Midnight Report: A Novel Faculty-Guided Night Curriculum to Enhance Resident Nighttime Education.

OBJECTIVES: A large discrepancy exists in resident educational activities between daytime and nighttime medical rotations. The Accreditation Council for Graduate Medical Education duty-hour regulations led to the increased adoption of the dedicated nighttime rotation called night float. Nighttime education has largely been negatively perceived by night float medical residents. Although there have been attempts to improve nighttime education, none of the initiatives included faculty-guided structured night curriculum. Our objective was to improve resident experience with and perception of nighttime education by implementing a structured, faculty-guided, nighttime educational curriculum. METHODS: This was an assessment of an educational initiative at a single academic medical center, Virginia Commonwealth University Health System. The internal medicine residency program implemented a teaching nocturnist program in 2013 and a novel faculty-guided nighttime teaching curriculum in 2016 called midnight report. We then evaluated resident experience with and perception of nighttime education at our institution using anonymous free-response surveys for the academic year July 2016-June 2017. RESULTS: Of the 142 eligible residents, 95 (67%) responded to the survey. The majority of the residents (54%-77%) positively perceived their experience of the nighttime educational environment during their night float rotation after implementation of the teaching nocturnist program and midnight report. CONCLUSIONS: Compared with the published literature reporting negative perceptions of the nighttime educational environment by residents at different academic centers, our results showed that the majority of our residents positively perceived the impact of our new faculty-guided nighttime educational curriculum.

Assessment of Patient Retention of Inpatient Care Information Post-Hospitalization.

BACKGROUND: Patient understanding of medical care improves readmission rates and patient satisfaction, yet the literature suggests patients often have poor retention of care information post-hospitalization. Although multiple interventions have been implemented to facilitate this process, the cumulative durability of their benefit remains unclear. The authors conducted this study to more objectively understand how well patients retain care information after hospital discharge and to assess patient perspectives on facilitators of this process (for example, whiteboards and patient portals). METHODS: Semistructured phone interviews of patients admitted to general medicine resident teaching services were performed within 24 to 48 hours post-hospitalization. Recall of four key domains of care (diagnoses addressed, inpatient treatment, postdischarge treatment plans, and medication changes) was elicited. Chart review was performed to verify patient responses. Responses were then categorized by independent reviewers as correct, partially correct, or incorrect. Patient perspectives on facilitators to help with information retention were also assessed. RESULTS: Fifty-three patients participated. The vast majority (> 90%) were confident in their knowledge of their diagnoses and treatment, yet independent review revealed only 58.5%, 64.2%, 50.9%, and 43.4% of patients correctly recalled each respective key domain. Whiteboards were the most frequently used facilitator (96.2%), yet their content was rated least helpful for retaining care information. Patients suggested several areas for improvement, including prioritizing bedside pen and paper along with updating whiteboards with diagnostic and therapeutic information. CONCLUSION: Patient recall of their inpatient care after discharge, despite modern facilitators, remains poor. Further efforts are needed to enhance or implement facilitators based on patient feedback.

Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework.

OBJECTIVES: To apply a human factors framework to understand whether checklists reduce clinical diagnostic error have (1) gaps in composition; and (2) components that may be more likely to reduce errors. DESIGN: Systematic review. DATA SOURCES: PubMed, EMBASE, Scopus and Web of Science were searched through 15 February 2022. ELIGIBILITY CRITERIA: Any article that included a clinical checklist aimed at improving the diagnostic process. Checklists were defined as any structured guide intended to elicit additional thinking regarding diagnosis. DATA EXTRACTION AND SYNTHESIS: Two authors independently reviewed and selected articles based on eligibility criteria. Each extracted unique checklist was independently characterised according to the well-established human factors framework: Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0). If reported, checklist efficacy in reducing diagnostic error (eg, diagnostic accuracy, number of errors or any patient-related outcomes) was outlined. Risk of study bias was independently evaluated using standardised quality assessment tools in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: A total of 30 articles containing 25 unique checklists were included. Checklists were characterised within the SEIPS 2.0 framework as follows: Work Systems subcomponents of Tasks (n=13), Persons (n=2) and Internal Environment (n=3); Processes subcomponents of Cognitive (n=20) and Social and Behavioural (n=2); and Outcomes subcomponents of Professional (n=2). Other subcomponents, such as External Environment or Patient outcomes, were not addressed. Fourteen checklists examined effect on diagnostic outcomes: seven demonstrated improvement, six were without improvement and one demonstrated mixed results. Importantly, Tasks-oriented studies more often demonstrated error reduction (n=5/7) than those addressing the Cognitive process (n=4/10). CONCLUSIONS: Most diagnostic checklists incorporated few human factors components. Checklists addressing the SEIPS 2.0 Tasks subcomponent were more often associated with a reduction in diagnostic errors. Studies examining less explored subcomponents and emphasis on Tasks, rather than the Cognitive subcomponents, may be warranted to prevent diagnostic errors.

