Written and Online Residency Guidebook to Improve Resident Efficiency and Knowledge of Best Patient Care Practices

**Contains time-sensitive information that will likely be inaccurate, obsolete, or irrelevant by December 01, 2018** Residents at most institutions change rotations every 2 to 4 weeks. It often takes significant time for residents to become acclimated to the different protocols, expectations, and environments of each unique rotation. As a result, residents often spend time searching for answers, time that could be spent in outside learning and direct patient care. The goal of this resource is to provide a novel guidebook that improves residents’ efficiency and knowledge of best patient care practices. The guidebook begins with an introductory chapter with key contact information that can be filled in for the user’s institution, which is followed by 16 rotation-specific chapters. A rotation-based approach was chosen as it focuses the content on the most pertinent information. Thus, trainees can quickly read a chapter to cover the most pertinent content for their current rotation. As a surrogate marker for efficiency, noon-conference attendance logs were queried to assess improvement in on-time attendance after introduction of the guidebook. After introduction of the learning resources, on-time arrival to noon conference improved for all residents and interns. Guidebook survey results were universally favorable; however, around half of respondents stated that they used the guidebook once or less per rotation. Underutilization of these resources potentially contributed to the lack of a statistically significant improvement overall. Future directions should focus on augmenting the quality and utilization of the guidebook and then reevaluating if, once well adopted, there is a sustained benefit. AAMC MedEdPORTAL publication ID 10424. Link to origina

Antibody contributes to heterosubtypic protection against influenza A-induced tachypnea in cotton rats

<p>Abstract</p> <p>Background</p> <p>Influenza virus infection or vaccination evokes an antibody response to viral hemagglutinin (HA) and neuraminidase (NA) surface glycoproteins, which results in immunity against influenza A viruses of the same HA and NA subtype. A heterosubtypic immune response that offers some protection against different influenza A subtypes has been suggested from epidemiologic studies in human influenza outbreaks, and has been induced in experimental animal models. Original studies of such cross-protection showed that cytotoxic T lymphocytes (CTL) protect H3N2-immune mice from a lethal H1N1 infection. More recent studies in mice demonstrate that antibodies also contribute to heterosubtypic immunity (HSI). We previously demonstrated that HSI in cotton rats (<it>Sigmodon hispidus</it>) is characterized by protection of H3N2-immune animals from influenza H1N1-induced increase in respiratory rate (tachypnea). Alternatively, H1N1-immune animals are protected from H3N2-induced tachypnea. The experiments described in this report were designed to elucidate the immune mechanism that prevents this very early sign of disease.</p> <p>Results</p> <p>Our results show that cotton rats provided with H1N1-immune serum prior to challenge with an H3N2 virus were protected from influenza-associated tachypnea, with the degree of protection correlating with the antibody titer transferred. Immunization with an inactivated preparation of virus delivered intramuscularly also provided some protection suggesting that CTL and/or mucosal antibody responses are not required for protection. Antibodies specific for conserved epitopes present on the virus exterior are likely to facilitate this protection since prophylactic treatment of cotton rats with anti-M2e (the extracellular domain of M2) but not anti-nucleoprotein (NP) reduced virus-induced tachypnea.</p> <p>Conclusion</p> <p>In the cotton rat model of heterosubtypic immunity, humoral immunity plays a role in protecting animals from influenza-induced tachypea. Partial protection against respiratory disease caused by different influenza A subtypes can be attained with either live virus administered intranasally or inactivated virus delivered intramuscularly suggesting that either vaccine regimen may provide some protection against potential pandemic outbreaks in humans.</p

Burden of Crohn's disease: economics and quality of life aspects in Italy.

