Development and Implementation of an Experiential Longitudinal Health Systems Science Thread Into an Existing Medical School Curriculum.

PROBLEM: Medical school graduates enter a complex health care delivery system involving interprofessional teamwork and multifaceted value-based patient care decisions. However, current curricula on health systems science (HSS) are piecemeal, lecture based, and confined to preclinical training. APPROACH: The VISTA program is a longitudinal, immersive learning curriculum integrated into the University of Chicago Pritzker School of Medicine curriculum between 2016 and 2018. Key components include a unit-based nursing interprofessional team experience, a discharge objective structured clinical examination (OSCE), a patient safety simulation, and the implementation of a Choosing Wisely SmartPhrase. Graduates before (2016-2017) and after (2018-2020) VISTA implementation completed a Likert-style survey assessing attitudes, knowledge, and behaviors on HSS topics. A free response question solicited improvement areas. The Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) was also examined. OUTCOMES: The overall VISTA survey response rate was 59%, with 126 fourth-year medical student respondents before VISTA and 120 after VISTA. Compared with pre-VISTA graduates, post-VISTA graduates reported a significantly higher rate of competence on the HSS questions, with the greatest increases seen in effective communication at discharge (n = 73/126 [57.9%] to 116/120 [96.7%], P < .001), knowledge on safety event reporting (n = 53/126 [42.1%] to 96/120 [79.8%], P < .001), and considering costs in making health care decisions (n = 76/126 [60.3%] to 117/120 [97.5%], P < .001). All were directly addressed through experiential learning interventions, and 2 were intended practice behaviors. VISTA graduate responses to free-text questions demonstrated a more nuanced understanding of HSS compared with pre-VISTA responses. The AAMC GQ data showed increased agreement with an item that mapped to HSS understanding. NEXT STEPS: The VISTA program provides a model for institutions to enhance HSS education between curricular overhauls. Next steps include implementing value-added roles and additional immersive learning exercises.

Necrotizing Fasciitis? A Mimic Produced by an Unusual Presentation of Necrotizing Neutrophilic Dermatosis of the Hand: A Case Report.

CASE: A 50-year-old woman presented to our emergency department with hand pain and a laceration. Despite administration of antibiotics, the patient progressively worsened leading to a concern for a necrotizing soft-tissue infection. She underwent multiple debridements yet continued to worsen clinically. Tissue biopsy was eventually consistent with a necrotizing neutrophilic dermatosis. The patient was then started on oral steroids with rapid improvement of her clinical status and hand examination. CONCLUSION: While neutrophilic dermatoses are rare, the orthopaedic surgeon treating soft-tissue infections should maintain a broad differential when treatment of a potential necrotizing infection has not led to diagnostic closure and clinical improvement.

Scalp Infection, Inflammation, and Infestation.

Tinea capitis, folliculitis, seborrheic dermatitis, and pediculosis capitis are four common scalp conditions. Although tinea capitis and seborrheic dermatitis are found more commonly in patients with skin of color and highly textured hair, all of these conditions have special diagnostic or management considerations in these populations. This article reviews the diagnosis and management of these common scalp conditions.

Impact of considering United States Medical Licensing Examination Step 1 pass/fail on diversity in dermatology residency recruitment.

The University of Chicago dermatology residency program considered the United States Medical Licensing Examination (USMLE) Step 1 pass/fail during the 2020-2021 application cycle with the goal of recruiting diverse dermatology residency candidates. We conducted a retrospective multiyear cross-sectional study among applicants to the dermatology residency program during the 2018-2019 and 2020-2021 application cycles, the latter excluding use of USMLE Step 1 cutoff scores as a screening tool. Of the applicants, 69.8% (n = 419) and 94.5% (n = 605) had their residency applications reviewed by our program during the 2018-2019 and 2020-2021 application cycles, respectively. There was a statistically significant upward trend in the number of underrepresented in medicine (URiM) applicants offered an interview from 10.4% (n = 5) to 37.7% (n = 20) across the application cycles. Multiple linear regression demonstrated there was a statistically significant decrease in the mean USMLE Step 1 score among applicants reviewed across application cycle and URiM status independently, and as a factor of their interaction (P = .016 and P = .001). By de-emphasizing the USMLE Step 1 score and using the test as originally intended, a marker for licensure, our program significantly increased the number of URiM applicants who were offered an interview and implemented a holistic review process focused on individual attributes and cultural competence.

Vitiligo-like manifestations of graft-versus-host disease in a pediatric population.

Vitiligo-like changes are an uncommon cutaneous manifestation of graft-versus-host disease (GVHD). We report three cases and review the literature of pediatric patients with vitiligo-like changes associated with GVHD. Improved characterization of this phenomenon may lend insight into the biologic pathways that underlie both vitiligo and GVHD.

