Investing in the Future: A Premedical Surgical Elective for Undergraduate Students.

BACKGROUND: Research has shown that providing surgical exposure and mentorship before clerkship can bolster interest and cultivate quality surgical residents. However, most studies have focused exclusively on programs for 1st and 2nd year medical students. The purpose of this study is to describe a novel undergraduate premedical surgical elective (PMSE) and the interests and perceptions of PMSE participants of the surgical field. METHODS: Undergraduate students applied for a semester long PMSE that included surgical shadowing, mentorship, a research component, attendance at seminars, and hands-on workshops. Post-PMSE completion, participants were invited to complete an online survey about their perceptions of pursuing a career in surgery and their specialties of interest. RESULTS: Thirty-six PMSE participants completed the survey (21 females and 15 males). More than half (57%) of female respondents expressed interest in a surgical career. Most respondents (78%) agreed or strongly agreed that they are confident in their ability to become a surgeon. A lower proportion of female respondents (33%) believed the atmosphere of the surgical field to be inclusive than males (53%). Males accumulated significantly more surgical shadowing hours than females (P < .05). DISCUSSION: Findings from this study describe a novel PMSE at a large undergraduate institution. Survey data of PMSE participants revealed a high proportion of female respondents would like to pursue a career in surgery and reported confidence in achieving this. However, females perceived the field to be less inclusive than male respondents. Improving inclusivity may require increased focus and attention by PMSEs and surgical education programs.

Refractory Adult-onset Still's Disease Treated with a Combination of Methotrexate and Etanercept.

BACKGROUND: Adult-onset Still's disease (AOSD) is a challenging diagnosis because of the variability in clinical presentation and lack of gold-standard diagnostic investigations. Even after diagnosis, the treatment is challenging, especially when the disease is refractory to first-line therapy. Multiple pharmacotherapeutic options exist for refractory AOSD, but treatment failures still occur. Etanercept, a Tumor necrosis factor (TNF)-alpha inhibitor, is one of the options that has been rarely used for refractory AOSD, with various outcomes ranging from no response to complete remission. CASE PRESENTATION: In this case, we highlight how a previously healthy lady had refractory AOSD to glucocorticoids, methotrexate, and hydroxychloroquine combination therapy. There was no response to interleukin (IL)-1 therapy, which necessitated a switch to a combination of etanercept, low-dose methotrexate, and low-dose glucocorticoids with complete remission for a total of three- -year follow-up. CONCLUSION: The combination of methotrexate and Etanercept can maintain remission in patients with refractory AOSD.

Longitudinal Studies of Wearables in Patients with Diabetes: Key Issues and Solutions.

Glucose monitoring is key to the management of diabetes mellitus to maintain optimal glucose control whilst avoiding hypoglycemia. Non-invasive continuous glucose monitoring techniques have evolved considerably to replace finger prick testing, but still require sensor insertion. Physiological variables, such as heart rate and pulse pressure, change with blood glucose, especially during hypoglycemia, and could be used to predict hypoglycemia. To validate this approach, clinical studies that contemporaneously acquire physiological and continuous glucose variables are required. In this work, we provide insights from a clinical study undertaken to study the relationship between physiological variables obtained from a number of wearables and glucose levels. The clinical study included three screening tests to assess neuropathy and acquired data using wearable devices from 60 participants for four days. We highlight the challenges and provide recommendations to mitigate issues that may impact the validity of data capture to enable a valid interpretation of the outcomes.

Cardiovascular autonomic neuropathy is associated with increased glycemic variability driven by hyperglycemia rather than hypoglycemia in patients with diabetes.

AIM: Cardiac autonomic neuropathy (CAN) has been suggested to be associated with hypoglycemia and impaired hypoglycemia unawareness. We have assessed the relationship between CAN and extensive measures of glucose variability (GV) in patients with type 1 and type 2 diabetes. METHODS: Participants with diabetes underwent continuous glucose monitoring (CGM) to obtain measures of GV and the extent of hyperglycemia and hypoglycemia and cardiovascular autonomic reflex testing. RESULTS: Of the 40 participants (20 T1DM and 20 T2DM) (aged 40.70 ± 13.73 years, diabetes duration 14.43 ± 7.35 years, HbA1c 8.85 ± 1.70%), 23 (57.5%) had CAN. Despite a lower coefficient of variation (CV) (31.26 ± 11.87 vs. 40.33 ± 11.03, P = 0.018), they had a higher CONGA (8.42 ± 2.58 vs. 6.68 ± 1.88, P = 0.024) with a lower median LBGI (1.60 (range: 0.20-3.50) vs. 4.90 (range: 3.20-7.40), P = 0.010) and percentage median time spent in hypoglycemia (4 (range:4-13) vs. 1 (range:0-5), P = 0.008), compared to those without CAN. The percentage GRADEEuglycemia (3.30 ± 2.78 vs. 5.69 ± 3.09, P = 0.017) and GRADEHypoglycemia (0.3 (range: 0 - 3.80) vs. 1.8 (range: 0.9-6.5), P = 0.036) were significantly lower, while the percentage median GRADEHyperglycemia (95.45 (range:93-98) vs. 91.6 (82.8-95.1), P = 0.013) was significantly higher in participants with CAN compared to those without CAN. CONCLUSION: CAN was associated with increased glycemic variability with less time in euglycemia attributed to a greater time in hyperglycemia but not hypoglycemia.