A Case of Familial Mediterranean Fever with Extensive Lymphadenopathy and Complex Heterozygous Genotype Presenting in the Fourth Decade.

Familial Mediterranean fever (FMF) is an inherited disease caused by loss of function mutations in the MEFV gene encoding pyrin, a negative regulator of interleukin-1. The disease is characterized by recurrent fever and self-limited attacks of joint, chest, and abdominal pain but lymphadenopathy is an infrequent manifestation. While mesenteric lymphadenopathy has been described in several cases in the literature; hilar, paratracheal, axillary, pelvic, and retroperitoneal lymphadenopathy are extremely rare and have been reported separately in very few individuals. In this report, we present a patient with late-onset FMF with extensive lymphadenopathy in all of the aforementioned anatomic regions. Genetic analysis identified three heterozygous pyrin mutations in a patient with no affected family members. Genetic investigation of the patient's mother identified a novel carrier haplotype E148Q/P369S. The proband also inherited the previously described and rare A744S mutation previously not thought to be a disease-defining lesion. This unique compound heterozygous genotype resulted in a novel genotype-phenotype association producing an atypical clinical presentation of FMF that fits within the pattern of several case reports of late-onset disease with respect to clinical course and therapeutic response.

Strategies to circumvent the T315I gatekeeper mutation in the Bcr-Abl tyrosine kinase.

Despite the remarkable success of imatinib against Bcr-Abl, development of secondary resistance, most often due to point mutations in the Bcr-Abl tyrosine kinase (TK) domain, is quite common. Of these, the T315I "gatekeeper" mutation is resistant to all currently registered Bcr-Abl TK inhibitors (TKIs) with the notable exception of ponatinib (Iclusig™), which was very recently approved by the United States Food and Drug Administration (FDA). Besides ponatinib, numerous strategies have been developed to circumvent this problem. These include the protein synthesis inhibitor omacetaxine (Synribo®), and "switch-control" inhibitors. Dual Bcr-Abl and aurora kinase inhibitors represent another promising strategy. Finally, several promising synergistic combinations, such as TKIs with histone deacetylase inhibitors (HDACIs), warrant attention.

The Inductive Effect of Purified Streptococcal M-protein on Immunity against Streptococcus pyogenes in Rabbit Model.

Aims: The study aimed to know the effects of the purified M-protein on immune system to produce protection against Streptococcus pyogenes in rabbits. Study Design: Case-control study. Place and Duration of Study: In this study, collection samples and bacterial identification were carried out in two hospitals; Child Protection Hospital and Central Child Hospital in Baghdad city, and experimental work was done in Department of Medical Microbiology, College of Medicine-Babylon university, Iraq. The study was done during the period between January to July 2014. Methodology: A total of 260 samples were collected from tonsillitis and pharyngitis cases. Three main parts involved in this study: the first part is bacterial diagnosis based on relied diagnostic procedures. The second part is detection of serogroup of GAS and antistreptolysin O (ASO) antibodies by using latex agglutination test, and the third part is experimental study conducted on the protective immune response against the group A streptococci using rabbit model. M-protein was purified by using Ion exchange chromatography. The rabbit models were immunized with purified M protein according to standard method. The immune response generated against the M protein was checked in an rabbit population. Results: From a total of 260 samples of tonsillitis and pharyngitis cases among children, only 8 (3.07%) isolates were identified as Streptococcus pyogenes. High amount of M-protein was detected in two isolates by indirect bacterial test. The concentration of purified M-protein ranged from 20-24.68 µg/ml. The purified M protein has important role in an induction of the immune response in experimental model. It leads to increased phagocytosis, stimulation of T-cell, and high level of antibody in serum of an immunized rabbits. Conclusion: The purified streptococcal M protein has strong antigenicity, and it has important role in an induction the strong protective immune response in experimental rabbit model. It may be used in future studies as vaccine against streptococcal infection among humans.

