Improving Assessment and Learning Environments for Graduate Medical Trainees to Advance Healthcare Language Equity.

Language-appropriate care is critical for equitable, high-quality health care, but educational standards to assure graduate medical trainees are prepared to give such care are lacking. Detailed guidance for graduate medical education is provided by the Accreditation Council for Graduate Medical Education through the following: (1) an assessment framework for competencies, subcompetencies, and milestones for trainees and (2) the Clinical Learning Environment Review (CLER) Pathways for assessment of trainees' learning environments. These tools do not include a robust framework to evaluate trainees' abilities to offer language-appropriate care. They also do not address the learning environment's potential to support such care. A multidisciplinary group of linguistic, medical, and educational experts drafted a new subcompetency with milestones and an expanded CLER Pathway to highlight the importance of equitable care for patients who prefer languages other than English. These resources offer residency and fellowship programs tools to guide assessment, curriculum development, and learning-environment improvements related to language-appropriate care. Recognizing that programs have unique needs and resources, we propose a range of initial actions to address language equity. A focus on language diversity in the learning environment can have a broad and lasting impact on care quality, patient safety, and health equity.

Strategies for Strengthening the Resilience of Public Health Systems for Pandemics, Disasters, and Other Emergencies.

OBJECTIVE: The aim of this study was to identify and prioritize strategies for strengthening public health system resilience for pandemics, disasters, and other emergencies using a scorecard approach. METHODS: The United Nations Public Health System Resilience Scorecard (Scorecard) was applied across 5 workshops in Slovenia, Turkey, and the United States of America. The workshops focused on participants reviewing and discussing 23 questions/indicators. A Likert type scale was used for scoring with zero being the lowest and 5 the highest. The workshop scores were analyzed and discussed by participants to prioritize areas of need and develop resilience strategies. Data from all workshops were aggregated, analyzed, and interpreted to develop priorities representative of participating locations. RESULTS: Eight themes emerged representing the need for better integration of public health and disaster management systems. These include: assessing community disease burden; embedding long-term recovery groups in emergency systems; exploring mental health care needs; examining ecosystem risks; evaluating reserve funds; identifying what crisis communication strategies worked well; providing non-medical services; and reviewing resilience of existing facilities, alternate care sites, and institutions. CONCLUSIONS: The Scorecard is an effective tool for establishing baseline resilience and prioritizing actions. The strategies identified reflect areas in most need for investment to improve public health system resilience.

Medical Spanish programs in the United States: a critical review of published studies and a proposal of best practices.

BACKGROUND: Despite an increasing demand for medical Spanish training, there has never been a comprehensive review of the methodology and outcomes of existing programs. PURPOSE: This article critically reviews studies published about medical Spanish education and proposes best practices for curriculum design and program research and evaluation. METHODS: The authors reviewed articles published on medical Spanish programs in the United States from 1977 to 2012, then appraised them for the presence of five factors commonly used in second-language acquisition (SLA) research. RESULTS: Only 2 of 23 published studies of programs met all 5 criteria. There was high variability in design and infrequent use of valid and reliable outcome measures. No consensus emerged as to best practices. Instead, reported outcomes were often inadequate surrogate markers for desired educational outcomes in interactions with Spanish speakers. CONCLUSIONS: There is a significant need for effective medical Spanish programs based on solid SLA principles and research methods.

Comparison of methods for measuring longitudinal brain change in cognitive impairment and dementia.

