Medical Spanish Standardization in U.S. Medical Schools: Consensus Statement From a Multidisciplinary Expert Panel.

Medical Spanish (MS) education is in growing demand from U.S. medical students, providers, and health systems, but there are no standard recommendations for how to structure the curricula, evaluate programs, or assess provider performance or linguistic competence. This gap in medical education and assessment jeopardizes health care communication with Hispanic/Latino patients and poses significant quality and safety risks. The National Hispanic Health Foundation and University of Illinois College of Medicine convened a multidisciplinary expert panel in March 2018 to define national standards for the teaching and application of MS skills in patient-physician communication, establish curricular and competency guidelines for MS courses in medical schools, propose best practices for MS skill assessment and certification, and identify next steps needed for the implementation of the proposed national standards. Experts agreed on the following consensus recommendations: (1) create a Medical Spanish Taskforce to, among other things, define educational standards; (2) integrate MS educational initiatives with government-funded research and training efforts as a strategy to improve Hispanic/Latino health; (3) standardize core MS learner competencies; (4) propose a consensus core curricular structure for MS courses in medical schools; (5) assess MS learner skills through standardized patient encounters and develop a national certification exam; and (6) develop standardized evaluation and data collection processes for MS programs. MS education and assessment should be standardized and evaluated with a robust interinstitutional medical education research strategy that includes collaboration with multidisciplinary stakeholders to ensure linguistically appropriate care for the growing Spanish-speaking U.S. population.

Peer teaching of the physical exam: a pilot study.

BACKGROUND: Mastery of the physical exam (PE), and the ability to teach it to peers and medical students, are important milestones for residents (junior doctors); however, several reports indicate that PE skills are in decline. To address this need, we explored the use of peer observation of teaching (POT) as a conceptual framework to develop an innovative approach to PE teaching at the postgraduate medical education level. INNOVATION: We designed a PE POT session to be conducted at the patient bedside, and piloted four sessions in April 2014. Sessions involved a senior medicine resident teaching a focused PE to their team (consisting of two postgraduate first-year residents), while being observed by a peer, followed by feedback anchored in 11 validated measures of clinical teaching. The sessions were completed in 30-35 minutes and were enthusiastically received by residents. Participants valued the interactive approach and the opportunity to exchange feedback with a peer on their PE teaching skills. IMPLICATIONS: This pilot using POT methodology to teach the PE addressed mandatory core competencies related to patient care and practice-based learning and improvement. Residents gained insights on their PE teaching skills while interacting with their peers in a novel and reciprocal learning opportunity. This experience helped participants to value their role as PE teachers and generate strategies to change their teaching behaviours. Despite this being a small study, POT offers an innovative approach to teach the PE at the postgraduate level, with the potential to address the gap of PE teaching and learning. Several reports indicate that physical exam skills are in decline.

The Effect of Rubric-Guided, Focused, Personalized Coaching Sessions and Video-Recorded Presentations on Teaching Skills Among Fourth-Year Medical Students: A Pilot Study.

PROBLEM: As medical students become residents, teaching becomes an expected and integral responsibility. Yet, training-for-teaching opportunities are lacking. In 2014, the authors designed a pilot study using rubric-guided, focused, personalized coaching sessions and video-recorded presentations to improve student teaching skills among fourth-year students at Harvard Medical School. APPROACH: In 2014-2015, the authors recruited students from an elective on how to tutor preclinical students for the pilot, which consisted of four phases: a precoaching teaching presentation, a 30- to 45-minute coaching session, a postcoaching teaching presentation, and blinded reviewer ratings. Students' pre- and postcoaching presentations were video recorded. Using a scoring rubric for 15 teaching skills, students rated their pre- and postcoaching videos. Blinded reviewers also rated the pre- and postcoaching presentations using the same rubric with an additional category to gauge their overall impression. OUTCOMES: Fourteen students completed all four phases of the pilot. Students' ratings demonstrated statistically significant improvement in several teaching skills, including presentation content (P < .001), rate of speech (P = .001), and opening statement and learning objectives (P = .004). Blinded reviewers' ratings demonstrated statistically significant improvements in several teaching skills, including opening statement and learning objectives (P < .001), overall impression (P = .001), and conclusion and summary of learning objectives (P = .004). Students provided largely positive comments on the interventions. NEXT STEPS: The authors will work toward addressing limitations in the rubric, using coaching in different teaching settings, addressing the interventions' generalizability, training coaches, and performing additional evaluations.

Losing weights: Failure to recognize and act on weight loss documented in an electronic health record.

