Relationships Matter: Enhancing Trainee Development with a (Simple) Clerkship Curriculum Reform.

PROBLEM: The traditional clerkship model of brief encounters between faculty and students results in reduced meaningful learning opportunities due to the lack of a relationship that enables repeated observation, supervisor feedback, trust formation, and growth. INTERVENTION: Clinical clerkships at our institution were restructured to decrease fragmentation of supervision and foster an educational alliance between faculty and student. A mixed-methods approach was used to study the impact of this curriculum reform on the student experience in the obstetrics and gynecology clerkship. Student participation in patient care was assessed by comparing the number of common obstetric procedures performed before and after clerkship reform. Separate qualitative analyses of comments from student surveys and a faculty focus group revealed themes impacting student involvement. The supervisor-trainee relationship was further investigated by analysis of "rich picture" discussions with students and faculty. CONTEXT: Clerkships in the 3rd year of our 4-year undergraduate medical curriculum were converted from an experience fragmented by both didactic activities and multiple faculty supervisors to one with a single supervisor and the elimination of competing activities. OUTCOMES: Students in the revised clerkship performed twice the number of obstetric procedures. Objective measures (United States Medical Licensing Examination Step 1 scores, receiving clerkship honors, self-reported interest in obstetrics, and gender) did not correlate with the number of procedures performed by students. Qualitative analysis of student survey comments revealed that procedure numbers were influenced by being proactive, having a supervisor with a propensity to teach (trust), and contextual factors (busy service or competition with other learners). Themes identified by faculty that influenced student participation included relationship continuity; growth of patient care skills; and observed student engagement, interest, and confidence. The quality of the relationship was cited by both students and faculty as a factor influencing meaningful clinical participation. Discussions of "rich pictures" drawn by students and faculty revealed that relationships are influenced by continuity, early alignment of goals, and the engagement and attitude of both student and faculty. LESSONS LEARNED: Clinical curricular reforms that strengthen the continuity of the supervisor-trainee relationship promote mutual trust and can result in a more meaningful training experience in less time. Reciprocal engagement and early alignment of goals between supervisor and trainee are critical for creating a positive relationship.

Prevalence and Distribution of Potential Vascularized Composite Allotransplant Donors, Implications for Optimizing the Donor-recipient Match.

BACKGROUND: Vascularized composite allotransplantation (VCA) is an emerging and growing field. Little is known about the prevalence and distribution of the adult potential donor population in the United States now that it falls under the oversight of the United Network for Organ Sharing (UNOS). METHODS: We assessed the UNOS database from 2008 to 2015 to estimate the prevalence and distribution of adult potential vascularized composite allograft donors. Donor inclusion and exclusion criteria were developed in a way to minimize risk to recipients and were applied to the dataset. Donors were categorized by factors that influence vascularized composite allograft matching including ABO blood type, cytomegalovirus status, and ethnicity (correlate for skin color) and sorted by UNOS region. RESULTS: Just under half of all brain dead donors met the inclusion/exclusion criteria. Blood type O, cytomegalovirus+, White donors represented the most frequent donor profile while blood type AB, cytomegalovirus-, Asian donors were the least common. UNOS region 3 had the most and region 1 had the least potential VCA donors per year. Nearly all potential VCA donors were solid organ donors with the liver being the most commonly donated solid organ in this population. CONCLUSIONS: A large portion of the solid organ donor pool would qualify as adult vascularized composite allograft donors in the current UNOS system. These data will assist transplant teams in determining the prevalence and distribution of vascularized composite allograft donors for their individual patients awaiting composite allografts based on relevant matching characteristics in addition to standard transplant criteria.

D-methionine (D-met) significantly reduces kanamycin-induced ototoxicity in pigmented guinea pigs.

OBJECTIVE: Test D-methionine (D-met) as an otoprotectant from kanamycin-induced ototoxicity and determine the lowest maximally protective D-met dose. DESIGN: Auditory brainstem responses (ABR) were measured at 4, 8, 14, and 20 kHz at baseline and two, four, and six weeks after kanamycin and D-met administration initiation. ABR threshold shifts assessed auditory function. Following six-week ABR testing, animals were decapitated and cochleae collected for outer hair cell (OHC) quantification. STUDY SAMPLE: Eight groups of 10 male pigmented guinea pigs were administered a subcutaneous kanamycin (250 mg/kg/dose) injection once per day and an intraperitoneal D-met injection (0 (saline), 120, 180, 240, 300, 360, 420, or 480 mg/kg/day) twice per day for 23 days. RESULTS: Significant ABR threshold shift reductions and increased OHC counts (p ≤ 0.01) were measured at multiple D-met-dosed groups starting at two-week ABR assessments. A 300 mg/kg/day optimal otoprotective D-met dose provided 34-41 dB ABR threshold shift reductions and OHC protection. Lesser, but significant, D-met otoprotection was measured at lower and higher D-met doses. CONCLUSIONS: D-met significantly reduced ABR threshold shifts and increased OHC percentages compared to kanamycin-treated controls. Results may be clinically significant particularly for multidrug-resistant tuberculosis patients who frequently suffer from kanamycin-induced hearing loss in developing countries.