PURPOSE: The goal of this project was to compare MRI measures of hippocampal, entorhinal cortex (ERC), and whole brain longitudinal change in cognitively normal elderly controls (C), non-demented subjects with cognitive impairment (CI), and demented (D) subjects. METHODS: 16 C, 6 CI, and 7 D subjects of comparable age were studied with MRI twice, at least 1 year apart. Longitudinal change in total brain size was measured by several methods, including computerized segmentation, non-linear warping, and change in the fluid/tissue boundaries between cerebrospinal fluid (CSF) and brain. Change in hippocampal volume was measured by semi-automated methods, and ERC volumes were manually measured. RESULTS: The annual rate of atrophy was greater in D versus C and D versus CI for cortical gray matter (cGM) (P=0.009 and 0.002), hippocampus (P=0.0001 and 0.002), and for the change in the fluid/tissue boundary (P=0.03 and 0.03). The annual rate of atrophy of ERC was greater in both CI and D versus C (P=0.01 and 0.0002). No significant differences between groups were found using non-linear warping. CONCLUSIONS: In CI, the greatest annual rates of atrophy were in ERC, while in D the greatest annual rates of atrophy were in hippocampus and cortex. Progressive ERC atrophy was observed with a greater degree of cognitive impairment, while hippocampal and cortical atrophy were only observed in demented subjects.

Machine learning models for lung cancer classification using array comparative genomic hybridization.

Array CGH is a recently introduced technology that measures changes in the gene copy number of hundreds of genes in a single experiment. The primary goal of this study was to develop machine learning models that classify non-small Lung Cancers according to histopathology types and to compare several machine learning methods in this learning task. DNA from tumors of 37 patients (21 squamous carcinomas, and 16 adenocarcinomas) were extracted and hybridized onto a 452 BAC clone array. The following algorithms were used: KNN, Decision Tree Induction, Support Vector Machines and Feed-Forward Neural Networks. Performance was measured via leave-one-out classification accuracy. The best multi-gene model found had a leave-one-out accuracy of 89.2%. Decision Trees performed poorer than the other methods in this learning task and dataset. We conclude that gene copy numbers as measured by array CGH are, collectively, an excellent indicator of histological subtype. Several interesting research directions are discussed.

Growth hormone treatment in children with cystic fibrosis.

Children with cystic fibrosis (CF) have problems with poor linear growth and inadequate weight gain. Nutritional augmentation has been the mainstay of therapy for improving both weight and height in CF; however inadequate growth continues to be a problem. Furthermore, protein catabolism has been documented even in non-acutely ill adults and children with CF, and could adversely affect longitudinal growth. Human recombinant growth hormone (GH) has positive effects on nitrogen balance, and multiple studies have demonstrated improved height and weight in children treated with GH. The purpose of this article is to summarize studies evaluating GH use in children with CF.

Growth hormone improves clinical status in prepubertal children with cystic fibrosis: results of a randomized controlled trial.

OBJECTIVES: We conducted a 1-year randomized controlled trial to test the hypothesis that growth hormone (GH) improves the clinical status of children with cystic fibrosis. STUDY DESIGN: Nineteen prepubertal children were randomized to control (NonTX, n = 9) or to daily injections of GH (0.3 mg/kg/wk) (GHTX, n = 10) for 1 year. Every 3 months height, weight, and lean tissue mass were measured. Caloric intake, resting energy expenditure, pulmonary function, and respiratory muscle strength were measured every 6 months, as were total number of hospitalizations and courses of outpatient intravenous antibiotics. RESULTS: The GHTX group had significantly greater height, height velocity (NonTX = 3.8 +/- 1.4 cm/y, GHTX = 8.1 +/- 2.4 cm/y; P =.002), weight, weight velocity (NonTX = 2.1 +/- 0.9 kg/y, GHTX = 4.5 +/- 1.1 kg/y; P =.004), and change in lean tissue mass (NonTX = 2.1 +/- 1.6 kg, GHTX = 4.7 +/- 1.7 kg; P =.01) analyzed by the Student t test. The GHTX group had significant improvement in delta forced vital capacity compared with the year before study, and respiratory muscle strength improved. The number of hospitalizations and outpatient intravenous antibiotic courses significantly decreased in the GHTX group but did not change in the NonTX group. No subject had development of cystic fibrosis-related diabetes. CONCLUSIONS: Results of the first randomized controlled trial of GH treatment in cystic fibrosis indicate that GH improves growth and clinical status.

