A Longitudinal Assessment of Self-directed Learning Readiness and Development in Medical Students.

OBJECTIVES: Self-directed learning (SDL) competency is important for physicians to stay abreast of advances in their field and to provide the best available evidence-based care to their patients. Therefore, an essential responsibility of medical educators is to ensure the development of SDL skills in their students. The first objective of this study was to investigate longitudinally the degree to which medical students were ready to engage in SDL. The second objective was to examine students' perceptions of their SDL development throughout training. METHODS: A 2-part study of preclinical and clinical medical students was carried out at a midwestern U.S. university. In Study A, a longitudinal assessment of preclinical medical students' readiness to engage in SDL was conducted by administering an SDL readiness survey (SDLRS). In Study B, third- and fourth-year medical students were asked to reflect on their SDL development, in addition to completing the SDLRS. RESULTS: After validating the Hendry and Ginns version of the SDLRS in preclinical medical students during Study A, we found that 3 of the 4 subscales remained constant over the 3 iterations of the survey while the self-determination subscale increased significantly between the first and third iteration of the survey. In Study B, an analysis of the clinical medical students' comments indicated a perceived increase in their SDL abilities and a growing appreciation of SDL. However, the SDLRS scores of clinical students did not differ from the results observed in preclinical students in Study A. CONCLUSIONS: The results of the SDLRS indicated that the experience of students in our medical school has a positive influence on self-determination by the end of the preclinical years. Furthermore, analysis of the reflections of clinical students indicated ongoing development of SDL skills throughout their medical school training that were influenced by a wide range of experiences.

Atypia Involving Fibroadenomas: Outcomes and Upgrade Rates.

OBJECTIVE: Fibroadenomas (FAs) involved by atypia are rare. Consensus guidelines for management of FAs involved by atypia when diagnosed on image-guided biopsy do not exist because of limited data reporting surgical upgrade rates to ductal carcinoma in situ (DCIS) or invasive malignancy. Therefore, these lesions commonly undergo surgical excision. METHODS: This single-institution retrospective study identified cases of FAs involved by atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and/or lobular carcinoma in situ (LCIS) diagnosed on image-guided biopsy between January 2014 and April 2023 to determine upgrade rates. Cases with incidental atypia adjacent to but not involving FAs were excluded. RESULTS: Among 1736 FAs diagnosed on image-guided biopsy, 32 cases (1.8%) were FAs involved by atypia including 43.8% (14/32) ALH, 28.1% (9/32) ADH, 18.8% (6/32) LCIS, 6.3% (2/32) LCIS + ALH, and 3.1% (1/32) unspecified atypia. The most common imaging finding was a mass. Most cases, 81.3% (26/32), underwent subsequent surgical excisional biopsy. A single case of ADH involving and adjacent to an FA was upgraded to FA involved by low-grade DCIS on excision for an overall surgical upgrade rate of 3.8%. There were no cases upgraded to invasive malignancy. For those omitting surgical excision, there was no subsequent malignancy diagnosis at the FA biopsy site over a mean follow-up of 73 months. CONCLUSION: Cases of radiologic-pathologic concordant FAs involved by atypia have a low upgrade rate of 3.8% and should undergo multidisciplinary review. Larger multi-institutional analysis is needed to determine whether guidelines for excision of atypia should apply to atypia involving FAs.

Pregnancy-associated Breast Cancer: Why Breast Imaging During Pregnancy and Lactation Matters.

Pregnancy-associated breast cancer is characterized as breast cancer diagnosed during pregnancy, within the first postpartum year, or during lactation. It usually presents as a palpable mass, although the large majority of palpable masses during pregnancy are benign. Breast cancer is the most common invasive malignancy diagnosed during pregnancy and lactation, and its incidence is increasing as more women delay childbearing. Understanding the appropriate methods for screening and diagnostic workup of breast findings in this population is imperative for radiologists to promptly diagnose pregnancy-associated breast cancer. Use of available imaging modalities should be tailored to patient-specific factors, with US typically the first-line modality due to patient age and decreased sensitivity of mammography in the setting of lactational changes. This article illustrates the spectrum of imaging appearances of pregnancy-associated breast cancer, the appropriate diagnostic imaging workup, and the unique challenges encountered in evaluation of this patient population.