BACKGROUND: Involuntary weight loss is associated with higher mortality. When this weight loss is unrecognized, opportunities for timely diagnosis of significant conditions may be missed. OBJECTIVE: To use electronic health record (EHR) data to estimate the frequency of unrecognized involuntary weight loss and its implications. METHODS: We performed a retrospective analysis of the weights recorded in an EHR of 100,000 adult patients seen in outpatient clinics over a five-year period using a novel data visualization and review tool. We reviewed charts of a random sample of 170 patients experiencing weight loss periods. Our outcomes included determinations of whether weight loss 1) was voluntary vs. involuntary; 2) was recognized and documented; and 3) possible explanations identifiable at the index visit or within the subsequent two years. RESULTS: Of 170 randomly-selected weight loss periods reviewed, 22 (13%) were involuntary, 36 (21%) were voluntary and 112 (66%) were indeterminate. Sixty-six (39%) weight loss periods were recognized by clinician at the index visits and an additional 3 (1%) at the next PCP visits. Possible explanations for weight loss emerged in the subsequent two years including medical conditions in 60 (45%), psycho-social conditions in 19 (14%), erroneous data entry in 9 (7%), voluntary weight loss in 8 (6%), and postpartum weight loss in 6 (4%). No possible explanations were found in 32 (24%). CONCLUSIONS: Periods of weight loss were common, often involuntary and frequently not recognized or documented. Many patients with involuntary weight loss had potential explanations that emerged within the subsequent two years.

Electrophysiologic study of globus pallidus projections to the thalamic reticular nucleus.

This study was designed to explore the electrophysiological relationships between the globus pallidus (GP), the substantia nigra pars reticulata (SNr) and the thalamic reticular nucleus (TRN) in urethane-anesthetized rats. The neuronal activity of the rostral part of the TRN was recorded by microelectrodes. Single pulse electrical stimulation of the GP and SNr produced inhibition of the spontaneous activity of the majority of TRN neurons. Stimulation of the GP by microinjections of bicuculline (25 ng/300 nl) produced also inhibition of the spontaneous activity of the reticular neurons. This could lead to facilitation of the cerebral cortex, as the reticular nucleus is reciprocally connected to, and inhibits, the thalamic motor nuclei, that in turn excite the motor cortex.

Preoperative hyponatremia and perioperative complications.

BACKGROUND: Although hyponatremia has been linked to increased morbidity and mortality in a variety of medical conditions, its association with perioperative outcomes remains uncertain. METHODS: To determine whether preoperative hyponatremia is a predictor of 30-day perioperative morbidity and mortality, we conducted a cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to identify 964 263 adults undergoing major surgery from more than 200 hospitals (from January 1, 2005, to December 31, 2010) and observed them for 30-day perioperative outcomes. We used multivariable logistic regression to estimate relative risks for death, major coronary events, wound infections, and pneumonia occurring within 30 days of surgery and quantile regression to estimate differences in average length of hospital stay. RESULTS: A total of 75 423 patients with preoperative hyponatremia (sodium level <135 mEq/L [to convert to millimoles per liter, multiply by 1.0]) were compared with 888 840 patients with normal baseline sodium levels (135-144 mEq/L). Preoperative hyponatremia was associated with a higher risk of 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% CI, 1.38-1.50), and this finding was consistent in all the subgroups. This association was particularly marked in patients undergoing nonemergency surgery (aOR, 1.59; 95% CI, 1.50-1.69; P < .001 for interaction) and American Society of Anesthesiologists class 1 and 2 patients (aOR, 1.93; 95% CI, 1.57-2.36; P < .001 for interaction). Furthermore, hyponatremia was associated with a greater risk of perioperative major coronary events (1.8% vs 0.7%; aOR, 1.21; 95% CI, 1.14-1.29), wound infections (7.4% vs 4.6%; 1.24; 1.20-1.28), and pneumonia (3.7% vs 1.5%; 1.17; 1.12-1.22) and prolonged median lengths of stay by approximately 1 day. CONCLUSION: Preoperative hyponatremia is a prognostic marker for perioperative 30-day morbidity and mortality.

Risk of thiazide-induced hyponatremia in patients with hypertension.