BACKGROUND: This was a prospective observational study designed to evaluate direct and indirect costs and quality of life for patients with Crohn's disease in Italy from the perspectives of the National Health System and of society. METHODS: A total of 162 male and female subjects aged 18-70 years with Crohn's disease in the active phase and a Crohn's Disease Activity Index score ≥150 were included in the study. Subjects were recruited from 25 Italian centers on a consecutive basis. The study consisted of four visits undertaken every 6 months with a follow-up period of 18 months. The study started on September 1, 2006 and was completed on April 12, 2010. Multivariate analyses were carried out on demographic characteristics, treatment costs based on the prescribed daily dose, resource use and other cost parameters, and changes in quality of life using the EQ5D questionnaire. RESULTS: Cost of illness per subject with Crohn's disease in Italy was estimated to be €15,521 per year, with direct costs representing 76% of total costs. Nonhealth care costs and loss of productivity accounted for 24% of total costs. Societal costs during the first months of enrolment were higher compared with costs in the final months of the study. Quality of life measured by the EQ-5D was 0.558 initially and then increased to 0.739, with a mean value of 0.677 during the enrolment period. The cost of illness was not correlated with age or gender. CONCLUSION: The cost of illness was correlated with quality of life; Crohn's disease had a negative impact on subjects' quality of life, and higher costs corresponded to a lower quality of life as measured with the EQ5D. Drug treatment may improve quality of life and reduce hospitalization costs. Our results appear to be in line with the results of other international cost-of-illness studie

Virtual Coaching and Deliberate Practice to Enhance Medical Students\u27 Clinical Reasoning during Oral Case Presentations

ABSTRACT: Introduction Oral case presentations (OP) provide an opportunity for medical students to practice clinical reasoning and communication skills, and for faculty to provide assessment. Specific teaching strategies are needed to improve students’ OP skills. Objective To compare the effectiveness of Virtual Coaching (VC) to Small Group (SG) discussion or Traditional Feedback (TF/control) in improving clinical reasoning during OP, using a validated PBEAR (Problem Representation, Background Evidence, Analysis, Recommendation) tool. Design/Methods Students from two medical schools were randomly assigned to three groups during their inpatient pediatric clerkship. All completed an eLearning module about using illness scripts to promote clinical reasoning and presenting in the PBEAR format. TF/control students completed online “Aquifer” cases; VC students recorded abstracted data from the same cases with on-line faculty feedback and self-reflection; SG students attended faculty facilitated discussions of the same cases. Students were video recorded presenting pre- and post-curriculum cases. Reviewers blinded to assignment groups rated pre and post videos with the PBEAR OP tool. Results The overall score and sub-scale scores improved for all groups. VC students significantly improved in the Analysis subscale compared to SG or controls. Students rated the SG teaching sessions as more enjoyable and effective in improving their clinical reasoning and presentation skills. Conclusions A blended learning curriculum using VC significantly improved students’ clinical reasoning as assessed by the Analysis subscale

Meiotic and mitotic aneuploidies drive arrest of in vitro fertilized human preimplantation embryos

Background The high incidence of aneuploidy in early human development, arising either from errors in meiosis or postzygotic mitosis, is the primary cause of pregnancy loss, miscarriage, and stillbirth following natural conception as well as in vitro fertilization (IVF). Preimplantation genetic testing for aneuploidy (PGT-A) has confirmed the prevalence of meiotic and mitotic aneuploidies among blastocyst-stage IVF embryos that are candidates for transfer. However, only about half of normally fertilized embryos develop to the blastocyst stage in vitro, while the others arrest at cleavage to late morula or early blastocyst stages. Methods To achieve a more complete view of the impacts of aneuploidy, we applied low-coverage sequencing-based PGT-A to a large series (n = 909) of arrested embryos and trophectoderm biopsies. We then correlated observed aneuploidies with abnormalities of the first two cleavage divisions using time-lapse imaging (n = 843). Results The combined incidence of meiotic and mitotic aneuploidies was strongly associated with blastocyst morphological grading, with the proportion ranging from 20 to 90% for the highest to lowest grades, respectively. In contrast, the incidence of aneuploidy among arrested embryos was exceptionally high (94%), dominated by mitotic aneuploidies affecting multiple chromosomes. In turn, these mitotic aneuploidies were strongly associated with abnormal cleavage divisions, such that 51% of abnormally dividing embryos possessed mitotic aneuploidies compared to only 23% of normally dividing embryos. Conclusions We conclude that the combination of meiotic and mitotic aneuploidies drives arrest of human embryos in vitro, as development increasingly relies on embryonic gene expression at the blastocyst stage