An elevational shift facilitated the Mesoamerican diversification of Azure-hooded Jays (Cyanolyca cucullata) during the Great American Biotic Interchange.

The Great American Biotic Interchange (GABI) was a key biogeographic event in the history of the Americas. The rising of the Panamanian land bridge ended the isolation of South America and ushered in a period of dispersal, mass extinction, and new community assemblages, which sparked competition, adaptation, and speciation. Diversification across many bird groups, and the elevational zonation of others, ties back to events triggered by the GABI. But the exact timing of these events is still being revealed, with recent studies suggesting a much earlier time window for faunal exchange, perhaps as early as 20 million years ago (Mya). Using a time-calibrated phylogenetic tree, we show that the jay genus Cyanolyca is emblematic of bird dispersal trends, with an early, pre-land bridge dispersal from Mesoamerica to South America 6.3-7.3 Mya, followed by a back-colonization of C. cucullata to Mesoamerica 2.3-4.8 Mya, likely after the land bridge was complete. As Cyanolyca species came into contact in Mesoamerica, they avoided competition due to a prior shift to lower elevation in the ancestor of C. cucullata. This shift allowed C. cucullata to integrate itself into the Mesoamerican highland avifauna, which our time-calibrated phylogeny suggests was already populated by higher-elevation, congeneric dwarf-jays (C. argentigula, C. pumilo, C. mirabilis, and C. nanus). The outcome of these events and fortuitous elevational zonation was that C. cucullata could continue colonizing new highland areas farther north during the Pleistocene. Resultingly, four C. cucullata lineages became isolated in allopatric, highland regions from Panama to Mexico, diverging in genetics, morphology, plumage, and vocalizations. At least two of these lineages are best described as species (C. mitrata and C. cucullata). Continued study will further document the influence of the GABI and help clarify how dispersal and vicariance shaped modern-day species assemblages in the Americas.

Emergency Critical Skills Training for Pre-clinical Physician Assistant Students: Mixed Method Comparison of Training Method.

Introduction: The fast-paced nature of physician assistant (PA) programs warrants an emphasis on high-fidelity, critical care skills training. Generally, manikins or task trainers are used for training and assessing. Soft-preserved cadavers provide a high-fidelity model to teach high-acuity, low-opportunity procedures; however, their effectiveness in PA pre-clinical training is not well understood. Objective: This study compared procedural competency of task trainer and soft-preserved cadaver trained pre-clinical PA (pcPA) students in completing tube thoracostomy, endotracheal intubation, intraosseous infusion, and needle thoracostomy. Methods: A randomized controlled study was conducted with pcPA students (n = 48) at a midwestern program. Participants were randomly assigned to cadaver trained (CT), task trainer (TT), or control group (CG). We assessed procedural competency using skill-specific rubrics and performed qualitative analysis of student comments regarding skill-specific procedural preparedness. Results: Intervention groups surpassed the control group on all skills. The CT students exhibited significantly higher procedural competency compared to TT-trained students in endotracheal intubation (p = 0.0003) and intraosseous infusion (p = 0.0041). Thematic analysis of student comments revealed pre-training students consistently felt unprepared and lacked confidence to perform needle thoracostomy, tube thoracostomy, and endotracheal intubation. Post-training perceptions, CT/TT, focused on preparedness and confidence. The CT group also consistently described the impact of realistic simulation. Conclusion: High-fidelity training with soft-preserved cadavers may be the most effective way to prepare pcPA students to perform endotracheal intubation and intraosseous infusion. Student perspectives on procedural preparedness highlight the importance of multidimensional, realistic training methods. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01575-0.

Implementation and evaluation of a self-directed learning activity for first-year medical students.