d-Methionine reduces tobramycin-induced ototoxicity without antimicrobial interference in animal models.

BACKGROUND: Tobramycin is a critical cystic fibrosis treatment however it causes ototoxicity. This study tested d-methionine protection from tobramycin-induced ototoxicity and potential antimicrobial interference. METHODS: Auditory brainstem responses (ABRs) and outer hair cell (OHC) quantifications measured protection in guinea pigs treated with tobramycin and a range of d-methionine doses. In vitro antimicrobial interference studies tested inhibition and post antibiotic effect assays. In vivo antimicrobial interference studies tested normal and neutropenic Escherichia coli murine survival and intraperitoneal lavage bacterial counts. RESULTS: d-Methionine conferred significant ABR threshold shift reductions. OHC protection was less robust but significant at 20kHz in the 420mg/kg/day group. In vitro studies did not detect d-methionine-induced antimicrobial interference. In vivo studies did not detect d-methionine-induced interference in normal or neutropenic mice. CONCLUSIONS: d-Methionine protects from tobramycin-induced ototoxicity without antimicrobial interference. The study results suggest d-met as a potential otoprotectant from clinical tobramycin use in cystic fibrosis patients.

Variations in senior medical student diagnostic justification ability.

PURPOSE: To determine the diagnostic justification proficiency of senior medical students across a broad spectrum of cases with common chief complaints and diagnoses. METHOD: The authors gathered diagnostic justification exercise data from the Senior Clinical Comprehensive Examination taken by Southern Illinois University School of Medicine's students from the classes of 2011 (n = 67), 2012 (n = 66), and 2013 (n = 79). After interviewing and examining standardized patients, students listed their key findings and diagnostic possibilities considered, and provided a written explanation of how they used key findings to move from their initial differential diagnoses to their final diagnosis. Two physician judges blindly rated responses. RESULTS: Student diagnostic justification performance was highly variable from case to case and often rated below expectations. Of the students in the classes of 2011, 2012, and 2013, 57% (38/67), 23% (15/66), and 33% (26/79) were judged borderline or poor on diagnostic justification performance for more than 50% of the cases on the examination. CONCLUSIONS: Student diagnostic justification performance was inconsistent across the range of cases, common chief complaints, and underlying diagnoses used in this study. More than 20% of students exhibited borderline or poor diagnostic justification performance on more than 50% of the cases. If these results are confirmed in other medical schools, attention needs to be directed to investigating new curricular methods that ensure deliberate practice of these competencies across the spectrum of common chief complaints and diagnoses and do not depend on the available mix of patients.

CSF neurofilament light chain is elevated in OMS (decreasing with immunotherapy) and other pediatric neuroinflammatory disorders.

Using a panel of seven brain cell-specific biomarkers in cerebrospinal fluid (CSF), pediatric opsoclonus-myoclonus syndrome (OMS) (n=234) was compared to pediatric non-inflammatory neurological controls (n=84) and other inflammatory neurological disorders (OIND) (n=44). Only CSF NFL was elevated in untreated OMS versus controls (+83%). It was 87% higher in OIND than in OMS. On combination treatment with front-loaded ACTH, IVIg, rituximab, median CSF NFL decreased by 60% to control levels. These biochemical data suggest neuronal/axonal injury in some children with OMS without indicators of astrogliosis, and reduction on sufficient immunotherapy.

D-methionine pre-loading reduces both noise-induced permanent threshold shift and outer hair cell loss in the chinchilla.

