Therapeutic Effect and Side Effects of Pharmacotherapy in Patients With Parkinson Disease and Myasthenia Gravis: A Systematic Review of Case Reports and Case Series Studies.

PURPOSE: The co-existence of Parkinson disease (PD) and myasthenia gravis (MG) in an individual should be exceptionally rare. The purpose of this study was to systematically review the current literature regarding the therapeutic effect and side effects of pharmacotherapy on patients with PD and MG. METHODS: Five bioscience and engineering databases (MEDLINE via PubMed, Cochrane Library, Scopus, EMBASE, and China National Knowledge Infrastructure) were searched from inception through February 21, 2022. Case reports and case series studies investigating pharmacotherapy in patients with PD and MG were included. Procedures were followed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The methodologic quality of included studies was evaluated by using the National Institutes of Health Quality Assessment Tool for Case Series Studies. FINDINGS: Sixteen case reports and 5 case series studies with 32 participants met the inclusion criteria. Eight studies were rated as good quality, 10 were fair quality, and 3 were poor quality. The side effects of pharmacotherapy for PD or MG led to another disease, indicating an imbalance between dopamine and acetylcholine within human bodies. IMPLICATIONS: When treating a patient who has PD or MG, health providers should be cautious about the occurrence of another disease. Timely treatment must rely on monitoring new symptoms as soon as the pharmacotherapy for PD or MG is initiated. Physical therapy may be helpful in decreasing the side effects of pharmacotherapy in patients with PD and MG. A new treatment pattern of pharmacotherapy + physical therapy for patients with PD and MG warrants further research. International Prospective Register of Systematic Reviews identifier: CRD42022308066.

Comparison Between Effects of Galvanic and Vibration-Based Vestibular Stimulation on Postural Control and Gait Performance in Healthy Participants: A Systematic Review of Cross-Sectional Studies.

Electricity and vibration were two commonly used physical agents to provide vestibular stimulation in previous studies. This study aimed to systematically review the effects of galvanic (GVS) and vibration-based vestibular stimulation (VVS) on gait performance and postural control in healthy participants. Five bioscience and engineering databases, including MEDLINE via PubMed, CINAHL via EBSCO, Cochrane Library, Scopus, and Embase, were searched until March 19th, 2023. Studies published between 2000 and 2023 in English involving GVS and VVS related to gait performance and postural control were included. The procedure was followed via the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The methodological quality of included studies was assessed using the NIH study quality assessment tool for observational cohort and cross-sectional studies. A total of 55 cross-sectional studies met the inclusion criteria and were included in this study. Five studies were good-quality while 49 were moderate-quality and 1 was poor-quality. There were 50 included studies involving GVS and 5 included studies involving VVS. GVS and VVS utilized different physical agents to provide vestibular stimulation and demonstrated similar effects on vestibular perception. Supra-threshold GVS and VVS produced vestibular perturbation that impaired gait performance and postural control, while sub-threshold GVS and VVS induced stochastic resonance phenomenon that led to an improvement. Bilateral vestibular stimulation demonstrated a greater effect on gait and posture than unilateral vestibular stimulation. Compared to GVS, VVS had the characteristics of better tolerance and fewer side effects, which may substitute GVS to provide more acceptable vestibular stimulation.

Teaching peer reviewing to medical students through authentic peer reviews: how to build the next generation of scholars.

Implication Statement: The peer review process is a critical step in producing sound scientific literature, traditionally conducted by professionals well-established in their field. It is uncommon for students, even at the graduate level, to contribute. Faculty created a novel course in which 18 medical students (nine per year) delivered peer reviews to the Canadian Medical Education Journal (CMEJ). The positive feedback and competency gained is described in the students' Letter to the Editor. While this course was initially created to benefit students, it has also helped to address a known deficit in peer reviewers. Énoncé des implications de la recherche: L'évaluation par les pairs est une étape essentielle de la production d'une littérature scientifique de bonne qualité. Traditionnellement faite par des professionnels confirmés dans leur domaine de compétences, il est rare que les étudiants, même ceux des cycles supérieurs, participent aux comités de lecture. Un cours novateur a permis à 18 étudiants en médecine (9 par année) de réaliser des évaluations par les pairs pour la Revue canadienne de l'éducation médicale (CMEJ). Les commentaires positifs et les compétences acquises sont décrits dans une lettre des étudiants à l'éditeur. Bien qu'à l'origine ce cours ait été créé pour profiter aux étudiants, il a également contribué à combler un déficit notoire de pairs évaluateurs.

Ultrasound-assisted bony landmark palpation in untrained palpators.

