A Model for a Structured Clinical Development Program for First-Year Residents: Utilizing the Entrance OSCE, Individualized Learning Plans (ILPs), and Peer Clinical Coaching

Identification of incoming residents’ unique strengths and weaknesses in a clinical setting is important for developing an individualized educational curriculum and ultimately addressing specific needs. This resource presents and describes materials for a clinical development program for first year residents. The program is structured around three educational elements: an entrance Objective Structured Clinical Examination (OSCE), Individualized Learning Plan (ILP), and peer clinical coaching. The included files, which describe these three elements, are intended to serve as a resource for residency directors and/or graduate medical education faculty interested in constructing a similar program. In the described clinical development program, first-year Obstetrics and Gynecology residents participated in an entrance OSCE as a component of their orientation to residency. Their performance was evaluated through Faculty and Self-assessment tools and scored on a nine-point scale in accordance with the ACGME core competency scoring evaluation system. These evaluations were utilized in the creation of ILPs. Stated goals were translated into discrete learning objectives and then developed further through a learning strategy and timeline using the SMART model. As a component of a research study, first-year residents were randomized into one of two groups: clinical coaching group or individual implementation group. Senior resident volunteers served as peer clinical coaches after participating in a two-hour interactive workshop. The peer clinical coaches met with first-year residents on a monthly basis for four months to develop the resident’s ILP. Exit questionnaires were completed at the conclusion of the year-long program. The OSCE is a well-utilized tool to ensure direct observation, evaluate clinical performance in a simulated environment, and provide timely feedback. Another potential application of the OSCE is to provide a baseline evaluation of clinical performance that may be utilized in determining a starting point for clinical competencies. Utilizing the feedback from the OSCE to create an ILP may translate valuable feedback into measurable objectives and competencies, while also providing a model for reassessment and follow up. While the OSCE and the faculty mentored ILP have been well characterized in the literature, the concept of clinical coaching is relatively novel to medicine. Teaching and coaching differ in that teachers disseminate knowledge whereas coaches ensure performance. Seeking to elaborate on this relatively novel paradigm, we sought to characterize how resident’s global clinical experience was affected within this working model. Despite time constraints, both first-year residents and peer clinical coaches reported that clinical coaching improved their clinical experience. A structured clinical program incorporating an entrance OSCE, ILP, and peer clinical coaching holds promise in documentation of milestones and promoting life-long learning. AAMC MedEdPORTAL publication ID 10084. Link to original

Tuning Nanocrystal Surface Depletion by Controlling Dopant Distribution as a Route Toward Enhanced Film Conductivity

Electron conduction through bare metal oxide nanocrystal (NC) films is hindered by surface depletion regions resulting from the presence of surface states. We control the radial dopant distribution in tin-doped indium oxide (ITO) NCs as a means to manipulate the NC depletion width. We find in films of ITO NCs of equal overall dopant concentration that those with dopant-enriched surfaces show decreased depletion width and increased conductivity. Variable temperature conductivity data shows electron localization length increases and associated depletion width decreases monotonically with increased density of dopants near the NC surface. We calculate band profiles for NCs of differing radial dopant distributions and, in agreement with variable temperature conductivity fits, find NCs with dopant-enriched surfaces have narrower depletion widths and longer localization lengths than those with dopant-enriched cores. Following amelioration of NC surface depletion by atomic layer deposition of alumina, all films of equal overall dopant concentration have similar conductivity. Variable temperature conductivity measurements on alumina-capped films indicate all films behave as granular metals. Herein, we conclude that dopant-enriched surfaces decrease the near-surface depletion region, which directly increases the electron localization length and conductivity of NC films

miRNA contributions to pediatric-onset multiple sclerosis inferred from GWAS.

ObjectiveOnset of multiple sclerosis (MS) occurs in childhood for approximately 5% of cases (pediatric MS, or ped-MS). Epigenetic influences are strongly implicated in MS pathogenesis in adults, including the contribution from microRNAs (miRNAs), small noncoding RNAs that affect gene expression by binding target gene mRNAs. Few studies have specifically examined miRNAs in ped-MS, but individuals developing MS at an early age may carry a relatively high burden of genetic risk factors, and miRNA dysregulation may therefore play a larger role in the development of ped-MS than in adult-onset MS. This study aimed to look for evidence of miRNA involvement in ped-MS pathogenesis.MethodsGWAS results from 486 ped-MS cases and 1362 controls from the U.S. Pediatric MS Network and Kaiser Permanente Northern California membership were investigated for miRNA-specific signals. First, enrichment of miRNA-target gene network signals was evaluated using MIGWAS software. Second, SNPs in miRNA genes and in target gene binding sites (miR-SNPs) were tested for association with ped-MS, and pathway analysis was performed on associated target genes.ResultsMIGWAS analysis showed that miRNA-target gene signals were enriched in GWAS (P = 0.038) and identified 39 candidate biomarker miRNA-target gene pairs, including immune and neuronal signaling genes. The miR-SNP analysis implicated dysregulation of miRNA binding to target genes in five pathways, mainly involved in immune signaling.InterpretationEvidence from GWAS suggests that miRNAs play a role in ped-MS pathogenesis by affecting immune signaling and other pathways. Candidate biomarker miRNA-target gene pairs should be further studied for diagnostic, prognostic, and/or therapeutic utility