Mechanisms of insulin resistance in cystic fibrosis.

Cystic fibrosis (CF) is associated with a high incidence of diabetes. Studies evaluating causes of CF-related diabetes (CFRD) have consistently documented decreased insulin secretion. In patients with CFRD, insulin sensitivity has been documented to be decreased, but controversy exists in patients with normal or impaired glucose tolerance (IGT). We undertook this study 1) to reexplore insulin sensitivity in patients with IGT and 2) to evaluate potential mechanisms of insulin resistance in CF, including GLUT-4 translocation, elevation of serum cytokines, and free fatty acid (FFA) levels. We recruited nine CF subjects with impaired glucose tolerance (IGTCF) and nine age-, gender-, and body mass index-matched control volunteers. Each underwent a hyperinsulinemic euglycemic clamp (200 mU. m(-2). min(-1)) to measure insulin sensitivity. A muscle biopsy was obtained at maximal insulin stimulation for measure of GLUT-4 translocation with sucrose gradients. An oral glucose tolerance test and National Institutes of Health (NIH) clinical status scores were measured in all volunteers. We also measured tumor necrosis factor (TNF)-alpha levels and FFA in all subjects. Additionally, we report the results of TNF-alpha and FFA in 32 CF patients previously studied by our group. Results were that glucose disposal rate (GDR) was significantly lower in the CFIGT subjects than in controls, indicative of impaired insulin action. GLUT-4 translocation was impaired in CF and correlated with GDR. TNF-alpha levels were higher in all CF subjects than in controls and correlated with GDR. There was no difference in FFA between CF and control subjects. Modified NIH clinical status scores were inversely correlated with GDR and TNF-alpha levels. We conclude that IGTCF patients have decreased peripheral insulin sensitivity. Mechanisms include elevation of TNF-alpha and impaired translocation of GLUT-4.

Z score prediction model for assessment of bone mineral content in pediatric diseases.

The objective of this study was to develop an anthropometry-based prediction model for the assessment of bone mineral content (BMC) in children. Dual-energy X-ray absorptiometry (DXA) was used to measure whole-body BMC in a heterogeneous cohort of 982 healthy children, aged 5-18 years, from three ethnic groups (407 European- American [EA], 285 black, and 290 Mexican-American [MA]). The best model was based on log transformations of BMC and height, adjusted for age, gender, and ethnicity. The mean +/- SD for the measured/predicted in ratio was 1.000 +/- 0.017 for the calibration population. The model was verified in a second independent group of 588 healthy children (measured/predicted In ratio = 1.000 +/- 0.018). For clinical use, the ratio values were converted to a standardized Z score scale. The whole-body BMC status of 106 children with various diseases (42 cystic fibrosis [CF], 29 juvenile dermatomyositis [JDM], 15 liver disease [LD], 6 Rett syndrome [RS], and 14 human immunodeficiency virus [HIV]) was evaluated. Thirty-nine patients had Z scores less than -1.5, which suggest low bone mineral mass. Furthermore, 22 of these patients had severe abnormalities as indicated by Z scores less than -2.5. These preliminary findings indicate that the prediction model should prove useful in determining potential bone mineral deficits in individual pediatric patients.

Growth hormone decreases protein catabolism in children with cystic fibrosis.

