An Exploratory Study of a Novel Approach to Improve Readiness for a Rural Family Medicine Residency.

BACKGROUND AND OBJECTIVES: Transitioning from medical school to residency is challenging, especially in rural training programs where a comprehensive scope of practice is needed to address rural health disparities. Oregon Health & Science University partnered with Cascades East Family Medicine Residency in Klamath Falls, Oregon to create an integrated fourth-year medical student experience (Oregon Family medicine Integrated Rural Student Training (Oregon FIRST). Participants may then enter this residency to complete their training with the intention to practice in rural underresourced settings. METHODS: In this exploratory study, we conducted key informant interviews with 9 of ten Oregon FIRST participants to determine how Oregon FIRST contributed both to their readiness for residency training and their choice to practice in rural underserved locations. Interviews were conducted between June 10, 2020 and July 8, 2020. We analyzed field notes taken during interviews for emergent themes using classical content analysis. RESULTS: Emergent themes included logistical ease, relationship development, key curricular elements, and commitment to rural practice. Overwhelmingly, Oregon FIRST participants reported the experience had many challenging and demanding components because they served as subinterns for their entire fourth year of medical school, but this prepared them very well for internship. When asked if they would choose to enroll in Oregon FIRST again, given what they now know about physician training and patient care, all nine (100%) said they would. CONCLUSIONS: This study demonstrated that Oregon FIRST students felt better prepared for the rigors of residency and are committed to practicing in rural areas.

Anti-inflammatory and anti-arthritic effects of the ethanolic extract of Aralia continentalis Kitag. in IL-1ß-stimulated human fibroblast-like synoviocytes and rodent models of polyarthritis and nociception.

BACKGROUND: Blocking the formation and invasive growth of pannus and its secretion of inflammatory cytokines and MMPs is important for treating rheumatoid arthritis. HYPOTHESIS/PURPOSE: Anti-arthritic activity of Aralia continentalis Kitag., an oriental herbal medicine, and the underlying mechanisms involved were investigated. STUDY DESIGN: Anti-inflammatory and anti-nocicpetive activities of the ethanolic extract (50% v/v) of Aralia continentalis Kitag. harvested from Imsil, Korea (ACI) were investigated in IL-1ß-stimulated human fibroblast-like synoviocyte (FLS) cells and rodent models of collagen-induced polyarthritis and carrageenan-induced acute paw pain. METHODS: In IL-1ß-stimulated FLS cells derived from rheumatoid arthritis patients, the anti-inflammatory activity of ACI was examined by analyzing the expression levels of inflammatory mediators such as TNF-α, IL-6, IL-8, MMP-1, MMP-3, MMP-13, PGE2, and COX-2 using ELISA and RT-PCR analysis. The anti-arthritic activity of ACI was investigated by measuring body weight, squeaking score, paw volume, and arthritis index in collagen-induced polyarthritis mice. The anti-nociceptive activity of ACI was examined in the paw-pressure test and Tail-flick latency test in rats. RESULTS: The ethanolic extract (50% v/v) of ACI reduced the levels of TNF-α, IL-6, IL-8, MMP-1, and MMP-13 secreted by IL-1ß-stimulated FLS cells, whereas MMP-3, COX-2, and PGE2 were not significantly affected. ACI inhibited the migration of NF-κB into the nucleus through the inhibition of ERK- and JNK-dependent MAP kinase pathways in IL-1ß-stimulated FLS cells. In collagen-induced polyarthritis mice, oral administration of ACI extract (200 mg/kg) significantly alleviated arthritic behaviors. Histological observations of arthritic mouse knees were consistent with their behaviors. The anti-arthritic and anti-inflammatory activities of 200 mg/kg ACI extract were comparable to those of 10 mg/kg prednisolone when administered to mice. However, ACI administration did not significantly affect carrageenan-induced hyperalgesia or thermal nociception in rats. CONCLUSION: These results suggest that the ethanolic extract of ACI have significant anti-inflammatory and anti-arthritic effects in a rodent arthritis model and in IL-1ß-stimulated FLS cells. Thus, ACI may be a useful candidate for developing pharmaceuticals or dietary supplements for the treatment of inflammatory arthritis.

