Sustainability of physical exam skills in a resident-led curriculum in a large internal medicine program with competency based medical education

Background: Competency Based Medical Education (CBME) designates physical examination competency as an Entrustable Professional Activity (EPA). Considerable concern persists regarding the increased time burden CBME may place on educators. We developed a novel physical examination curriculum that shifted the burden of physical examination case preparation and performance assessment from faculty to residents. Our first objective was to determine if participation led to sustainable improvements in physical examination skills. The second objective was to determine if resident peer assessment was comparable to faculty assessment.    Methods: We selected physical exam case topics based on the Objectives of Training in the Specialty of Internal Medicine as prescribed by the Royal College of Physicians and Surgeons of Canada. Internal Medicine residents compiled evidence-based physical exam checklists that faculty reviewed before distribution to all learners. Physical exam practice sessions with whole-group demonstration followed by small-group practice sessions were performed weekly. We evaluated this pilot curriculum with a formative OSCE, during which a resident peer and a faculty member simultaneously observed and assessed examinee performance by .Results: Participation in the novel curriculum practice sessions improved OSCE performance (faculty score mean 78.96 vs. 62.50, p<0.05). Peer assessment overestimated faculty scores (76.2 vs. 65.7, p<0.001), but peer and faculty assessments were highly correlated (R2 = 0.73 (95% CI 0.50-0.87).Conclusion: This novel physical examination curriculum leads to sustainable improvement of physical examination skills. Peer assessment correlated well with the gold standard faculty assessment. This resident-led physical examination curriculum enhanced physical examination skills in a CBME environment, with minimal time commitment from faculty members

Less is more: a rationalization of daily labwork

Routine daily phlebotomy can often act as a replacement for direct patient care.  Some tests are necessary to gauge treatment response, however many are unnecessary and increase a patient’s risk of complications and can impede laboratory processing times. This study addresses the effects of providing resident trainees, who often lack an understanding of the financial impact of the tests they order, with summative feedback. This encouraged them to be resource-conscious. Internal Medicine teams were provided with weekly laboratory spending reports and this resulted in a 33% reduction in Per Person Per Day spending. No changes in mortality were noted

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience

Introduction: Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. Methods: This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. Results: All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. Conclusion: POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school

Skin examination behavior: the role of melanoma history, skin type, psychosocial factors, and region of residence in determining clinical and self-conducted skin examination

Objective: To examine the frequency and correlates of skin examination behaviors in an international sample of individuals at varying risk of developing melanoma. Design: A cross-sectional, web-based survey. Setting: Data were collected from the general population over a 20-month period on behalf of the Melanoma Genetics Consortium (GenoMEL). Participants: A total of 8178 adults from Northern (32%), Central (33%), and Southern (14%) Europe, Australia (13%), and the United States (8%). Main outcome measures: Self-reported frequency of skin self-examination (SSE) and clinical skin examination (CSE). Results: After adjustment for age and sex, frequency of skin examination was higher in both Australia (odds ratio [OR]SSE=1.80 [99% CI, 1.49-2.18]; ORCSE=2.68 [99% CI, 2.23-3.23]) and the United States (ORSSE=2.28 [99% CI, 1.76-2.94]; ORCSE=3.39 [99% CI, 2.60-4.18]) than in the 3 European regions combined. Within Europe, participants from Southern Europe reported higher rates of SSE than those in Northern Europe (ORSSE=1.61 [99% CI, 1.31-1.97]), and frequency of CSE was higher in both Central (ORCSE=1.47 [99% CI, 1.22-1.78]) and Southern Europe (ORCSE=3.46 [99% CI, 2.78, 4.31]) than in Northern Europe. Skin examination behavior also varied according to melanoma history: participants with no history of melanoma reported the lowest levels of skin examination, while participants with a previous melanoma diagnosis reported the highest levels. After adjustment for region, and taking into account the role of age, sex, skin type, and mole count, engagement in SSE and CSE was associated with a range of psychosocial factors, including perceived risk of developing melanoma; perceived benefits of, and barriers to, skin examination; perceived confidence in one's ability to engage in screening; and social norms. In addition, among those with no history of melanoma, higher cancer-related worry was associated with greater frequency of SSE. Conclusions: Given the strong association between psychosocial factors and skin examination behaviors, particularly among people with no history of melanoma, we recommend that greater attempts be made to integrate psycho-education into the fabric of public health initiatives and clinical care, with clinicians, researchers, and advocacy groups playing a key role in guiding individuals to appropriate tools and resources

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Disparities in dialysis treatment and outcomes for Dutch and Belgian children with immigrant parents

BACKGROUND: In Belgium and the Netherlands, up to 40% of the children on dialysis are children with immigrant parents of non-Western European origin (non-Western). Concerns exist regarding whether these non-Western patients receive the same quality of care as children with parents of Western European origin (Western). We compared initial dialysis, post-initial treatment, and outcomes between non-Western and Western patients on dialysis. METHODS: All children <19 years old on chronic dialysis in the Netherlands and Belgium between September 2007 and May 2011 were included in the study. Non-Western patients were defined as children of whom one or both parents were born in non-Western countries. RESULTS: Seventy-nine of the 179 included patients (44%) were non-Western children. Compared to Western patients, non-Western patients more often were treated with hemodialysis (HD) instead of peritoneal dialysis (PD) as first dialysis mode (52 vs. 37%, p = 0.046). Before renal transplantation, non-Western patients were on dialysis for a median (range) of 30 (5-99) months, vs. 15 (0-66) months in Western patients (p = 0.007). Renal osteodystrophy was diagnosed in 34% of non-Western vs. 18% of Western patients (p = 0.028). The incidence rate ratio [95% confidence interval] for acute peritonitis was 2.44 [1.43-4.17] (p = 0.032) for non-Western compared to Western patients. CONCLUSIONS: There are important disparities between children on chronic dialysis with parents from Western European origin and those from non-Western European origin in the choice of modality, duration, and outcomes of dialysis therapy