CONTEXT: Medical students with no previous experience may find it difficult to identify and palpate bony landmarks while learning physical examination skills. In a study of 168 medical schools, 72.6 % have indicated that they are utilizing ultrasound in their curriculum. Although the integration of ultrasound curriculum has become more widespread, the depth of instruction is inconsistent. Ultrasound is not commonly taught in conjunction with palpation of bony landmarks in osteopathic structural examination. OBJECTIVES: The objective of this analysis was to identify whether utilizing ultrasound assistance in teaching palpation of specific thoracic vertebral bony landmarks would improve palpation accuracy in first-year medical students with no previous palpatory experience. METHODS: First-year medical students were given video instructions to palpate and identify a thoracic vertebral transverse process and to mark it with invisible ink. The participants were then taught and instructed to utilize ultrasound to identify the same landmark and mark it with a different color. The accuracy of palpation was measured with digital calipers. RESULTS: A test of the overall hypothesis that participants will show improved accuracy utilizing ultrasound compared with hand palpation was not significant (F=0.76, p>0.05). When separating students into groups according to patient body mass index (BMI), however, there was a trend toward significance (F=2.90, p=0.071) for an interaction effect between patient BMI and the repeated measures variable of palpation/ultrasound. When looking specifically at only those participants working with a normal BMI patient, there was a significant improvement in their accuracy with the use of ultrasound (F=7.92, p=0.017). CONCLUSIONS: The analysis found increased accuracy in bony landmark identification in untrained palpators utilizing ultrasound vs. palpation alone in a normal BMI model, but not in obese or overweight BMI models. This study shows promise to the value that ultrasound may have in medical education, especially with respect to early palpation training and landmark identification.

Resident-teaching of ethics in undergraduate medical education: a grounded theory analysis.

Background: In graduate medical education, teaching is a required subcompetency largely fulfilled via clinical teaching, journal clubs, and grand rounds. Evidence shows that when moving to undergraduate teaching, residents often face a steep learning curve. We aimed to assess residents' perspective of the experience of teaching medical students. Methods: Psychiatry residents taught small group sections of bioethics to first- and second-year medical students in December 2018. We conducted two 1-hour focus group interviews with four residents on their perspectives on the teaching experience. Results: Resident-teachers described receiving certain benefits from teaching, such as meeting their altruistic desire to give back to the profession. Nonetheless, some participants felt frustrated by students' varying engagement and respect, while also feeling insecure and intimidated. Resident-teachers experienced some of the medical students as disrespectful and limited in their appreciation for diversity and the profession of medicine and perceived the students' disengagement and lessened professionalism. Conclusion: As residency programs seek to implement initiatives to improve teaching skills of residents, resident experiences should be considered when implementing these initiatives.

Neuroendoscopic Evacuation Improves Outcomes Compared with External Ventricular Drainage in Patients with Spontaneous Intraventricular Hemorrhage: A Systematic Review with Meta-Analyses.

BACKGROUND: Spontaneous intraventricular hemorrhage (IVH) is a cause of significant morbidity and mortality. Treatment for resulting obstructive hydrocephalus has traditionally been via an external ventricular drain (EVD). We aimed to compare patient outcomes after neuroendoscopic surgery (NES) evacuation of IVH versus EVD management. METHODS: MEDLINE, Embase, and Cochrane Library databases were searched on October 8, 2022. Of the 252 records remaining after removal of duplicates, 12 met study inclusion criteria. After extraction of outcomes data, fixed-effect and random-effects models were used to establish odds ratios (ORs) with 95% confidence intervals (CIs) for intensive care unit length of stay, rate of permanent cerebrospinal fluid diversion, Glasgow Outcome Scale score, and mortality rate. RESULTS: The results of the pooled analysis showed that intensive care unit length of stay was shorter (OR -2.61 [95% CI -5.02, -0.19]; I2 = 97.76%; P = 0.034), permanent cerebrospinal fluid diversion was less likely (OR -0.79, 95% CI [-1.17, -0.41], I2 = 46.96%, P < 0.001), higher Glasgow Outcome Scale score was more likely (OR 0.48, 95% CI [0.04, 0.93], I2 = 60.12%, P = 0.032), and all-cause mortality was less likely (OR -1.11, 95% CI [-1.79, -0.44], I2 = 0%, P = 0.001) in the NES evacuation group compared with the EVD group. CONCLUSIONS: NES for evacuation of spontaneous IVH results in reduced intensive care unit length of stay, reduced permanent cerebrospinal fluid diversion rates, improved Glasgow Outcome Scale score, and reduced mortality when compared with EVD. More robust prospective, randomized studies are necessary to help inform the safety and utility of NES for IVH.