BACKGROUND: Although hyponatremia is a well-recognized complication of treatment with thiazide diuretics, the risk of thiazide-induced hyponatremia remains uncertain in routine care. METHODS: We conducted a retrospective cohort study using a multicenter clinical research registry to identify 2613 adult outpatients that were newly treated for hypertension between January 1, 2000 and December 31, 2005 at 2 teaching hospitals in Boston, Massachusetts, and followed them for up to 10 years. RESULTS: Two hundred twenty patients exposed to ongoing thiazide therapy were compared with 2393 patients who were not exposed. In the exposed group, 66 (30%) developed hyponatremia (sodium ≤130 mmol/L). The adjusted incidence rate of hyponatremia was 140 cases per 1000 person-years for patients treated with thiazides, compared with 87 cases per 1000 person-years in those without thiazides. Patients exposed to thiazides were more likely to develop hyponatremia (adjusted incidence rate ratio, 1.61; 95% confidence interval [CI], 1.15-2.25). There was no significant difference in the risk of hospitalizations associated with hyponatremia (adjusted rate ratio, 1.04; 95% CI, 0.46-2.32) or mortality (adjusted rate ratio, 0.41; 95% CI, 0.12-1.42). The number needed to harm (to result in one excess case of incident hyponatremia in 5 years) was 15.02 (95% CI, 7.88-160.30). CONCLUSIONS: Approximately 3 in 10 patients exposed to thiazides who continue to take them develop hyponatremia.

[Continuing medical education: a clinical research institutional project]. / Proyecto institucional para la educación médica continua en investigación clínica.

In Argentina, education in clinical investigation is based on courses with theoric content. In developed countries programs with ongoing and practical content exist, generating the proper context to learn. In 2006, the Hospital Italiano de Buenos Aires (HIBA) created an area to train physicians, Research Area in Internal Medicine, and enable them to participate in every step of the clinical investigation process. The objective of this study is to describe this teaching area and its impact on the investigation in Internal Medicine in the HIBA, in the period 2006-2008. This area counts with fellow positions and provides training in Clinical Investigation for rotating residents. It has different activities including lectures, project counseling and 3 ongoing Institutional Registers for prevalent medical problems, 33% (6/18) of Intern staff are currently participating, with 3 fellows and 7 monitors for the Registers; 25 residents rotated in the area and generated their own research projects. 59 posters were presented in local and international congresses. Currently 6 original articles are in process of publication and 2 in peer review evaluation. A survey was carried out to evaluate the area where 76% (35/46) of the participants believed that they have acquired new skills; with 93% (44/47) using these knowledges in their every day practice. A 100% thought that they were adequately oriented in their projects, their ideas being fully respected (97%) (45/46). The inclusion of the Research Area in Internal Medicine improved the knowledge of the process of clinical Investigation and increased independent scientific production.

Proyecto institucional para la educación médica continua en investigación clínica / Continuing medical education: A clinical research institutional project

En la Argentina, educar en investigación clínica consiste principalmente en cursos teóricos. En países desarrollados existen programas que generan el entorno propicio para un aprendizaje práctico y continuo. En el 2006, en el Servicio de Clínica Médica del Hospital Italiano de Buenos Aires se creó el Área de Investigación en Medicina Interna para formar profesionales capaces de participar en todas las etapas de la investigación clínica. El propósito de este estudio es describir el área y su impacto en la educación en investigación en medicina interna durante el período 2006-2008. El proyecto cuenta con un programa de capacitación en investigación clínica para residentes y otro de perfeccionamiento para becarios. Además de becas, asesoramiento en proyectos, ateneos sobre investigación clínica y registros de enfermedades prevalentes en medicina interna. Participan el 33% (6/18) de los clínicos de internación, se encuentran en formación 3 becarios y 7 monitores de investigación. 25 residentes pasaron por el programa de capacitación, completaron una propuesta de investigación 19 (76%). Se hicieron 59 presentaciones en congresos. Se encuentran en proceso de publicación 6 artículos originales y 2 en revisión por comités editoriales. De un cuestionario de evaluación del área, el 76% (35/46) considera que ha adquirido nuevas habilidades, y 93% (44/47) refiere que las utiliza en la práctica diaria. El 100% (47/47) considera que ha recibido orientación adecuada. El 97% (45/46) considera que sus ideas han sido respetadas. La implementación del área de investigación logró aumentar la capacitación y producción científica en investigación clínica independiente.