Competence Revisited in a Rural Context.

BACKGROUND AND OBJECTIVES: General competencies developed in undergraduate and graduate medical education are sometimes promoted as applicable in any practice context. However, rural practice presents challenges and opportunities that may require unique training. The objectives of this national survey of both undergraduate and graduate medical educators and practicing physicians were to further develop a previously published list of competency domains for working in rural communities and to assess their relative importance in education and practice. METHODS: Using six rural competency domains first refined with a national group at the Society of Teachers of Family Medicine Annual Meeting in Baltimore in 2008, the authors employed a snowball strategy to survey medical educators and physicians regarding the importance and relevance of this list and to solicit additional domains and competencies. RESULTS: All six domains were considered important, with average responses for each domain ranging from 4.16 to 4.78 on a 5-point Likert scale (1-not important; 5-extremely important). Unique relevance to rural practice was more varied, with average responses for domains ranging from 2.36 to 3.6 (1-not at all unique; 5-extremely unique). Analysis of free text responses identified two important new domains-Comprehensiveness and Agency/Courage-and provided clarification of some competencies within existing domains. CONCLUSIONS: This study validates and further elaborates dimensions of competence believed to be important in rural practice. The authors propose these domains as a common language and framework for addressing the unique challenges and opportunities that training and practicing in a rural setting present.

Rural Curricular Guidelines Based on Practice Scope of Recent Residency Graduates Practicing in Small Communities.

BACKGROUND AND OBJECTIVES: The optimal curriculum for training family physicians for rural practice within a traditional urban-based residency is not defined. We used the scope of practice among recent family medicine graduates of residencies associated with Preparing the Personal Physician for Practice (P4), practicing in small communities, to identify rural curriculum components. METHODS: We surveyed graduates 18 months after residency between 2007 and 2014. The survey measured self-reported practice characteristics, including community size, and scope of practice. We compared the subgroups according to practice community size. RESULTS: Compared to graduates in larger communities, those practicing in small communities were more likely to report a broader scope of clinical practice including: adult hospital care (59% vs 35%), vaginal deliveries (23% vs 12%), C sections as primary surgeon (14% vs 5%) and assistant (21% vs 8%), newborn hospital care (45% vs 24%), and procedures such as endometrial biopsy (46% vs 33%), joint injections and aspirations (89% vs 79%), and fracture care (58% vs 42%). Graduates in small communities were also more often engaged in assessing community health needs (78% vs 64%) and developing community interventions (67% vs 51%) compared to graduates in larger communities. In contrast, graduates in small communities were less likely to have integrated behavioral health (26% vs 46%) and case management support (37% vs 52%). CONCLUSIONS: A rural practice curriculum should include training toward a broad medical scope of practice as well as skills in community-oriented primary care and integrated behavioral health.

Scope of Practice Among Recent Family Medicine Residency Graduates.

BACKGROUND AND OBJECTIVES: The scope of practice among primary care providers varies, and studies have shown that family physicians' scope may be shrinking. We studied the scope of practice among graduates of residencies associated with Preparing the Personal Physician for Practice (P4) and how length of training and individualized education innovations may influence scope. METHODS: We surveyed graduates 18 months after residency between 2008 and 2014. The survey measured self-reported practice characteristics, scope of practice and career satisfaction. We assessed scope using individual practice components (25 clinical activities, 30 procedures) and a scaled score (P4-SOP) that measured breadth of practice scope. We conducted subgroup analyses according to exposure to innovations over the project period and exposure to specific innovations. RESULTS: No significant differences were found in mean P4-SOP scores between the Pre and Full P4 groups. Compared to national data, P4 graduates reported higher rates for vaginal deliveries (19.3% vs 9.2%), adult inpatient care (48.5% vs 33.7%) and nursing home care (25.4 vs 11.7%) in practice. Graduates exposed to innovations that lengthened training, compared to standard training length, were more likely to include adult hospital care (58.2% vs 38.5%, P=0.002), adult ICU care (30.6% vs 19.2%, P=0.047) and newborn resuscitation (25.6% vs 14%, P=0.028) in their practice and performed 19/30 procedures at higher rates. Graduates of programs with individualized training innovations reported no significant differences in scope compared to graduates without this innovation. CONCLUSIONS: Graduates of residencies engaged in significant educational redesign report a broad scope of practice. Innovations around the length of training may broaden scope and individualized education appears not to constrict scope.