Despite aggressive nutritional therapy, low body weight and protein catabolism are common problems in children with cystic fibrosis. Previous studies by our group and others have demonstrated improvement in both height and weight in children with cystic fibrosis who were treated with human recombinant GH, and our group has recently documented improved clinical status and lean tissue mass as well. The purpose of this report is to summarize our findings of the effect of GH on whole body protein kinetics in cystic fibrosis and to relate these findings to changes in TNF-alpha levels. We conducted a 1-yr study of 19 prepubertal children with cystic fibrosis (age 7-12 yr, all <94% of ideal body weight). Ten children were randomly assigned to take daily injections of GH (0.3 mg/kg.wk), and nine were randomly assigned to be controls. Baseline results from the subjects with cystic fibrosis were compared with results obtained from nine age- and gender-matched healthy children. Whole body protein turnover was measured at baseline and every 6 months using the stable isotope [1-(13)C]leucine and mass spectrometric analysis. Leucine rate of appearance, a measure of protein catabolism, was similar in both cystic fibrosis subgroups at baseline and was significantly higher than in the control children without cystic fibrosis. Treatment with GH resulted in a significantly lower leucine rate of appearance, as well as significantly lower leucine oxidation. The rate of protein synthesis, as calculated from these numbers, actually decreased in the cystic fibrosis subgroup. TNF-alpha levels were higher in both cystic fibrosis subgroups than in controls and correlated with leucine rate of appearance. The results of this study suggest that one reason GH improves body weight and lean tissue mass is due to improved whole body protein catabolism and improved efficiency of whole body protein kinetics.

Normal bone mineral density in cystic fibrosis.

BACKGROUND: Osteoporosis has been reported as a complication of cystic fibrosis (CF). AIMS: To measure bone mineral density (BMD) in non-acutely ill adults and bone mineral content (BMC) in children with CF. METHODS: We analysed data from 28 adults and 13 children with CF. Corticosteroid use was minimal for the year prior to study in both groups. Dual x ray absorptiometry was used to measure total body and regional bone mineral density in adults. In children, whole body BMC was measured. Lean tissue mass (LTM) was also measured in all subjects. There were two control groups: A (matched for LTM and height, in addition to age and gender); and B (matched for age and gender only). RESULTS: There was no difference in whole body or regional BMD density between adult CF patients and control A subjects. Both whole body and regional BMD were significantly lower in adult CF patients than in control B subjects. Total body BMD was correlated with body mass index, LTM, and percent fat in both CF and control subjects. There was no significant correlation between total body BMD or regional BMD and either NIH clinical status scores, or pulmonary function tests in adults. There was no difference in total body BMC between CF children and control A subjects. Total body BMC was significantly lower in CF children than in control B subjects. There was no correlation between pulmonary function results and BMC in children. CONCLUSION: Osteopenia and osteoporosis in CF may be caused more by malnutrition and chronic use of intravenous or oral corticosteroids than by a CF related inherent defect in BMD. Appropriate "normal" data should be selected when determining whether or not osteoporosis is present in a CF patient.

Multiwavelet prefilters--part II: optimal orthogonal prefilters.

Prefiltering a given discrete signal has been shown to be an essential and necessary step in applications using unbalanced multiwavelets. In this paper, we develop two methods to obtain optimal second-order approximation preserving prefilters for a given orthogonal multiwavelet basis. These procedures use the prefilter construction introduced in part I of this paper. The first prefilter optimization scheme exploits the Taylor series expansion of the prefilter combined with the multiwavelet. The second one is achieved by minimizing the energy compaction ratio (ECR) of the wavelet coefficients for an experimentally determined average input spectrum. We use both methods to find prefilters for the cases of the DGHM and Chui-Lian (CL) multiwavelets. We then compare experimental results using these filters in an image compression scheme. Additionally, using the DGHM multiwavelet with the optimal prefilters from the first scheme, we find that quadratic input signals are annihilated by the high-pass portion of the filter bank at the first level of decomposition.

Ingested IFN-alpha preserves residual beta cell function in type 1 diabetes.