The marine isotope stage 1–5 cryptotephra record of Tenaghi Philippon, Greece:Towards a detailed tephrostratigraphic framework for the Eastern Mediterranean region

The iconic climate archive of Tenaghi Philippon (TP), NE Greece, allows the study of short-term palaeoclimatic and environmental change throughout the past 1.3 Ma. To provide high-quality age control for detailed palaeoclimate reconstructions based on the TP archive, (crypto)tephra studies of a peat core ‘TP-2005’ have been carried out for the 0–130 ka interval. The results show that the TP basin is ideally positioned to receive tephra fall from both the Italian and Aegean Arc volcanic provinces. Two visible tephra layers, the Santorini Cape Riva/Y-2 (c. 22 ka) and the Campanian Ignimbrite (CI)/Y-5 (c. 39.8 ka) tephras, and six primary cryptotephra layers, namely the early Holocene E1 tephra from the Aeolian Islands (c. 8.3 ka), the Campanian Y-3 (c. 29 ka) and X-6 tephras (c. 109.5 ka), as well as counterpart tephras TM-18-1d (c. 40.4 ka), TM-23-11 (c. 92.4 ka) and TM-33-1a (c. 116.7 ka) from the Lago Grande di Monticchio sequence (southern Italy), were identified along with repeatedly redeposited Y-2 and CI tephra material. Bayesian modelling of the ages of seven of the primary tephra layers, 60 radiocarbon measurements and 20 palynological control points have been applied to markedly improve the chronology of the TP archive. This revised chronology constrains the age of tephra TM-18-1d to 40.90–41.66 cal ka BP (95.4% range). Several tephra layers identified in the TP record form important isochrons for correlating this archive with other terrestrial (e.g., Lago Grande di Monticchio, Sulmona Basin and Lake Ohrid) and marine (e.g., Adriatic Sea core PRAD 1-2 and Aegean Sea core LC21) palaeoclimate records in the Mediterranean region

CACHD1 is an α2δ-like protein that modulates CaV3 voltage-gated calcium channel activity

The putative cache (Ca2+ channel and chemotaxis receptor) domain containing 1 (CACHD1) protein has predicted structural similarities to members of the alpha2delta voltage-gated Ca2+ channel (VGCC) auxiliary subunit family. CACHD1 mRNA and protein were highly expressed in the male mammalian CNS, in particular in the thalamus, hippocampus and cerebellum, with a broadly similar tissue distribution to CaV3 subunits, in particular, CaV3.1. In expression studies, CACHD1 increased cell-surface localization of CaV3.1 and these proteins were in close proximity at the cell surface consistent with the formation of CACHD1-CaV3.1 complexes. In functional electrophysiological studies, co-expression of human CACHD1 with CaV3.1, CaV3.2 and CaV3.3 caused a significant increase in peak current density and corresponding increases in maximal conductance. By contrast, alpha2delta-1 had no effect on peak current density or maximal conductance in either CaV3.1, CaV3.2 or CaV3.3. Comparison of CACHD1-mediated increases in CaV3.1 current density and gating currents revealed an increase in channel open probability. In hippocampal neurons from male and female E19 rats, CACHD1 overexpression increased CaV3-mediated action potential (AP) firing frequency and neuronal excitability. These data suggest that CACHD1 is structurally an alpha2delta-like protein that functionally modulates CaV3 voltage-gated calcium channel activity

Randomized controlled trials in pediatric complementary and alternative medicine: Where can they be found?

BACKGROUND: The safety and effectiveness of CAM interventions are of great relevance to pediatric health care providers. The objective of this study is to identify sources of reported randomized controlled trials (RCTs) in the field of pediatric complementary and alternative medicine (CAM). METHODS: Reports of RCTs were identified by searching Medline and 12 additional bibliographic databases and by reviewing the reference lists of previously identified pediatric CAM systematic reviews. RESULTS: We identified 908 reports of RCTs that included children under 18 and investigated a CAM therapy. Since 1965, there has been a steady growth in the number of these trials that are being published. The four journals that published the most reported RCTs are The American Journal of Clinical Nutrition, Pediatrics, Journal of Pediatrics, and Lancet. Medline, CAB Health, and Embase were the best database sources for identifying these studies; they indexed 93.2%, 58.4% and 42.2 % respectively of the journals publishing reports of pediatric CAM RCTs. CONCLUSIONS: Those working or interested in the field of pediatric CAM should routinely search Medline, CAB Health and Embase for literature in the field. The four core journals identified above should be included in their collection