Safety Monitoring Activity During EGFR or Anaplastic Lymphoma Kinase Inhibitor Therapy for Patients With Lung Cancer.

Epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) are highly effective for treatment of EGFR- or ALK-mutated lung cancer. Nevertheless, they are associated with several unique toxicities. Although the available US Food and Drug Administration (FDA)-approved drug label can provide guidance for safety monitoring, its integration into clinical practice has not been previously described. We studied the conduct of safety monitoring activity (SMA) at a large academic institution. On the basis of FDA-approved drug labels, two drug-specific SMAs were identified for osimertinib, crizotinib, alectinib, or lorlatinib. Electronic medical records of patients initiated on these drugs from 2017 to 2021 were retrospectively reviewed. Each course of treatment was evaluated for the occurrence of SMAs and the corresponding adverse events. Analyses included 130 treatment courses from 111 unique patients. For each SMA evaluated, the prevalence of SMA conduct ranged from 10.0% to 84.6%. The most frequently conducted SMA was ECG for lorlatinib therapy and the least was creatine phosphokinase analysis for alectinib. We observed none of the assessed SMAs being conducted in 41 treatment courses (31.5%). EGFR inhibitor predicted a higher likelihood of both SMAs being conducted than ALK inhibitors (P = .02). Serious, grade 3 or 4 adverse events were observed in 21 treatment courses (16.2%), including one grade 4 transaminitis related to alectinib. On the basis of our experience, the conduct of SMA was more challenging to implement for ALK inhibitor than for EGFR inhibitor. Clinicians should be vigilant and review the FDA-approved drug label before prescribing.

Amivantamab for Metastatic Lung Cancer With Paraneoplastic Disseminated Intravascular Coagulation: A Case Report.

Advanced cancers may be accompanied by paraneoplastic disseminated intravascular coagulation (DIC), resulting in thromboembolism or thrombocytopenia. Thrombocytopenia can limit the feasibility of myelosuppressive chemotherapy. Therefore, an alternative treatment option is needed. This report described a patient with metastatic pulmonary adenocarcinoma with EGFR exon 20 insertion and paraneoplastic DIC. Frontline chemotherapy failed to control the disease and worsened thrombocytopenia. However, treatment with amivantamab resulted in a rapid resolution of DIC and produced a partial tumor response. Based on our experience, for patients with EGFR exon 20 insertions with paraneoplastic DIC, amivantamab could be considered a preferred frontline treatment.

Continuous glucose monitoring reveals a novel association between duration and severity of hypoglycemia, and small nerve fiber injury in patients with diabetes.

Objective: Continuous glucose monitoring (CGM) has revealed that glycemic variability and low time in range are associated with albuminuria and retinopathy. We have investigated the relationship between glucose metrics derived from CGM and a highly sensitive measure of neuropathy using corneal confocal microscopy in participants with type 1 and type 2 diabetes. Methods: A total of 40 participants with diabetes and 28 healthy controls underwent quantification of corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL) and inferior whorl length (IWL) and those with diabetes underwent CGM for four consecutive days. Results: CNBD was significantly lower in patients with high glycemic variability (GV) compared to low GV (median (range) (25.0 (19.0-37.5) vs 38.6 (29.2-46.9); P = 0.007); in patients who spent >4% compared to <4% time in level 1 hypoglycemia (54-69 mg/dL) (25.0 (22.9-37.5) vs 37.5 (29.2-46.9); P = 0.045) and in patients who spent >1% compared to <1% time in level 2 hypoglycemia (<54 mg/dL) (25.0 (19.8-41.7) vs 35.4 (28.1-44.8); P = 0.04). Duration in level 1 hypoglycemia correlated with CNBD (r = -0.342, P = 0.031). Duration in level 1 (181-250 mg/dL) and level 2 (>250 mg/dL) hyperglycemia did not correlate with CNFD (P > 0.05), CNBD (P > 0.05), CNFL (P > 0.05) or IWL (P > 0.05). Conclusions: Greater GV and duration in hypoglycemia, rather than hyperglycemia, are associated with nerve fiber loss in diabetes.

Sense and Learn: Recent Advances in Wearable Sensing and Machine Learning for Blood Glucose Monitoring and Trend-Detection.

Diabetes mellitus is characterized by elevated blood glucose levels, however patients with diabetes may also develop hypoglycemia due to treatment. There is an increasing demand for non-invasive blood glucose monitoring and trends detection amongst people with diabetes and healthy individuals, especially athletes. Wearable devices and non-invasive sensors for blood glucose monitoring have witnessed considerable advances. This review is an update on recent contributions utilizing novel sensing technologies over the past five years which include electrocardiogram, electromagnetic, bioimpedance, photoplethysmography, and acceleration measures as well as bodily fluid glucose sensors to monitor glucose and trend detection. We also review methods that use machine learning algorithms to predict blood glucose trends, especially for high risk events such as hypoglycemia. Convolutional and recurrent neural networks, support vector machines, and decision trees are examples of such machine learning algorithms. Finally, we address the key limitations and challenges of these studies and provide recommendations for future work.