Agrobacterium tumefaciens-transient genetic transformation of Habanero pepper (Capsicum chinense Jacq.) leaf explants

Most of the pepper species of the genus Capsicum have been recalcitrant to efficient Agrobacterium tumefaciens-mediated stable or transient, genetic transformation. In the present work, we optimized a protocol for transient transformation of the Habanero pepper (Capsicum chinense Jacq.) through the standardization of several experimental factors. These included the age of the plants, the temperature, the length of co-cultivation, the application of a negative (vacuum) and/or a positive (infiltration) pressure, along with micro injection, the use of acetosyringone during the bacterial culturing, and modification of the pH during the GUS assay to eliminate the endogenous \u3b2-glucuronidase activity. The standardized protocol, which yielded nearly 55% fully transformed leaf explants, was used to successfully mobilize two empty binary vectors (pCAMBIA2301 and pCAMex), as well as the C. chinense cDNAs encoding the pathogenesis-related protein 10 and esterase, respectively

Does surrounding greenness moderate the relationship between apparent temperature and physical activity? Findings from the PHENOTYPE project

Background: Physical activity can be affected by both meteorological conditions and surrounding greenness, but few studies have evaluated the effects of these environmental factors on physical activity simultaneously. This multi-city comparative study aimed to assess the synergetic effects of apparent temperature and surrounding greenness on physical activity in four European cities. Specifically, we aimed to identify an interaction between surrounding greenness and apparent temperature in the effects on physical activity. Methods: Data were collected from 352 adult residents of Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands), and Kaunas (Lithuania) as part of the PHENOTYPE study. Participants wore a smartphone for seven consecutive days between May-December 2013 and provided additional sociodemographic survey data. Hourly average physical activity (Metabolic Equivalent of Task (MET)) and surrounding greenness (NDVI) were derived from the Calfit mobile application collecting accelerometer and location data. Hourly apparent temperature was calculated from temperature and relative humidity, which were obtained from local meteorological stations along with other meteorological covariates (rainfall, windspeed, and sky darkness). We assessed the interaction effects of apparent temperature and surrounding greenness on hourly physical activity for each city using linear mixed models, while adjusting for meteorological, demographic, and time-related variables. Results: We found significant interactions between apparent temperature and surrounding greenness on hourly physical activity in all four cities. Significant quadratic effects of apparent temperature were found in the highest level of surrounding greenness for Stoke-on-Trent and Doetinchem, with 4% decrease in median MET observed for a 10°C departure from optimal temperature (15.2°C and 14.6°C, respectively). On the other hand, significant linear effects were found for higher levels of surrounding greenness in Barcelona and Kaunas, whereby an increase of 10°C was associated with ∼4% increase in median MET. Conclusion: Apparent temperature and surrounding greenness interacted in the effect on hourly physical activity across the four European cities, with varying effect between cities. While quadratic effects of temperature suggest diminishing levels of physical activity in the highest greenness levels in cities of temperate climates, the variation in surrounding greenness between cities could be further explored, particularly by looking at indoor-outdoor locations. The study findings support the need for evidence-based physical activity promotion and urban design

Particulate matter exposure during pregnancy is associated with birth weight, but not gestational age, 1962-1992: a cohort study

<p>Abstract</p> <p>Background</p> <p>Exposure to air pollutants is suggested to adversely affect fetal growth, but the evidence remains inconsistent in relation to specific outcomes and exposure windows.</p> <p>Methods</p> <p>Using birth records from the two major maternity hospitals in Newcastle upon Tyne in northern England between 1961 and 1992, we constructed a database of all births to mothers resident within the city. Weekly black smoke exposure levels from routine data recorded at 20 air pollution monitoring stations were obtained and individual exposures were estimated via a two-stage modeling strategy, incorporating temporally and spatially varying covariates. Regression analyses, including 88,679 births, assessed potential associations between exposure to black smoke and birth weight, gestational age and birth weight standardized for gestational age and sex.</p> <p>Results</p> <p>Significant associations were seen between black smoke and both standardized and unstandardized birth weight, but not for gestational age when adjusted for potential confounders. Not all associations were linear. For an increase in whole pregnancy black smoke exposure, from the 1^st(7.4 μg/m³) to the 25^th(17.2 μg/m³), 50^th(33.8 μg/m³), 75^th(108.3 μg/m³), and 90^th(180.8 μg/m³) percentiles, the adjusted estimated decreases in birth weight were 33 g (SE 1.05), 62 g (1.63), 98 g (2.26) and 109 g (2.44) respectively. A significant interaction was observed between socio-economic deprivation and black smoke on both standardized and unstandardized birth weight with increasing effects of black smoke in reducing birth weight seen with increasing socio-economic disadvantage.</p> <p>Conclusions</p> <p>The findings of this study progress the hypothesis that the association between black smoke and birth weight may be mediated through intrauterine growth restriction. The associations between black smoke and birth weight were of the same order of magnitude as those reported for passive smoking. These findings add to the growing evidence of the harmful effects of air pollution on birth outcomes.</p