Comparison of airway measurements during influenza-induced tachypnea in infant and adult cotton rats

<p>Abstract</p> <p>Background</p> <p>Increased respiratory rate (tachypnea) is frequently observed as a clinical sign of influenza pneumonia in pediatric patients admitted to the hospital. We previously demonstrated that influenza infection of adult cotton rats (<it>Sigmodon hispidus</it>) also results in tachypnea and wanted to establish whether this clinical sign was observed in infected infant cotton rats. We hypothesized that age-dependent differences in lung mechanics result in differences in ventilatory characteristics following influenza infection.</p> <p>Methods</p> <p>Lung tidal volume, dynamic elastance, resistance, and pleural pressure were measured in a resistance and compliance system on mechanically-ventilated anesthestized young (14–28 day old) and adult (6–12 week old) cotton rats. Animals at the same age were infected with influenza virus, and breathing rates and other respiratory measurements were recorded using a whole body flow plethysmograph.</p> <p>Results</p> <p>Adult cotton rats had significantly greater tidal volume (TV), and lower resistance and elastance than young animals. To evaluate the impact of this increased lung capacity and stiffening on respiratory disease, young and adult animals were infected intra-nasally with influenza A/Wuhan/359/95. Both age groups had increased respiratory rate and enhanced pause (<it>Penh</it>) during infection, suggesting lower airway obstruction. However, in spite of significant tachypnea, the infant (unlike the adult) cotton rats maintained the same tidal volume, resulting in an increased minute volume. In addition, the parameters that contribute to <it>Penh </it>were different: while relaxation time between breaths and time of expiration was decreased in both age groups, a disproportionate increase in peak inspiratory and expiratory flow contributed to the increase in <it>Penh </it>in infant animals.</p> <p>Conclusion</p> <p>While respiratory rate is increased in both adult and infant influenza-infected cotton rats, the volume of air exchanged per minute (minute volume) is increased in the infant animals only. This is likely to be a consequence of greater lung elastance in the very young animals. This model replicates many respiratory features of humans and consequently may be a useful tool to investigate new strategies to treat respiratory disease in influenza-infected infants.</p

The association between socioeconomic status and traditional chinese medicine use among children in Taiwan

<p>Abstract</p> <p>Background</p> <p>Traditional Chinese medicine (TCM) utilization is common in Asian countries. Limited studies are available on the socioeconomic status (SES) associated with TCM use among the pediatric population. We report on the association between SES and TCM use among children and adolescents in Taiwan.</p> <p>Methods</p> <p>A National Health Interview Survey was conducted in Taiwan in 2001 that included 5,971 children and adolescents. We assessed the children's SES using the head of household's education, occupation and income. This information was used to calculate pediatric SES scores, which in turn were divided into quartiles. Children and adolescents who visited TCM in the past month were defined as TCM users.</p> <p>Results</p> <p>Compared to children in the second SES quartile, children in the fourth SES quartile had a higher average number of TCM visits (0.12 vs. 0.06 visits, p = 0.027) and higher TCM use prevalence (5.0% vs. 3.6%, p = 0.024) within the past month. The adjusted odds ratio (OR) for TCM use was higher for children in the fourth SES quartile than for those in the first SES quartile (OR 1.49; 95% confidence interval [CI] 1.02-2.17). The corresponding OR was 2.17 for girls (95% CI 1.24-3.78). The highest-SES girls (aged 10-18 years) were most likely to visit TCM practices (OR 2.47; 95% CI 1.25-4.90).</p> <p>Conclusions</p> <p>Children and adolescents with high SES were more likely to use TCM and especially girls aged 10-18 years. Our findings point to the high use of complementary and alternative medicine among children and adolescents.</p