Comparison of Pediatric Dermatology Conditions Across Telehealth and In-Person Visits During the COVID-19 Pandemic.

Understanding the utility of virtual visits in pediatric dermatology practice has become increasingly important in the telehealth era. We compared the conditions diagnosed in pediatric dermatology between traditional in-person visits and virtual telehealth visits during the initial 8-month phase of the COVID-19 pandemic at an urban medical institution. When given the option, pediatric dermatology patients and their families were more likely to choose telehealth visits for the diagnosis and/or management of acne, hemangiomas, and contact dermatitis; however, they were more likely to choose in-person visits for atopic dermatitis, viral warts, and alopecia areata. These differences may be attributed to clinical features of pediatric skin conditions, treatment options, and other factors which may influence patient preference for telehealth or in-person care for their condition. J Drugs Dermatol. 2022;21(11):1260-1263. doi:10.36849/JDD.6843.

Qualitative Study of Interprofessional Collaboration in Radiation Oncology Clinics: Is There a Need for Further Education?

PURPOSE: Interprofessional education (IPE) is gaining recognition as a means of improving health care delivery and patient outcomes. A primary goal of IPE is improved interprofessional collaboration (IPC). The multidisciplinary team in the radiation oncology clinic requires effective IPC for optimal delivery of radiation therapy. However, there are limited data on IPE and IPC in radiation oncology. This qualitative study aims to characterize IPC in radiation oncology. METHODS AND MATERIALS: Semistructured phone interviews were performed from June to August 2019 with radiation oncologists, nurses, dosimetrists, radiation therapists, medical physicists, and medical students across a single academic medical center and affiliated network sites. Interviews were recorded, de-identified, and transcribed verbatim. Resulting transcripts were analyzed using thematic analysis. RESULTS: Seventeen interviews were performed with 4 radiation oncologists, 2 nurses, 2 dosimetrists, 4 radiation therapists, 2 medical physicists, and 3 medical students. Thematic analysis identified 4 themes: (1) management of the radiation oncology clinic, (2) potential impact of interprofessional training in radiation oncology, (3) current climate of interprofessional education in radiation oncology, and (4) creating an interprofessional training program in radiation oncology. Each theme elicited between 2 and 7 subthemes. CONCLUSIONS: From the analytical themes that emerged, it is hypothesized that misunderstanding professionals' roles can lead to communication breakdown, which creates less efficient clinic management and disorganized patient care. Although other medical professionals shadow physicians during their training, physicians are not learning about other professions in the same way. Interviewees from each professional category recommend a formal shadowing program for radiation oncology trainees at the medical student or resident level. Having structured opportunities for IPE is important given competing demands of learners during medical student rotations and residency. This study suggests an unmet need for exposure of radiation oncology medical trainees to IPE with the ultimate goal of improving IPC in the radiation oncology clinic.

Physician review of image registration and normal structure delineation.

INTRODUCTION: Image registration and delineation of organs at risk (OARs) are key components of three-dimensional conformal (3DCRT) and intensity-modulated radiotherapy (IMRT) treatment planning. This study hypothesized that image registration and OAR delineation are often performed by medical physicists and/or dosimetrists and are not routinely reviewed by treating physicians. METHODS: An anonymous, internet-based survey of medical physicists and dosimetrists was distributed via the MEDPHYS and MEDDOS listserv groups. Participants were asked to characterize standard practices for completion and review of OAR contouring, target volume contouring, and image registration at their institution along with their personal training in these areas and level of comfort performing these tasks. Likert-type scales are reported as Median [Interquartile range] with scores ranging from 1 = "Extremely/All of the time" to 5 = "Not at all/Never." RESULTS: Two hundred and ninety-seven individuals responded to the survey. Overall, respondents indicated significantly less frequent physician review (3 [2-4] vs 2 [1-3]), and less confidence in the thoroughness of physician review (3 [2-4] vs 2 [1-3], P < 0.01) of OAR contours compared to image registration. Only 19% (95% CI 14-24%) of respondents reported a formal process by which OAR volumes are reviewed by physicians in their clinic. The presence of a formal review process was also associated with significantly higher perceived thoroughness of review of OAR volumes compared to clinics with no formal review process (2 [2-3] vs 3 [2-4], P < 0.01). CONCLUSION: Despite the critical role of OAR delineation and image registration in the 3DCRT and IMRT treatment planning process, physician review of these tasks is not always optimal. Radiotherapy clinics should consider implementation of formal processes to promote adequate physician review of OARs and image registrations to ensure the quality and safety of radiotherapy treatment plans.

Estimation of critical end-test torque using neuromuscular electrical stimulation of the quadriceps in humans.