The effect of mechanical vibration-based stimulation on dynamic balance control and gait characteristics in healthy young and older adults: A systematic review of cross-sectional study.

BACKGROUND: A good dynamic balance control and stable gait played an important role in the daily ambulation, especially for older adults with sensorimotor degeneration. This study aimed to systematically review the effects and potential mechanisms of mechanical vibration-based stimulation (MVBS) on dynamic balance control and gait characteristics in healthy young and older adults. METHOD: Five bioscience and engineering databases, including MEDLINE via PubMed, CINAHL via EBSCO, Cochrane Library, Scopus, and Embase, were searched until September 4th, 2022. Studies published between 2000 and 2022 in English and Chinese involving mechanical vibration related to gait and dynamic balance were included. The procedure was followed via the preferred reporting items for systematic reviews and meta-analysis method. The methodological quality of included studies was assessed using the NIH study quality assessment tool for observational cohort and cross-sectional studies. RESULTS: A total of 41 cross-sectional studies met the inclusion criteria and were included in this study. Eight studies were good-quality while 26 were moderate-quality and 7 were poor-quality. There were six categories of MVBS at various frequencies and amplitudes utilized in included studies, including plantar vibration, focal muscle vibration, Achilles tendon vibration, vestibular vibration, cervical vibration, and vibration on nail of hallux. SIGNIFICANCE: Different types of MVBS targeting different sensory systems affected the dynamic balance control and gait characteristics differently. MVBS could be used to provide improvement or perturbation to specific sensory systems, to induce different sensory reweight strategies during gait.

Scoping review of costs of implementation strategies in community, public health and healthcare settings.

OBJECTIVES: To identify existing evidence concerning the cost of dissemination and implementation (D&I) strategies in community, public health and health service research, mapped with the 'Expert Recommendations for Implementing Change' (ERIC) taxonomy. DESIGN: Scoping review. DATA SOURCES: MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus and the Cochrane Library were searched to identify any English language reports that had been published between January 2008 and December 2019 concerning the cost of D&I strategies. DATA EXTRACTION: We matched the strategies identified in each article using ERIC taxonomies; further classified them into five areas (eg, dissemination, implementation, integration, capacity building and scale-up); and extracted the corresponding costs (total costs and cots per action target and per evidence-based programme (EBP) participant). We also recorded the reported level of costing methodology used for cost assessment of D&I strategies. RESULTS: Of the 6445 articles identified, 52 studies were eligible for data extraction. Lack of D&I strategy cost data was the predominant reason (55% of the excluded studies) for study exclusion. Predominant topic, setting, country and research design in the included studies were mental health (19%), primary care settings (44%), the US (35%) and observational (42%). Thirty-five (67%) studies used multicomponent D&I strategies (ranging from two to five discrete strategies). The most frequently applied strategies were Conduct ongoing training (50%) and Conduct educational meetings (23%). Adoption (42%) and reach (27%) were the two most frequently assessed outcomes. The overall costs of Conduct ongoing training ranged from $199 to $105 772 ($1-$13 973 per action target and $0.02-$412 per EBP participant); whereas the cost of Conduct educational meetings ranged from $987 to $1.1-$2.9 million/year ($33-$54 869 per action target and $0.2-$146 per EBP participant). The wide range of costs was due to the varying scales of the studies, intended audiences/diseases and the complexities of the strategy components. Most studies presented limited information on costing methodology, making interpretation difficult. CONCLUSIONS: The quantity of published D&I strategy cost analyses is increasing, yet guidance on conducting and reporting of D&I strategy cost analysis is necessary to facilitate and promote the application of comparative economic evaluation in the field of D&I research.

Physician Disengagement and Spiritual Dissonance in Medical Students.