OBJECTIVE: This study tested multiple dosing epochs of pre-loaded D-methionine (D-met) for otoprotection from noise-induced hearing loss (NIHL). DESIGN: Auditory brainstem response (ABR) thresholds were measured at baseline, 1 day, and 21 days following a 6-hour 105 dB sound pressure level (SPL) octave band noise (OBN) exposure. Outer hair cell (OHC) counts were measured after day 21 sacrifice. STUDY SAMPLE: Three groups of five Chinchillas laniger each were given a 2-day regimen comprising five doses of D-met (200 mg/kg/dose) intraperitoneally (IP) starting 2, 2.5, or 3 days prior to noise exposure. A control group (n = 5) received five doses of equivalent volume saline IP starting 2.5 days prior to noise exposure. RESULTS: ABR threshold shifts from baseline to day-21 post-noise exposure were reduced in all D-met groups versus controls, reaching significance (p < 0.05) in the 3-day group. D-met groups showed reduced OHC loss relative to controls at day-21 post-noise exposure, reaching significance (p < 0.05) at all frequency regions in the 3-day group and at the 2, 4, and 8 kHz frequency regions in the 2.5-day group. CONCLUSIONS: D-met administration in advance of noise-exposure, without further administration, significantly protects from noise-induced ABR threshold shift and OHC loss.

From test validity to construct validity and back?

CONTEXT: Major changes in thinking about validity have occurred during the past century, shifting the focus in thinking from the validity of the test to the validity of test score interpretations. These changes have resulted from the 'new' thinking about validity in which construct validity has emerged as the central or unifying idea of validity today. Construct validity was introduced by Cronbach and Meehl in the mid-1950s in an attempt to address the validity of those many psychological concepts that have no clear referent in reality. To do this, construct validity theory required a nomological network--an elaborate theoretical network of constructs and observations connected by scientific laws--to validate the constructs. However, nomological networks are hard to come by and none that would do the job required by construct validity has been forthcoming to date. Thus, the current construct validity approach has retreated to one of simply 'interpretation and argument', but this seems to be too general to tie down the constructs in the way a nomological network would do to give credibility to the validity of the construct. As a result, the concept of validity seems to have been watered down and the credibility of validity claims weakened. OBJECTIVES: The purpose of this paper is to encourage a discussion of the use of construct validity in medical education, and to suggest that test developers and users reconsider the use of abstract theoretical constructs that have no referent apart from theory. METHODS: We present a critical review of these concerns about construct validity and provide for contrast a brief overview of a recently proposed view of measurement based on scientific realism and causality analysis.

Active comparator-controlled, rater-blinded study of corticotropin-based immunotherapies for opsoclonus-myoclonus syndrome.

To test the efficacy and safety of corticotropin-based immunotherapies in pediatric opsoclonus-myoclonus syndrome, 74 children received corticotropin alone or with intravenous immunoglobulin (groups 1 and 2, active controls); or both with rituximab (group 3) or cyclophosphamide (group 4); or with rituximab plus chemotherapy (group 5) or steroid sparers (group 6). There was 65% improvement in motor severity score across groups (P < .0001), but treatment combinations were more effective than corticotropin alone (P = .0009). Groups 3, 4, and 5 responded better than group 1; groups 3 and 5 responded better than group 2. The response frequency to corticotropin was higher than to prior corticosteroids (P < .0001). Fifty-five percent had adverse events (corticosteroid excess), more so with multiagents (P = .03); and 10% had serious adverse events. This study demonstrates greater efficacy of corticotropin-based multimodal therapy compared with conventional therapy, greater response to corticotropin than corticosteroid-based therapy, and overall tolerability.

Chemokine/cytokine profiling after rituximab: reciprocal expression of BCA-1/CXCL13 and BAFF in childhood OMS.

The aim of the study was to test the hypothesis that B-cell repopulation following rituximab (anti-CD20) therapy is orchestrated by chemokines and non-chemokine cytokines. Twenty-five children with opsoclonus-myoclonus syndrome (OMS) received rituximab with or without conventional agents. A comprehensive panel of 40 chemokines and other cytokines were measured in serum by ELISA and multiplexed fluorescent bead-based immunoassay. Serum BAFF concentration changed dramatically (even after first infusion) and inversely with B-cell depletion/repopulation and CXCL13 concentration at 1, 3, and 6 months. Negative correlations were found for BAFF concentration vs blood B cell percentage and serum CXCL13 concentration; positive correlations with serum rituximab concentrations. Six months after initiation of therapy, no significant difference in the levels of APRIL, CXCL10, IL-6, or 17 other cytokines/chemokines were detected. These data reveal a major role for BAFF in peripheral B cell repopulation following rituximab-induced B-cell depletion, and novel changes in CXCL13. ClinicalTrials.gov NCT0024436.

A validity study of the Working Group's Autobiographical Memory Test for individuals with moderate to severe intellectual disability.