Type 1 diabetes mellitus is a chronic disorder that presumably results from an autoimmune destruction of the insulin-producing pancreatic beta cells. The therapeutic potential of interventions aimed at preventing type 1 diabetes can be assessed in newly diagnosed patients. Because there is a historical experience of a low incidence of spontaneous remission in type 1 diabetes mellitus, interventions preserving beta cell function have been used to identify positive therapeutic outcomes. We treated 10 newly diagnosed type 1 diabetes patients with 30,000 IU ingested interferon-alpha (IFN-alpha) within 1 month of diagnosis and examined the difference between baseline and Sustacal-induced (Mead Johnson Nutritionals, Evansville, IN) C-peptide responses, respectively, at 0, 3, 6, 9, and 12 months. Eight of the ten patients showed preserved beta cell function, with at least a 30% increase in stimulated C-peptide levels at 0, 3, 6, 9, and 12 months after initiation of treatment. There was no discernible chemical or clinical toxicity associated with ingested IFN-alpha. Our results support the potential of ingested IFN-alpha to preserve residual beta cell function in recent onset type 1 diabetes mellitus and the testing of IFN-alpha in a placebo-controlled trial.

On the vicissitudes of early primary surrogate mothering II: loss of the surrogate mother and arrest of mourning.

Among the catastrophic events experienced by infants and young children, one of the most frequent is the loss of an early primary surrogate mother (EPSM). Usually permanent, the loss is often followed by the advent of a new, "replacement" caregiver. One aspect of the emotional environment is unique to this kind of caregiving situation: that parents are often unable to validate the true nature of their child's relationship with the EPSM or, ultimately, the trauma experienced by the child when the EPSM leaves. The marked discrepancy between the parent's and the infant or child's experience of the surrogate mothering leads to an arrest of the child's mourning process, with the potential for serious developmental consequences. Issues related to EPSM loss and its aftermath are examined in the light of two examples. Further exploration of the environment of this kind of caregiving directs attention to the critical need to nurture and protect the attachments of both the infant or child and the parent to the ESPM.

Diabetes mellitus in cystic fibrosis.

Glucose intolerance and diabetes are common complications of cystic fibrosis (CF), affecting up to 75% of the adult population. This article discusses the prevalence and pathophysiology of glucose tolerance abnormalities in CF, and reviews recent recommendations for diagnosis, screening, and management of CF-related diabetes (CFRD).

Acute appendicitis: review and update.

Appendicitis is common, with a lifetime occurrence of 7 percent. Abdominal pain and anorexia are the predominant symptoms. The most important physical examination finding is right lower quadrant tenderness to palpation. A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and supporting the presence or absence of appendicitis, while appendiceal computed tomographic scans and ultrasonography can be helpful in equivocal cases. Delay in diagnosing appendicitis increases the risk of perforation and complications. Complication and mortality rates are much higher in children and the elderly.

Increased leucine turnover and insulin resistance in men with advanced HIV infection.

BACKGROUND: The purpose of this study was to determine if patients with advanced HIV infection exhibit increased rates of leucine turnover and to determine dose effects of insulin on suppression of leucine turnover. We also wished to evaluate hepatic glucose production and re-examine peripheral insulin sensitivity in HIV infected adults. METHODS: Results from 9 males with advanced HIV disease (96-121% ideal body weight, NW-AIDS) and 3 males (80-88% ideal body weight, UW-AIDS) were compared to age and weight matched normal volunteers (NW-C and UW-C). Each subject underwent basal leucine turnover studies followed by insulin dose response studies using a step-up hyperinsulinemic euglycemic clamp (insulin dose: 10, 20 and 120 mU/m2/min) and the stable isotope [1-13C]leucine. Hepatic glucose production was measured using the stable isotope d-6,6(2)H2-glucose. Resting energy expenditure (REE) was measured by indirect calorimetry and a 24-hour food recall was obtained. Viral load, Karnofsky score, and CD4 counts were measured in AIDS subjects. RESULTS: All subjects with AIDS had higher rates of leucine appearance (leucine Ra) than controls. Although both AIDS and Controls demonstrated suppression of leucine Ra with insulin, suppression was less in AIDS subjects. There was a strong relationship between leucine Ra and viral load (r = 0.87, P = 0.02). The AIDS subjects exhibited peripheral insulin resistance when compared to controls. CONCLUSIONS: Our results suggest that patients with HIV have both peripheral insulin resistance and resistance to the anticatabolic effects of insulin.