Multigenerational challenges and the future of graduate medical education

Background: Demographics are changing on a global scale. In the United States, an aging population continues to work, either by preference or because of insufficient resources to retire. Of even greater importance, a younger generation, referred to as the Millennial Generation, will soon predominate in the workforce and even now accounts for nearly 100% of resident physicians. By the year 2020, there will be 5 generations in the workplace. Methods: This paper defines and details the characteristics of the 5 generations and examines how the vision, attitudes, values, and expectations of the most recent generations will reshape the workforce and graduate medical education. Results: The need for change is imminent to educate the next generation of physicians. Among the changes necessary to adapt to the multigenerational challenges ahead are adopting mobile devices as preferred communication tools; using social networking sites to recruit residents; adding games, simulations, and interactive videos to the curriculum to engage students; breaking down departmental silos and forming learning teams that come from different specialties; developing benchmarks and milestones to measure progress; extending the social learning ecosystem beyond the resident years; embracing diversity as the norm for both practice and learning; and providing both coaching and mentoring. Conclusion: For decades, resident physicians have shown commitment, tenacity, and selflessness while shouldering the dual responsibility of patient care and the pursuit of their own education and skills development. Resident engagement has been shown to drive change in undergraduate medical education and in the learning and performance of their teachers. The latter is evidence of reverse mentoring that will be a major factor for improvement in this digital age. We have only to embrace this opportunity to the benefit of our patients, our learners, and ourselves

Evaluation of seven tumour markers in pleural fluid for the diagnosis of malignant effusions

Carcinoembryonic antigen (CEA), carbohydrate antigens 15–3, 19–9 and 72–4 (CA 15–3, CA 19–9 and CA 72–4), cytokeratin 19 fragments (CYFRA 21–1), neuron-specific enolase (NSE) and squamous cell carcinoma antigen (SCC) were evaluated in pleural fluid for the diagnosis of malignant effusions. With a specificity of 99%, determined in a series of 121 benign effusions, the best individual diagnostic sensitivities in the whole series of 215 malignant effusions or in the subgroup of adenocarcinomas were observed with CEA, CA 15–3 and CA 72–4. As expected, a high sensitivity was obtained with SCC in squamous cell carcinomas and with NSE in small-cell lung carcinomas. CYFRA and/or CA 15–3 were frequently increased in mesotheliomas. Discriminant analysis showed that the optimal combination for diagnosis of non-lymphomatous malignant effusions was CEA + CA 15–3 + CYFRA + NSE: sensitivity of 94.4% with an overall specificity of 95%. In malignant effusions with a negative cytology, 83.9% were diagnosed using this association. The association CYFRA + NSE + SCC was able to discriminate adenocarcinomas from small-cell lung cancers. Regarding their sensitivity and their complementarity, CEA, CA 15–3, CYFRA 21–1, NSE and SCC appear to be very useful to improve the diagnosis of malignant pleural effusions. © 1999 Cancer Research Campaig

Movilidad urbana y pobreza: Aprendizajes de Medellín y Soacha, Colombia

Este libro es un análisis de la experiencia de Medellín, la segunda ciudad de Colombia, en intentar reducir la pobreza e integrar en el tejido urbano barrios marginalizados y estigmatizados durante muchos años por la pobreza y la violencia. En particular, examina el impacto de dos cables aéreos que conectan densos barrios en colinas empinadas con el resto de la ciudad, y un programa de mejoramiento urbano asociado a estos. También contrasta la experiencia exitosa de Medellín con la de Soacha, un municipio adyacente a Bogotá, la capital colombiana, donde se ha propuesto un cable aéreo como medio de conexión de dos barrios en colina con una vía arteria. El contraste entre un municipio bien gestionado y abundante en recursos como Medellín con un municipio denso, homogéneamente pobre e institucionalmente débil como Soacha ofrece aprendizajes muy valiosos para otras ciudades en América Latina y otras regiones del mundo. La mayor parte de los capítulos se apoyan en un proyecto de investigación de dos años coordinado por la Development Planning Unit, University College London (UCL), en asocio con la Universidad Nacional de Colombia (sede Medellín) y la Universidad de los Andes de Bogotá. Además de estudios de caso detallados de Medellín y Soacha, el libro agrupa también casos en América Latina en donde se han construido o se han propuesto cables aéreos en barrios de bajos ingresos, como Caracas y Rio de Janeiro

Urban Mobility and Poverty: Lessons from Medellin and Soacha, Colombia

This book examines the experience of Medellín, Colombia's second largest city, in seeking to reduce poverty and integrate large marginalised areas, marked by years of severe poverty and violence, into the urban fabric. It pays particular attention to the impact of two aerial cable-cars connecting high density hilly neighbourhoods with the rest of the city, and an associated urban upgrading programme. It also contrasts Medellín’s successful experience with that of Soacha, a municipality adjacent to Bogotá, Colombia’s capital city, where an aerial cable-car has been proposed as a means of linking two low-income hilly neighbourhoods with a main arterial road. The contrast between a well-resourced, well-managed municipality like Medellín with a dense and homogenously poor and institutionally weak municipality like Soacha offers valuable lessons to other cities in Latin America and elsewhere. Contributions draw from a two-year research project coordinated by the Development Planning Unit, University College London (UCL), in conjunction with Universidad Nacional de Colombia (Medellín campus) and Universidad de los Andes in Bogotá. In addition to the detailed case studies of Medellín and Soacha, the book also brings together cases in Latin America where aerial cable-cars have either been built or proposed in low-income neighbourhoods, including Caracas and Rio de Janeiro