Clinical Inquiry: Do oral decongestants have a clinically significant effect on BP in patients with hypertension?

It is unclear. Pseudoephedrine causes an average increase of 1.2 mm Hg in systolic blood pressure (BP) in patients with controlled hypertension. However, the studies are not adequately powered to provide evidence about whether this rise in systolic BP is linked to patient-oriented outcomes (strength of recommendation: C, multiple randomized controlled trials supporting disease-oriented evidence). Significant variations in BP are defined differently among studies. In addition, we do not have data on chronic use of oral decongestants; the longest time on medication in these trials was 4 weeks.

Multichannel compression hearing aids: effect of channel bandwidth on consonant and vowel identification by hearing-impaired listeners.

Aided consonant and vowel identification was measured in 13 listeners with high-frequency sloping hearing losses. To investigate the influence of compression-channel analysis bandwidth on identification performance independent of the number of channels, performance was compared for three 17-channel compression systems that differed only in terms of their channel bandwidths. One compressor had narrow channels, one had widely overlapping channels, and the third had level-dependent channels. Measurements were done in quiet, in speech-shaped noise, and in a three-talker background. The results showed no effect of channel bandwidth, neither on consonant nor on vowel identification scores. This suggests that channel bandwidth per se has little influence on speech intelligibility when individually prescribed, frequency-varying compressive gain is provided.

Temporal aspects of suppression in distortion-product otoacoustic emissions.

This study examined the time course of cochlear suppression using a tone-burst suppressor to measure decrement of distortion-product otoacoustic emissions (DPOAEs). Seven normal-hearing subjects with ages ranging from 19 to 28 yr participated in the study. Each subject had audiometric thresholds ≤ 15 dB HL [re ANSI (2004) Specifications for Audiometers] for standard octave and inter-octave frequencies from 0.25 to 8 kHz. DPOAEs were elicited by primary tones with f(2) = 4.0 kHz and f(1) = 3.333 kHz (f(2)/f(1) = 1.2). For the f(2), L(2) combination, suppression was measured for three suppressor frequencies: One suppressor below f(2) (3.834 kHz) and two above f(2) (4.166 and 4.282 kHz) at three levels (55, 60, and 65 dB SPL). DPOAE decrement as a function of L(3) for the tone-burst suppressor was similar to decrements obtained with longer duration suppressors. Onset- and setoff- latencies were ≤ 4 ms, in agreement with previous physiological findings in auditory-nerve fiber studies that suggest suppression results from a nearly instantaneous compression of the waveform. Persistence of suppression was absent for the below-frequency suppressor (f(3) = 3.834 kHz) and was ≤ 3 ms for the two above-frequency suppressors (f(3) = 4.166 and 4.282 kHz).

Guidelines for biosafety laboratory competency: CDC and the Association of Public Health Laboratories.

These guidelines for biosafety laboratory competency outline the essential skills, knowledge, and abilities required for working with biologic agents at the three highest biosafety levels (BSLs) (levels 2, 3, and 4). The competencies are tiered to a worker's experience at three levels: entry level, midlevel (experienced), and senior level (supervisory or managerial positions). These guidelines were developed on behalf of CDC and the Association of Public Health Laboratories (APHL) by an expert panel comprising 27 experts representing state and federal public health laboratories, private sector clinical and research laboratories, and academic centers. They were then reviewed by approximately 300 practitioners representing the relevant fields. The guidelines are intended for laboratorians working with hazardous biologic agents, obtained from either samples or specimens that are maintained and manipulated in clinical, environmental, public health, academic, and research laboratories.

Comparison of distortion-product otoacoustic emission growth rates and slopes of forward-masked psychometric functions.