Background: It is critical that medical students develop self-directed, life-long learning skills to navigate medical school successfully and to become competent healthcare professionals. Moreover, the Liaison Committee on Medical Education (LCME), the USA medical school accrediting body, requires activities designed to help students develop self-directed learning (SDL) skills in the preclinical years.Objective: We evaluated the feasibility and effectiveness of a self-directed learning activity in a 6-week first-year medical student course.Design: The course director assigned infectious disease case studies to teams of first-year medical students who individually assessed their knowledge gaps of the case, identified scholarly sources to fill their knowledge gaps, shared the information with their teammates, and reflected on their ability to guide their own learning. Students were asked to rate workload, team effort, acquisition of new clinical knowledge, and life-long learning skills. Students were also asked to reflect on how this assignment affected their perception of their SDL skills. Descriptive statistics were used to analyze responses to the Likert scale questions. Thematic analysis was applied to the comments.Results: Survey response rate was 80% (131/163). Students strongly or moderately agreed that 1) they spent an appropriate amount of time on the project (94%), 2) the workload was evenly distributed among their teammates (95%), 3) their teammates made significant and timely contributions to the project (97%), 4) the project contributed to learning new clinical knowledge (92%), and 5) the project contributed to the acquisition of life-long learning skills (85%). The analysis team identified four themes from student reflections on their perception of their self-directed learning skills: self-learning skills, collaboration, application, and meta-cognition,Conclusions: Study results demonstrated that we successfully implemented a case-based SDL activity in a first-year medical school course and that students perceived the activity as a valuable learning experience.

Pretreatment with troglitazone decreases lethality during endotoxemia in mice.

Troglitazone is an oral antidiabetic drug that is a ligand for peroxisome proliferator activated receptor gamma (PPARgamma). Based on other studies that have implicated an immunosuppressive role for PPARgamma during inflammatory responses, we hypothesized that troglitazone treatment would improve survival in a murine model of endotoxemia and that the protective effect would be mediated by decreased expression of inflammatory mediators. C57Bl/6N x Sv/129 (wild-type [WT]) or PPARalpha null mice treated for 2 weeks with dietary troglitazone (0.1%) had significantly fewer deaths and a higher LD(50) value compared to control-fed mice when challenged with lipopolysaccharide (LPS). PPARalpha null mice were more sensitive to the lethal effects of LPS as evidenced by a 2-fold lower LD(50) (6.6 mg/kg) compared to WT mice (14.6 mg/kg). Troglitazone treatment had no significant effect on LPS-induced plasma TNF, glucose, or nitric oxide levels in WT or PPARalpha null mice at any of the time points examined. However, troglitazone treatment significantly reduced LPS-induced plasma IL-6 levels in both WT and PPARalpha null mice. The results of these studies suggest that troglitazone treatment protects mice against a lethal challenge of LPS, but whether or not this effect is mediated through decreased expression of inflammatory mediators remains unclear.

Food entrainment of circadian gene expression altered in PPARalpha-/- brown fat and heart.

The circadian clock is subject to food entrainment. Since PPARalpha exhibits a circadian expression profile, we hypothesized that PPARalpha deficiency would alter the food entrainable response of adipose, cardiac, and liver tissues. Wild-type and PPARalpha null mice were compared under ad libitum or restricted food access for the expression of circadian transcription factor-encoding mRNAs. Temporally restricted food access caused between a mean 5.8-11.5 h phase shift in the expression profiles of the circadian genes Bmal1, Per3, and Rev-erbalpha in all tissues of control mice. In contrast, these same conditions phase shifted the circadian genes in tissues of PPARalpha null mice between a mean of 10.8-14.2 h with amplitude attenuation. The food entrained phase shifts in the brown adipose and cardiac tissue circadian transcription factors of the PPARalpha null mice were prolonged significantly relative to wild-type controls. Likewise, PPARalpha responsive genes in the livers of PPARalpha null mice exhibited a significantly prolonged phase shift relative to control mice. These findings confirm and extend recent observations in the literature.