Pneumocystis jirovecii genotypes and granulomatous pneumocystosis

International audienceThis study describes the initial data concerning molecular typing of Pneumocystis jirovecii in a patient having developed granulomatous Pneumocystis pneumonia (PCP). Three types, B(1)a(3), B(1)a(4), B(1)b(2), were identified. All three had been described in reports concerning patients with common diffuse alveolar PCP. The present data show that identical microorganisms can be involved in both granulomatous PCP and diffuse alveolar PCP and that the pathogenesis of the granulomatous response to P. jirovecii may more likely be related to host factors. = Nous présentons les premières données concernant l'identification des génotypes de Pneumocystis jirovecii chez un patient ayant développé une pneumocystose (PPC) granulomateuse. Trois génotypes, B1a3, B1a4, B1b2, ont été identifiés. Ces génotypes sont usuellement retrouvés dans la forme classique alvéolaire de la PPC. Ces résultats montrent que des micro-organismes identiques peuvent être impliqués dans ces deux formes histologiques de la PPC et suggèrent que l'étiologie de la réaction granulomateuse se rapporterait plutôt à des facteurs liés aux patients

Critical steps during the prilling process of molten lipids: Main stumbling blocks due to pharmaceutical excipient properties

International audiencePrilling by ultrasonic jet break-up is an efficient process to produce perfectly spherical microparticles homogeneous in size. However, the material properties could affect the manufacturability and the final product properties especially with lipid-based excipients which often exhibit complex structural properties. This work presents the characterisation of six lipid-based excipients differing by their melting point and polymorphic behaviour which were used to produce microspheres using a pilot-scale prilling equipment. The experimental results were compared to theoretical calculations, especially the droplet solidification time which is a keyparameter for this process. This work highlighted that monotropic polymorphism of excipients and supercooling effect have a significant impact on process parameters which should be considered with care during formulation design

Effect of Osteopathic Manipulative Treatment vs Sham Treatment on Activity Limitations in Patients With Nonspecific Subacute and Chronic Low Back Pain: A Randomized Clinical Trial.

Osteopathic manipulative treatment (OMT) is frequently offered to people with nonspecific low back pain (LBP) but never compared with sham OMT for reducing LBP-specific activity limitations. To compare the efficacy of standard OMT vs sham OMT for reducing LBP-specific activity limitations at 3 months in persons with nonspecific subacute or chronic LBP. This prospective, parallel-group, single-blind, single-center, sham-controlled randomized clinical trial recruited participants with nonspecific subacute or chronic LBP from a tertiary care center in France starting February 17, 2014, with follow-up completed on October 23, 2017. Participants were randomly allocated to interventions in a 1:1 ratio. Data were analyzed from March 22, 2018, to December 5, 2018. Six sessions (1 every 2 weeks) of standard OMT or sham OMT delivered by nonphysician, nonphysiotherapist osteopathic practitioners. The primary end point was mean reduction in LBP-specific activity limitations at 3 months as measured by the self-administered Quebec Back Pain Disability Index (score range, 0-100). Secondary outcomes were mean reduction in LBP-specific activity limitations; mean changes in pain and health-related quality of life; number and duration of sick leaves, as well as number of LBP episodes at 12 months; and consumption of analgesics and nonsteroidal anti-inflammatory drugs at 3 and 12 months. Adverse events were self-reported at 3, 6, and 12 months. Overall, 200 participants were randomly allocated to standard OMT and 200 to sham OMT, with 197 analyzed in each group; the median (range) age at inclusion was 49.8 (40.7-55.8) years, 235 of 394 (59.6%) participants were women, and 359 of 393 (91.3%) were currently working. The mean (SD) duration of the current LBP episode was 7.5 (14.2) months. Overall, 164 (83.2%) patients in the standard OMT group and 159 (80.7%) patients in the sham OMT group had the primary outcome data available at 3 months. The mean (SD) Quebec Back Pain Disability Index scores for the standard OMT group were 31.5 (14.1) at baseline and 25.3 (15.3) at 3 months, and in the sham OMT group were 27.2 (14.8) at baseline and 26.1 (15.1) at 3 months. The mean reduction in LBP-specific activity limitations at 3 months was -4.7 (95% CI, -6.6 to -2.8) and -1.3 (95% CI, -3.3 to 0.6) for the standard OMT and sham OMT groups, respectively (mean difference, -3.4; 95% CI, -6.0 to -0.7; P = .01). At 12 months, the mean difference in mean reduction in LBP-specific activity limitations was -4.3 (95% CI, -7.6 to -1.0; P = .01), and at 3 and 12 months, the mean difference in mean reduction in pain was -1.0 (95% CI, -5.5 to 3.5; P = .66) and -2.0 (95% CI, -7.2 to 3.3; P = .47), respectively. There were no statistically significant differences in other secondary outcomes. Four and 8 serious adverse events were self-reported in the standard OMT and sham OMT groups, respectively, though none was considered related to OMT. In this randomized clinical trial of patients with nonspecific subacute or chronic LBP, standard OMT had a small effect on LBP-specific activity limitations vs sham OMT. However, the clinical relevance of this effect is questionable. ClinicalTrials.gov Identifier: NCT02034864

The SNARE Sec22b has a non-fusogenic function in plasma membrane expansion.

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