Characterization of critical power/torque (CP/CT) during voluntary exercise requires maximal effort, making difficult for those with neuromuscular impairments. To address this issue we sought to determine if electrically stimulated intermittent isometric exercise resulted in a critical end-test torque (ETT) that behaved similar to voluntary CT. In the first experiment participants (n = 9) completed four bouts of stimulated exercise at a 3:2 duty cycle, at frequencies of 100, 50, 25 Hz, and a low frequency below ETT (Sub-ETT; ≤ 15 Hz). The second experiment (n = 20) consisted of four bouts at a 2:2 duty cycle-two bouts at 100 Hz, one at an intermediate frequency (15-30 Hz), and one at Sub-ETT. The third experiment (n = 12) consisted of two bouts at 50 Hz at a 3:2 duty* cycle with proximal blood flow occlusion during one of the bouts. ETT torque was similar (p ≥ 0.43) within and among stimulation frequencies in experiment 1. No fatigue was observed during the Sub-ETT bouts (p > 0.05). For experiment 2, ETT was similar at 100 Hz and at the intermediate frequency (p ≥ 0.29). Again, Sub-ETT stimulation did not result in fatigue (p > 0.05). Altering oxygen delivery by altering the duty cycle (3:2 vs. 2:2; p = 0.02) and by occlusion (p < 0.001) resulted in lower ETT values. Stimulated exercise resulted in an ETT that was consistent from day-to-day and similar regardless of initial torque, as long as that torque exceeded ETT, and was sensitive to oxygen delivery. As such we propose it represents a parameter similar to voluntary CT.

Voluntary muscle activation and evoked volitional-wave responses as a function of torque.

INTRODUCTION: This study employed a unique stimulation paradigm which allowed for the simultaneous assessment of voluntary activation levels (VA) via twitch-interpolation, and the evoked V-wave responses of the plantar flexors during submaximal and maximal contractions. Test-retest reliability was also examined. METHODS: Fourteen participants repeated a stimulation protocol over four visits to assess VA and evoked V-wave amplitude across torque levels ranging from 20% to 100% MVC. MVC torque and EMG amplitude were also measured. RESULTS: VA increased nonlinearly with torque production and plateaued by 80% MVC. V-wave amplitude increased linearly from 20% to 100% MVC. There were no differences in any dependent variable across visits (p > 0.05). VA demonstrated moderate to substantial reliability across all torque levels (ICC = 0.76-0.91) while V-wave amplitude exhibited fair to moderate reliability from 40% to 100% (ICC = 0.48-0.74). DISCUSSION: We were able to reliably collect VA and the V-wave simultaneously in the plantar flexors. Collection of VA and V-wave during the same contraction provides distinct information regarding the contribution of motor-unit recruitment and descending cortico-spinal drive/excitability to force production.

Adaptations in antagonist co-activation: Role in the repeated-bout effect.

Eccentric exercise results in an adaptation which attenuates muscle damage from subsequent exercise-termed the "repeated-bout effect (RBE)." PURPOSE: Study examined antagonist co-activation and motor-unit recruitment strategy, assessed via dEMG, concomitant to the RBE. METHODS: Nine participants performed 5 sub-maximal isometric trapezoid (ramp-up, hold, ramp-down) contractions at force levels corresponding to 50% and 80% of maximal isometric strength (MVC). Surface EMG signals of the biceps brachii were decomposed into individual motor-unit action potential trains. The relationship between mean firing rate (MFR) of each motor-unit and its recruitment threshold (RT) was examined using linear regression. Eccentric exercise was then performed until biceps brachii MVC had decreased by ~40%. Surface EMG of the biceps and triceps were collected during eccentric exercise. MVC, range-of-motion (ROM), and delayed onset muscle soreness (DOMS) were measured 24-hours, 72-hours, and 1-week following eccentric exercise. Three weeks later all procedures were repeated. RESULTS: Changes in MVC (-32±14% vs -25±10%; p = 0.034), ROM (-11% vs 6%; p = 0.01), and DOMS (31.0±19mm vs 19±12mm; p = 0.015) were attenuated following the second bout of exercise. Triceps EMG was reduced (16.8±9.5% vs. 12.6±7.2%; p = 0.03) during the second bout of eccentric exercise. The slope (-0.60±0.13 vs -0.70±0.18; p = 0.029) and y-intercept (46.5±8.3 vs 53.3±8.8; p = 0.020) of the MFR vs. RT relationship was altered during contractions at 80% of MVC prior to the second bout of eccentric exercise. No changes were observed at 50% of MVC. CONCLUSION: A reduction in antagonist co-activation during the second bout of eccentric exercise suggests less total force was required to move an identical external load. This finding is supported by the increased negative slope coefficient and an increased y-intercept of the linear relationship between RT and MFR.