In Argentina, education in clinical investigation is based on courses with theoric content. In developed countries programs with ongoing and practical content exist, generating the proper context to learn. In 2006, the Hospital Italiano de Buenos Aires (HIBA) created an area to train physicians, Research Area in Internal Medicine, and enable them to participate in every step of the clinical investigation process. The objective of this study is to describe this teaching area and its impact on the investigation in Internal Medicine in the HIBA, in the period 2006-2008. This area counts with fellow positions and provides training in Clinical Investigation for rotating residents. It has different activities including lectures, project counseling and 3 ongoing Institutional Registers for prevalent medical problems, 33% (6/18) of Intern staff are currently participating, with 3 fellows and 7 monitors for the Registers; 25 residents rotated in the area and generated their own research projects. 59 posters were presented in local and international congresses. Currently 6 original articles are in process of publication and 2 in peer review evaluation. A survey was carried out to evaluate the area where 76% (35/46) of the participants believed that they have acquired new skills; with 93% (44/47) using these knowledges in their every day practice. A 100% thought that they were adequately oriented in their projects, their ideas being fully respected (97%) (45/46). The inclusion of the Research Area in Internal Medicine improved the knowledge of the process of clinical Investigation and increased independent scientific production.

Melanin-covered nanoparticles for protection of bone marrow during radiation therapy of cancer.

PURPOSE: Protection of bone marrow against radiotoxicity during radioimmunotherapy and in some cases external beam radiation therapy such as hemi-body irradiation would permit administration of significantly higher doses to tumors, resulting in increased efficacy and safety of treatment. Melanin, a naturally occurring pigment, possesses radioprotective properties. We hypothesized that melanin, which is insoluble, could be delivered to the bone marrow by intravenously administrated melanin-covered nanoparticles (MNs) because of the human body's "self-sieving" ability, protecting it against ionizing radiation. METHODS AND MATERIALS: The synthesis of MNs was performed via enzymatic polymerization of 3,4-dihydroxyphenylalanine and/or 5-S-cysteinyl-3,4-dihydroxyphenylalanine on the surface of 20-nm plain silica nanoparticles. The biodistribution of radiolabeled MNs in mice was done at 3 and 24 h. Healthy CD-1 mice (Charles River Laboratories International, Inc., Wilmington, MA) or melanoma tumor-bearing nude mice were given MNs intravenously, 50 mg/kg of body weight, 3 h before either whole-body exposure to 125 cGy or treatment with 1 mCi of (188)Re-labeled 6D2 melanin-binding antibody. RESULTS: Polymerization of melanin precursors on the surface of silica nanoparticles resulted in formation of a 15-nm-thick melanin layer as confirmed by light scattering, transmission electron microscopy, and immunofluorescence. The biodistribution after intravenous administration showed than MN uptake in bone marrow was 0.3% and 0.2% of injected dose per gram at 3 and 24 h, respectively, whereas pre-injection with pluronic acid increased the uptake to 6% and 3% of injected dose per gram, respectively. Systemic MN administration reduced hematologic toxicity in mice treated with external radiation or radioimmunotherapy, whereas no tumor protection by MNs was observed. CONCLUSIONS: MNs or similar structures provide a novel approach to protection of bone marrow from ionizing radiation based on prevention of free radical formation by melanin.

Phage display library derived peptides that bind to human tumor melanin as potential vehicles for targeted radionuclide therapy of metastatic melanoma.

Metastatic melanoma remains an incurable disease, and there is a great need for novel therapeutic modalities. We have recently identified melanin as a target for radionuclide therapy of melanoma and demonstrated the feasibility of this approach using a 188-rhenium ( (188)Re)-radiolabeled melanin-binding decapeptide to fungal melanin known as 4B4. Although the results indicated that radiolabeled melanin-binding decapeptide had activity against melanoma, that peptide also manifested high kidney uptake and this might become a concern during clinical trials. We hypothesized that by identifying peptides with different amino acid composition against tumor melanin we might be able to decrease their kidney uptake. Using the Heptapeptide Ph.D.-7 Phage Display Library, we identified three heptapeptides that bind to human tumor melanin. These peptides were radiolabeled with (188)Re via HYNIC ligand, and their comprehensive biodistribution in A2058 human metastatic melanoma tumor-bearing nude mice was compared to that of (188)Re-4B4 decapeptide. While tumor uptake of heptapeptides was quite similar to that of (188)Re-4B4 decapeptide, there was dramatically less uptake in the kidneys at both 3 h (6% ID/g vs 38%) and 24 h (2% ID/g vs 15%) postinjection. Administration of one of the generated heptapeptides, (188)Re-HYNIC-AsnProAsnTrpGlyProArg, to A2058 human metastatic melanoma-bearing nude mice resulted in significant retardation of the tumor growth. Immunofluorescence showed that in spite of their relatively small size heptapeptides were not able to penetrate through the membranes of viable melanoma cells and bound only to extracellular melanin, which provides assurance that they will be safe to healthy melanin-containing tissues during radionuclide therapy. Thus, these heptapeptides appear to have potentially significant advantages for targeted therapy of melanoma relative to existing melanin-binding peptides.