D levels between the groups and levels did not correlate to any disease parameters in the children undergoing T&A. The only significant differences were related to race in that African American children had significantly lower vitamin D levels compared to Caucasians. CONCLUSION: This pilot study did not show an association between serum vitamin D and the need to have adenotonsillectomy.