Slopes of forward-masked psychometric functions (FM PFs) were compared with distortion-product otoacoustic emission (DPOAE) input/output (I/O) parameters at 1 and 6 kHz to test the hypothesis that these measures provide similar estimates of cochlear compression. Implicit in this hypothesis is the assumption that both DPOAE I/O and FM PF slopes are functionally related to basilar-membrane (BM) response growth. FM PF-slope decreased with signal level, but this effect was reduced or reversed with increasing hearing loss; there was a trend of decreasing psychometric function (PF) slope with increasing frequency, consistent with greater compression at higher frequencies. DPOAE I/O functions at 6 kHz exhibited an increase in the breakpoint of a two-segment slope as a function of hearing loss with a concomitant decrease in the level of the distortion product (L(d)). Results of the comparison between FM PF and DPOAE I/O parameters revealed only a weak correlation, suggesting that one or both of these measures may provide unreliable information about BM compression.

The role of suppression in psychophysical tone-on-tone masking.

This study tested the hypothesis that suppression contributes to the difference between simultaneous masking (SM) and forward masking (FM). To obtain an alternative estimate of suppression, distortion-product otoacoustic emissions (DPOAEs) were measured in the presence of a suppressor tone. Psychophysical-masking and DPOAE-suppression measurements were made in 22 normal-hearing subjects for a 4000-Hz signal/f(2) and two masker/suppressor frequencies: 2141 and 4281 Hz. Differences between SM and FM at the same masker level were used to provide a psychophysical estimate of suppression. The increase in L(2) to maintain a constant output (L(d)) provided a DPOAE estimate of suppression for a range of suppressor levels. The similarity of the psychophysical and DPOAE estimates for the two masker/suppressor frequencies suggests that the difference in amount of masking between SM and FM is at least partially due to suppression.

Dementia-free survival among centenarians: an evidence-based review.

BACKGROUND: The 2000 U.S. census identified 50,454 Americans older than 100 years (18 per 100,000). Increased longevity is only of benefit if accompanied by the maintenance of physical, social, and cognitive function into advanced age. The goal of this review was to identify research describing centenarians to find the prevalence of dementia-free survival. METHODS: We reviewed 650 publications to find studies that described the prevalence of dementia in centenarians, were community-based, had data that were specific to persons older than 100 years, and were published in peer-reviewed journals. For each study, we identified the prevalence of dementia, the completeness of the sample, the number of study participants, the method used to diagnose dementia, and the duration of the study. RESULTS: We identified 20 research groups from 14 countries with publications meeting our search criteria. The studies showed substantial variation in methods of assessing cognitive status, assuring a complete cohort, and sample size. Few studies reported longitudinal data or attempted diagnosis of the cause of dementia. The prevalence of dementia-free survival past 100 years of age varied between 0 and 50 percent. CONCLUSIONS: The methodology used in studies regarding dementia prevalence among centenarians is sufficiently varied that combination of existing studies into a meta-analysis is not possible. Suggestions for assuring quality in future centenarian research are presented.

Hyperkalemia.

Hyperkalemia is a potentially life-threatening metabolic problem caused by inability of the kidneys to excrete potassium, impairment of the mechanisms that move potassium from the circulation into the cells, or a combination of these factors. Acute episodes of hyperkalemia commonly are triggered by the introduction of a medication affecting potassium homeostasis; illness or dehydration also can be triggers. In patients with diabetic nephropathy, hyperkalemia may be caused by the syndrome of hyporeninemic hypoaldosteronism. The presence of typical electrocardiographic changes or a rapid rise in serum potassium indicates that hyperkalemia is potentially life threatening. Urine potassium, creatinine, and osmolarity should be obtained as a first step in determining the cause of hyperkalemia, which directs long-term treatment. Intravenous calcium is effective in reversing electrocardiographic changes and reducing the risk of arrhythmias but does not lower serum potassium. Serum potassium levels can be lowered acutely by using intravenous insulin and glucose, nebulized beta2 agonists, or both. Sodium polystyrene therapy, sometimes with intravenous furosemide and saline, is then initiated to lower total body potassium levels.