The effects of caffeine ingestion on exercise-induced hypoalgesia: A pilot study.

Exercise acutely reduces pain sensitivity, termed exercise-induced hypoalgesia (EIH). The mechanisms underlying EIH remain unclear. Caffeine, a non-specific adenosine receptor antagonist has been shown to attenuate EIH in animals-suggesting the involvement of the adenosinergic system. This pilot study investigated the effects of caffeine on pain sensitivity following cycling exercise in college-aged men. Pressure pain threshold (PPT) and thermal pain threshold (TPT) were assessed in thirteen low caffeine consuming men prior to ingestion of a counter-balanced 5mg·kg(-1) dose of caffeine or a placebo (Pre), 60min following ingestion (Post-In), and then following a 15min bout of cycling exercise (Post-Ex) at an intensity eliciting a quadriceps muscle pain rating of 3 out of 10. Nine of the men completed follow-up testing which was identical except that the exercise consisted of 10min of cycling eliciting a pain rating of 5 out of 10. Caffeine had no effect compared to placebo on PPT (p≥0.15) or TPT (p≥0.41) 60min following ingestion and following exercise. PPT increased from 599±176kPa to 648±202kPa (p=0.009) and from 578±217kPa to 666±278kPa (p=0.01) following 15 and 10min of cycling, respectively. TPT increased from 46.2±2.9°C to 46.8±2.6°C (p=0.008) following the 15min exercise bout, but did not change (46.4±3.6°C vs. 46.8±3.3°C; p=0.24) following the shorter, higher intensity exercise bout. The results from this study indicate cycling exercise reduces pain sensitivity, especially to pressure stimuli. Caffeine ingestion did not alter the EIH response-suggesting adenosine may not play a prominent role in the EIH response in humans.

Ecstasy (MDMA) Alters Cardiac Gene Expression and DNA Methylation: Implications for Circadian Rhythm Dysfunction in the Heart.

MDMA (ecstasy) is an illicit drug that stimulates monoamine neurotransmitter release and inhibits reuptake. MDMA's acute cardiotoxicity includes tachycardia and arrhythmia which are associated with cardiomyopathy. MDMA acute cardiotoxicity has been explored, but neither long-term MDMA cardiac pathological changes nor epigenetic changes have been evaluated. Microarray analyses were employed to identify cardiac gene expression changes and epigenetic DNA methylation changes. To identify permanent MDMA-induced pathogenetic changes, mice received daily 10- or 35-day MDMA, or daily 10-day MDMA followed by 25-day saline washout (10 + 25 days). MDMA treatment caused differential gene expression (p < .05, fold change >1.5) in 752 genes following 10 days, 558 genes following 35 days, and 113 genes following 10-day MDMA + 25-day saline washout. Changes in MAPK and circadian rhythm gene expression were identified as early as 10 days. After 35 days, circadian rhythm genes (Per3, CLOCK, ARNTL, and NPAS2) persisted to be differentially expressed. MDMA caused DNA hypermethylation and hypomethylation that was independent of gene expression; hypermethylation of genes was found to be 71% at 10 days, 68% at 35 days, and 91% at 10 + 25 days washout. Differential gene expression paralleled DNA methylation in 22% of genes at 10-day treatment, 17% at 35 days, and 48% at 10 + 25 days washout. We show here that MDMA induced cardiac epigenetic changes in DNA methylation where hypermethylation predominated. Moreover, MDMA induced gene expression of key elements of circadian rhythm regulatory genes. This suggests a fundamental organism-level event to explain some of the etiologies of MDMA dysfunction in the heart.

Time-course of recovery of peak oxygen uptake after exercise-induced muscle damage.

V̇O2 peak has been shown to be reduced 48 h following exercise-induced muscle damage (EIMD), but it is unclear how long this reduction may persist. In this study eight endurance trained participants (21.5 ± 1.1 years old) performed a maximal exercise tests over 10-days followings EIMD. Cardiorespiratory variables were collected via open-circuit spirometry and soreness, maximal strength (MVC), motor-unit recruitment, and contractile properties were assessed prior to each test. MVC was reduced for up to 4-days (p ≤ 0.05) and soreness was evident for 10-days in the quadriceps (p < 0.05). V̇O2peak was reduced 7.4% 2-days post EIMD (55.5 ± 6.0 vs. 51.3 ± 5.8; p = 0.006) and remained reduced in 6 of 8 participants at 10-days post (p = 0.005). No relationship was found between changes in MVC, soreness, motor-unit recruitment, and contractile properties and changes in V̇O2peak (p > 0.05). EIMD resulted in small, but prolonged reductions in V̇O2peak. Our findings suggest mechanisms aside from force loss and soreness are primarily responsible for the reductions in V̇O2peak after EIMD.