BACKGROUND AND OBJECTIVES: Religion and spirituality constitute aspects of diversity that physicians must respect to provide patient-centered care. By seeing patients as individuals and integrating their religious and spiritual needs into their medical care, providers can deliver personalized health care. Their needs become even more critical for the frontline providers during the COVID-19 pandemic. Most patients want their physicians to address their religious and spiritual needs when it comes to their health (eg, during isolation precautions). Despite increases in educational curricula about this integration, most physicians still do not provide this aspect of patient-centered care. METHODS: In this observational study, we examined how medical students responded to a patient experiencing a religious and spiritual issue by having standardized patients (SPs) rate the students' level of engagement with them. We also asked students to reflect on their own spirituality, in terms of their current and ideal levels of spirituality, the difference of which indicates spiritual dissonance. Medical students (n=232) completed the Spiritual Health and Life-Outcome Measure (SHALOM) questionnaire, and their SPs completed the Princess Margaret Hospital Satisfaction With Doctor Questionnaire (PSQ-MD). RESULTS: Results indicated a significant, positive correlation between disengagement (from PSQ-MD) and transcendent spirituality dissonance (from SHALOM). CONCLUSIONS: Higher levels of disconnection from a patient case with a religious and spiritual issue (portrayed by an SP) were associated with higher levels of incongruity in medical students' responses as to their ideal relationship with the transcendent (eg, God, Allah, peace).

Coping with the Practice of Medicine: Religion, Spirituality, and Other Personal Strategies.

With the increasing demands on the practice of medicine, this qualitative study asked residents and their faculty (n = 44) to reflect on how they cope with their work. They provided written reflections to questions about successful and disappointing patient experiences, as well as describing their personal, religious, or spiritual practices. Key themes included connecting with family and friends, learning from their mistakes, using cognitive behavioral tools, and engaging with their spirituality and religiosity. One third specifically mentioned they used prayer and/or meditation. We contextualized selected quotes with their level of spiritual well-being, religiosity, and burnout.

Targeted therapy with phosphodiesterase 5 inhibitors in patients with pulmonary hypertension due to heart failure and elevated pulmonary vascular resistance: a systematic review.

Pulmonary Hypertension due to left heart disease is the most common type of Pulmonary Hypertension. Morbidity and mortality significantly increase once Pulmonary Hypertension is present. Treatment is aimed toward optimizing the underlying condition. Targeted therapy has been evaluated in small studies with mixed results. The goal of this systematic review is to identify the possible benefit and safety of Phosphodiesterase 5 inhibitors in Pulmonary Hypertension due to left heart disease with elevated pulmonary vascular resistance, diagnosed by right heart catheterization. Electronic searches using MEDLINE/PREMEDLINE, EMBASE, and The Cochrane Library were searched on 21 October 2018. Randomized clinical trials comparing Phosphodiesterase 5 inhibitors versus placebo in patients with proven Pulmonary Hypertension by right heart catheterization secondary to left heart disease (both heart failure with reduced ejection fraction and with preserved ejection fraction) and reported pulmonary vascular resistance were included. We identified 436 potentially relevant studies. After reviewing the titles and abstracts to exclude irrelevant articles, five randomized clinical trials were considered for the study. Sildenafil was well tolerated among all studies. Sildenafil was found to improve hemodynamics, exercise capacity, and quality of life in patients with elevated pulmonary vascular resistance. Phosphodiesterase 5 inhibitors therapy in patients with proven Pulmonary Hypertension due to left heart disease and elevated pulmonary vascular resistance by right heart catheterization may improve the quality of life, exercise capacity, and pulmonary hemodynamics. Further prospective randomized controlled studies are needed to confirm.

Medical students' personal experiences, religion, and spirituality explain their (dis)comfort with a patient's religious needs.

BACKGROUND: Physicians often avoid discussing patients' religious and spiritual concerns, even though most patients (i.e., 50-94%) want integrated care. To address this gap, medical students interviewed a Standardized Patient (SP) who was upset because the daughter did not confront her fiancée about converting to Orthodox Judaism. Students reflected on how their own religion and spirituality affected engaging with their patient. METHODS: With a 97% response rate, 231 first-year medical students responded to open-ended questions about their patient encounter. For this quantitative content analysis, we used inductive reasoning, identifying three themes: (1) impact of students' own religion on their comfort, (2) change in comfort, and (3) their learning. We used deductive reasoning to compare qualitative results from half of the students who began the curriculum with a questionnaire about their own spirituality with the other students completing afterwards. RESULTS: Most students said being religious positively influenced their comfort, whether they were also Orthodox Jewish or from a different religion. Among uncomfortable students (6.5%), some attributed this to not being religious. Some students (4.8%) grew more comfortable discussing the religious issue, and 18.2% became uncomfortable due to lacking knowledge of Orthodox Judaism and the awkwardness of the topic. Students who had completed the questionnaire beforehand gave more comments about connecting with their patients than students who completed the questionnaire afterwards (X2=11.047, p<.001). CONCLUSIONS: Students' own religion influenced their comfort with discussing religious concerns, with some feeling more connected and others becoming uncomfortable. This finding helps inform medical educators about teaching mind-body-spirit care.Résumé.