Prevalence of ß-hemolytic groups C and F streptococci in patients with acute pharyngitis.

BACKGROUND: The roles of group C and F streptococci in causing endemic pharyngitis are still controversial, although group C streptococci are implicated in the outbreaks of pharyngitis and associated disorders. AIM: The aim of this study was to determine the prevalence and the role of these groups of ß-hemolytic streptococci in acute pharyngitis with emphasis on the Streptococcus anginosus group. The antimicrobial susceptibility profile of these bacterial isolates and their ability to produce some virulence factors was also determined. MATERIALS AND METHODS: Throat swab specimens were collected from 177 patients suffering from acute pharyngitis who had been admitted to the Hilla Teaching Hospital, Hilla, Iraq, during October 2009 to January 2010. The necessary biochemical tests were conducted and the organisms identified using standard procedures. Susceptibility of isolates pathogens to several antibiotics was examined using standard susceptibility testing. Virulence factors of these isolates were also determined using standard methods. RESULTS: Results revealed that a total of 67 isolates belonged to ß-hemolytic streptococci, of which 11(16.4%) isolates belonged to anginosus group streptococci, which possessed Lancefield group C and F antigens. Most of these bacterial isolates have the ability to produce more than one virulence factor such as capsule, hemolysin, CFA III, and lipase enzyme. The bacterial isolates were highly resistant to ampicillin, cefotaxime, and cefepime while they exhibited moderate resistance to tetracycline, ceftriaxone, and ciprofloxacin. On the other hand, they showed a high sensitivity to vancomycin, ofloxacin, and clindamycin. CONCLUSION: This study concluded that groups C and F Streptococci were implicated as a cause of acute pharyngitis in 6.2% of the specimens among other groups of streptococci. Most of these isolates have the ability to produce more than one virulence factor. There was a high rate of resistance among isolates for ß-lactam antibiotics; however, they were highly susceptible to vancomycin, ofloxacin, and clindamycin.

Effect of Cytomegalovirus and Diabetes Mellitus on the Cytokine Profile of Cellular Immunity in Tuberculosis Patients.

Aims: This study aims to investigate the effect of cytomegalovirus (CMV) and diabetes mellitus (DM) on the cell-mediated immunity against TB represented by cytokine profile Study Design: Case control study. Place and Duration of Study: This study was carried out in Specialized Chest and Respiratory Center in Baghdad, Iraq and Department of Medical Microbiology-College of Medicine -Babylon university Hilla-Iraq, the period of study was October 2012 to January 2013. Methodology: This study was applied on 70 TB patients .It involved also 30 apparently healthy control. The patients consists of 43 males and 27 females with age range 8-76 years old, 29 of them were diabetic .Blood samples were collected from patients and controls to estimate the immune parameters interferon-gamma (IFN-γ) and interleukin - 2(IL-2 )as , and anti –CMV IgG antibodies by enzyme linked immunosorbent assay (ELISA). Results: The immune parameters showed that there is no significant difference in the mean serum concentration between the patients and control groups for IFN-γ and IL-2 (P=0.05), while there was a significant increase in the mean serum concentration of anti- CMV IgG between study groups (P≤0.001). The study also showed that there is a significant decrease in the mean serum concentration of IL-2 and IFN-γ between diabetic TB patients comparing with those nondiabetic TB patients where p values were 0.008 and 0.024 respectively. Conclusion: Both CMV and diabetes mellitus have a role in the suppression of cellular immunity in TB patients.

BabelMeSH and PICO Linguist in Arabic.

BabelMeSH is a multilanguage search for MEDLINE/PubMed. We created a database of Arabic translations of MeSH terms and other medical terms using MySQL and developed a Web interface for searching MEDLINE/PubMed in Arabic. We evaluated the accuracy of BabelMeSH using a list of medical terms from BMJ Clinical Evidence. The accuracy was 58% (machine scoring) and 65% human review.) The result obtained may be explained by variations in expressing medical terms in Arabic.