Model of the Quark Mixing Matrix

The structure of the Cabibbo-Kobayashi-Maskawa (CKM) matrix is analyzed from the standpoint of a composite model. A model is constructed with three families of quarks, by taking tensor products of sufficient numbers of spin-1/2 representations and imagining the dominant terms in the mass matrix to arise from spin-spin interactions. Generic results then obtained include the familiar relation $|V_{us}| = (m_d/m_s)^{1/2} - (m_u/m_c)^{1/2}$, and a less frequently seen relation $|V_{cb}| = \sqrt{2} [(m_s/m_b) - (m_c/m_t)]$. The magnitudes of $V_{ub}$ and $V_{td}$ come out naturally to be of the right order. The phase in the CKM matrix can be put in by hand, but its origin remains obscure.Comment: Presented by Mihir P. Worah at DPF 92 Meeting, Fermilab, November, 1992. 3 pages, LaTeX fil

Repeat lumbar punctures in infants with meningitis in the neonatal intensive care unit

The purpose of this study is to examine the results of repeat lumbar puncture in infants with initial positive cerebrospinal fluid (CSF) cultures in order to determine the clinical characteristics and outcomes of infants with repeat positive cultures

A novel approach to modeling tissue-level activity of cortisol levels according to the theory of Endobiogeny, applied to chronic heart failure

Background: Chronic heart failure (CHF) is an inflammatory disorder in which cortisol plays an important role. Despite this, cortisol is not routinely quantitatively measured for a number of reasons. It is considered non-specific. Accuracy and validity remain in question. It is not considered convenient or cost effective. Finally, tissue level effects of cortisol do not correlate linearly to quantitative levels. If the functional, tissue level effectiveness of cortisol could be modeled, its evaluation in CHF patient may become relevant. Endobiogeny is a global systems theory that claims to be able to model complex physiology through biomarkers, offering context-rich interpretations of data for meaningful clinical applicability. Cortisol is known to alter circulating levels of elements from a complete blood count (CBC). By relating these biomarkers in a qualitative fashion, the theory of Endobiogeny posits that these elements can be contextualized to reflect the tissue level activity of cortisol, referred to as the cortisol index (CI). The algorithm derived from the theory is called the Biology of Functions (BoF). Aim: The aim of this study was to determine if the cortisol index is accurate in reflecting a greater expression of cortisol activity in ambulatory CHF patients versus controls subjects. Methods: A retrospective observational case control study was performed in 93 patients with New York Heart Association class II-III heart failure patients and 104 individuals with no cardiovascular pathology as a control group. Results from a CBC were entered into BOF modeling software, from which the cortisol index is derived. Results: The Cortisol index (3-7) was significantly elevated in CHF vs. control patients (12.8±0.91 vs. 8.48±0.74, p< 001), as were individual CBC elements used to form the index. Conclusions: The cortisol index, derived from the theory of Endobiogeny showed results consistent with CHF pathophysiology. The cortisol index was able to model the effective tissue level activity of cortisol in CHF patients using only a CBC, without measuring serum cortisol. Future studies should compare the cortisol index to standard inflammatory markers in CHF patients to further correlate the validity of the index to other known effects of cortisol

ATP-binding cassette transporter A7 enhances phagocytosis of apoptotic cells and associated ERK signaling in macrophages

The mammalian ATP-binding cassette transporters A1 and A7 (ABCA1 and -A7) show sequence similarity to CED-7, a Caenorhabditis elegans gene that mediates the clearance of apoptotic cells. Using RNA interference or gene targeting, we show that knock down of macrophage ABCA7 but not -A1 results in defective engulfment of apoptotic cells. In response to apoptotic cells, ABCA7 moves to the macrophage cell surface and colocalizes with the low-density lipoprotein receptor–related protein 1 (LRP1) in phagocytic cups. The cell surface localization of ABCA7 and LRP1 is defective in ABCA7-deficient cells. C1q is an opsonin of apoptotic cells that acts via phagocyte LRP1 to induce extracellular signal–regulated kinase (ERK) signaling. We show that ERK signaling is required for phagocytosis of apoptotic cells and that ERK phosphorylation in response to apoptotic cells or C1q is defective in ABCA7-deficient cells. These studies reveal a major role of ABCA7 and not -A1 in the clearance of apoptotic cells and therefore suggest that ABCA7 is an authentic orthologue of CED-7

Is Persistent Motor or Vocal Tic Disorder a Milder Form of Tourette Syndrome?

BACKGROUND: Persistent motor or vocal tic disorder (PMVT) has been hypothesized to be a forme fruste of Tourette syndrome (TS). Although the primary diagnostic criterion for PMVT (presence of motor or vocal tics, but not both) is clear, less is known about its clinical presentation. OBJECTIVE: The goals of this study were to compare the prevalence and number of comorbid psychiatric disorders, tic severity, age at tic onset, and family history for TS and PMVT. METHODS: We analyzed data from two independent cohorts using generalized linear equations and confirmed our findings using meta‐analyses, incorporating data from previously published literature. RESULTS: Rates of obsessive–compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) were lower in PMVT than in TS in all analyses. Other psychiatric comorbidities occurred with similar frequencies in PMVT and TS in both cohorts, although meta‐analyses suggested lower rates of most psychiatric disorders in PMVT compared with TS. ADHD and OCD increased the odds of comorbid mood, anxiety, substance use, and disruptive behaviors, and accounted for observed differences between PMVT and TS. Age of tic onset was approximately 2 years later, and tic severity was lower in PMVT than in TS. First‐degree relatives had elevated rates of TS, PMVT, OCD, and ADHD compared with population prevalences, with rates of TS equal to or greater than PMVT rates. CONCLUSIONS: Our findings support the hypothesis that PMVT and TS occur along a clinical spectrum in which TS is a more severe and PMVT a less severe manifestation of a continuous neurodevelopmental tic spectrum disorder. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Societ