CONTEXTE: Les médecins évitent souvent de discuter des préoccupations religieuses et spirituelles des patients même si la plupart d'entre eux (soit entre 50 et 94 %) désirent recevoir des soins intégrés. Pour combler cette lacune, les étudiants en médecine ont interviewé un patient simulé (PS) qui était contrarié parce que sa fille n'avait pas confronté son fiancé à l'idée de se convertir au judaïsme orthodoxe. Les étudiants ont réfléchi sur l'impact qu'avait leur propre religion et spiritualité sur la façon dont ils abordent leur patient. MÉTHODES: Avec un taux de réponse de 97 pour cent, 231 étudiants de première année en médecine ont répondu à des questions ouvertes sur la rencontre avec leur patient. Dans le cadre de cette analyse de contenu quantitative, nous nous sommes servis du raisonnement inductif et avons déterminé trois thèmes :(1) impact de la religion des étudiants sur leur niveau de confort, (2) changement du niveau de confort et (3) leur apprentissage. Nous avons utilisé le raisonnement déductif pour comparer les résultats qualitatifs obtenus pour la moitié des étudiants qui ont commencé leur cursus en remplissant un questionnaire sur leur propre spiritualité, l'autre moitié ayant répondu au questionnaire subséquemment. RÉSULTATS: La plupart des étudiants ont affirmé que d'être religieux avait eu un impact positif sur leur niveau de confort, qu'ils soient juifs orthodoxes ou d'une religion différente. Parmi les étudiants inconfortables (6,5 %), certains ont attribué ce sentiment au fait qu'ils n'étaient pas religieux. D'autres (4,8 %) se sont sentis plus à l'aise après avoir discuté le problème religieux et 18,2 % d'entre eux se sont sentis moins à l'aise en raison de leur manque de connaissance sur le judaïsme orthodoxe et du sujet embarrassant. Les étudiants qui avaient rempli le questionnaire auparavant ont fourni plus de commentaires sur leur façon d'aborder leurs patients que ceux qui y avaient répondu après (X2 =11,047; p<,001). CONCLUSIONS: La religion des étudiants a eu un impact sur leur degré d'aisance au moment de discuter les questions religieuses; certains se sentant plus proches et d'autres, plus inconfortables. Cette conclusion informe les éducateurs en médecine de l'importance d'enseigner les soins du corps, de l'esprit et de l'âme.

Medical Students' (Dis)comfort with Assessing Religious and Spiritual Needs in a Standardized Patient Encounter.

Most patients want to discuss their religious and spiritual concerns, yet few physicians discuss it. First-year medical students (n = 92) interviewed a standardized patient experiencing spiritual distress. There was a significant difference among the students' reasoning for their (dis)comfort and (mis)matching religion with their patient (X2 = 21.0831, p < .05). Most students whose religion matched their patient felt comfortable because of having this in common with their patient. Most students whose religion did not match that of their patient ascribed their comfort to their religious belief to be open and accepting. Discomfort may stem from more individual factors than a (mis)match in religion, as most of the students reported feeling comfortable.

A Conceptual Framework for Barriers to the Recruitment and Retention of Rural CVD Participants in Behavior Intervention Trials.

BACKGROUND: Rural residents diagnosed with cardiovascular disease (CVD) or with CVD-related risks are underrepresented in behavioral intervention trials based on an extensive review of published studies. The low participation rate of rural residents weakens both the internal and external validity of published studies. Moreover, compared to urban residents, limited research exists to describe the unique barriers that limit the participation of rural residents in behavioral intervention trials. OBJECTIVE: The purpose of this review is to identify a conceptual framework (CF) underpinning common barriers faced by rural CVD patients to enroll in behavioral intervention trials. METHODS: We conducted a literature review using several electronic databases to obtain a representative sample of research articles, synthesized the evidence, and developed a CF to explain the barriers that may affect the research participation rate of rural residents with CVD or related risks. RESULTS: We found our evidence-based CF well explained the barriers for rural CVD patients to take part in behavioral intervention trials. Besides contextual factors (i.e. patient, community and research levels), other common factors impacting rural patients' intent to enroll are lack of awareness and understanding about behavioral trials, limited support from their healthcare providers and social circles, unfavorable attitudes, and the lack of opportunity to participating research. CONCLUSION AND IMPLICATION OF RESULT: The findings demonstrate the evidence-based model consisting of interlinked multi-level factors may help our understanding of the barriers encountered by rural CVD patients participating interventions to promote behavioral change. The implication for researchers is that identifying and developing strategies to overcome the barriers precedes conducting studies in rural communities.