Dataset for influence of visual and haptic feedback on the detection of threshold forces in a surgical grasping task.

The data is related to minimal force thresholds perception in robotic surgical grasping applications. The experimental setup included an indenter-based haptic device acting on the fingertip of a participant and a visual system that displays grasping tasks by a surgical grasper. The experiments included the display of two presentations at different force levels (i.e., grasping and indentation) in three different modes, namely, visual-alone, haptic-alone, and bimodal (i.e., combined). For each mode, the participants were asked to identify which of the two presentations was higher. Each experiment was repeated till the termination conditions were met. Sixty participants took part in these experiments. The experiments were randomized and the threshold forces were calculated based on an algorthim. The datasets contain the individual responses of each participant, the threshold forces calculations, and the number of iterations.

Datasets for recognition of aggressive interactions of children toward robotic toys.

The data is related to unwanted interactions between a person and a small robotic toy based on acceleration sensor embedded within the robotic toy. Three toys were considered namely, a stuffed panda, a stuffed robot, and an excavator. Each toy was embedded with an accelerometer to record the interactions. Five different unwanted interactions were performed by adult participants and children. The considered interactions were hit, shake, throw, pickup, drop, and idle for the no interaction case. The collected data contains the magnitude of the resultant acceleration from the interactions. The data was processed by extracting the instances of interactions. A secondary dataset was created from the original one by creating artificial sequences. This data article contains the processed data that can be used to explore different machine learning models and techniques in classifying such interactions. Online repository contains the files: https://doi.org/10.7910/DVN/FHOO0Q.

Data on the impact of an object with different thicknesses of different soft materials at different impact velocities on a dummy head.

The purpose of this data is to investigate the effect of different thicknesses of different soft materials samples added to an object on the resultant head acceleration of a developed dummy head upon impact. The object was a cylinder (10 × 10 cm2, diameter and height) and weighs 0.4 kg. The investigated materials were Ecoflex, Dragon Skin, and Clay while the thickness were 1 mm, 2 mm, 3 mm, and 5 mm. The velocities of the impacts for the 108 experiments were between 1 m/s and 3 m/s. Three severity indices (i.e. peak head linear acceleration, 3 ms criterion and the Head Injury Criterion (HIC)) were calculated from the raw acceleration data. The impact velocities were tabulated from the video recordings. A summary of the processed data and the raw data are included in this dataset. Online repository contains the files: https://doi.org/10.7910/DVN/TXOPUH.

Data on the impact of objects with different shapes, masses, and impact velocities on a dummy head.

In this article, a data generated from impacts of objects with different shapes, masses, and impact velocities on a developed dummy head. The mass considered was in the range of 0.3-0.5 kg while the shapes considered were cube, wedge, and cylinder. The impact velocities levels were in the range of 1-3 m/s. A total of 144 experiments were conducted and the corresponding videos and raw data were analyzed for impact velocity, peak head linear acceleration, 3 ms criterion, and the Head Injury Criterion (HIC). This dataset includes the raw acceleration data and a summary of the overall processed data. The data is available on Harvard Dataverse: https://doi.org/10.7910/DVN/AVC8GG.

Disruption of symmetry: A quantitative assessment of facial skeleton anatomy in children born with unilateral cleft lip and palate.

Unilateral cleft lip and palate (UCLP) is a craniofacial deformity characterized by lip and palate clefting on one side of the face. UCLP originates from failures in neural crest migration and differentiation during embryological development, impairing facial primordia fusion (medial nasal, maxillary, and lateral processes) resulting in clefting. Persons with UCLP experience issues in nasal breathing, speaking, and mastication. Facial directional asymmetry (DA), consisting of left-right side differences biased toward one particular side, can arise from environmental or hereditary factors. This retrospective, cross-sectional study, quantifies DA in the facial skeleton of children with surgically repaired UCLP. We tested the hypothesis that DA is significantly increased in persons with UCLP. Twenty-three anatomical landmark coordinates were measured from cone beam computed tomography images of two age- and sex-matched samples: (1) persons with UCLP post-surgery (n = 26, 7-17 years); (2) typical children (n = 26, 7-17 years). From these coordinates, 81 bilateral paired measurements were calculated and statistically assessed for DA differences using Principal Components Analysis and Euclidean Distance Matrix Analysis. Samples separate in high-dimensional space and 35.8% of bilateral measures are statistically significant. Patterns of significant DA differences between samples were explored based on magnitude. Compared with the control group, in all but five cases, significant DA was greater in persons with UCLP. Regions derived from the maxillary and nasal prominences demonstrated the most DA. These results are important for medical practitioners for identifying the extent to which patients with UCLP deviate from the norm. Clin. Anat. 31:1129-1136, 2018. © 2018 Wiley Periodicals, Inc.