The purpose of the present study was to investigate the validity of the Working Group's Autobiographical Memory Test as a dementia screening tool for individuals with moderate to severe intellectual disabilities (ID). Twenty-one participants with Dementia of Alzheimer's Type (DAT) and moderate to severe ID and 42 controls with similar levels of ID were tested. The majority were re-tested one year after the initial evaluation. The DAT group scored considerably lower than the control group on the initial evaluation. The controls with DS exhibited a considerable decline on the follow-up evaluation whereas other participants exhibited little changes. This demonstrates an insignificant overall difference between the DAT group and the control group on the follow-up evaluation. Virtually all participants exhibited the same scores on 3 out of 6 test items and the percentage of participants who correctly answered the remaining three test items were not significantly different from the DAT or control groups. In conclusion, the Working Group's Autobiographical Memory Test may be useful as a dementia screening tool for individuals with moderate to severe ID from DS when validated with a large sample size study. However, it is questionable whether this test is a reliable dementia screening tool for individuals with moderate to severe ID from non-DS etiologies. This test has a significant psychometric weakness because of the restricted score variability among the participants.

A pilot study of a test for visual recognition memory in adults with moderate to severe intellectual disability.

Objective assessment of memory functioning is an important part of evaluation for Dementia of Alzheimer Type (DAT). The revised Picture Recognition Memory Test (r-PRMT) is a test for visual recognition memory to assess memory functioning of persons with intellectual disabilities (ID), specifically targeting moderate to severe ID. A pilot study was performed to investigate whether the r-PRMT could differentiate DAT-related memory decline from pre-existing poor memory functioning of persons with moderate to severe ID. The r-PRMT scores were compared between 26 participants with DAT and moderate to severe ID and 33 controls with similar levels of ID. The results revealed that the controls with DS showed uniformly high scores in contrast to those with DAT on the r-PRMT and the score distributions of two groups were distinctly different with no overlap. On the other hand, the controls with non-DS etiologies scored much lower with a wider score spread, resulting in significant overlap with the score distribution of the participants with DAT. In conclusion, the r-PRMT may be effective in identifying persons with DAT among persons with moderate to severe ID from DS. However, the r-PRMT may result in a high false positive error rate in discriminating those with DAT among persons with moderate to severe ID from non-DS etiologies, if the judgment is based on a single point assessment.

Pediatric dosing of rituximab revisited: serum concentrations in opsoclonus-myoclonus syndrome.

To longitudinally assess serum concentrations of rituximab, it was administered intravenously to 25 children with opsoclonus-myoclonus syndrome at 375 mg/m2 on each of 4 consecutive weeks with (Group I and II) or without (Group III) conventional immunotherapy. Serum rituximab levels, drawn before and after each infusion and at later intervals, were analyzed by enzyme-linked immunosorbent assay. Rituximab concentration increased stepwise with each infusion, dropping by the next infusion, thereby forming 4 discrete peaks (Cmax) and troughs (Cmin). It then fell precipitously to trace levels at 4 months. However, Cmax and Cmin curves differed significantly between groups. Compared with the youngest children (Group I), the oldest (Group III) had a 34% lower rituximab concentration at the fourth infusion, 45% less IgM depletion 1 month later, and received 20% less rituximab when the dose was recalculated as mg/kg. Serum IgM and rituximab levels were negatively correlated. Peak rituximab concentration did not correlate with adrenocorticotropic hormone dose. These results indicate that the degree of serum IgM depletion is a useful indicator for rituximab dose equivalency in children of different ages. They also suggest that pediatric rituximab dosing should be based on body weight, not surface area. (ClinicalTrials.gov NCT00244361).

Reports of the decline of empathy during medical education are greatly exaggerated: a reexamination of the research.

PURPOSE: Research is said to show that empathy declines during medical school and residency training. These studies and their results were examined to determine the extent of the decline and the plausibility of any alternative explanations. METHOD: Eleven studies published from 2000 to 2008 which reported empathy at various stages of physician training were reexamined. Their results were transformed back to the original units of the rating scales to make results more interpretable by reporting them in the metric of the original anchors. Next, the relationship between empathy ratings and response rates were examined to see whether response bias was a plausible threat to the validity of the empathy decline conclusion. RESULTS: The changes in mean empathy ranged across the 11 studies from a 0.1-point increase in empathy to a 0.5-point decrease, with an average of a 0.2-point decline for the 11 studies (ratings were on 5-point, 7-point, and 9-point scales). Mean ratings were similar in medical school and residency. Response rates were low and-where reported-declined on average about 26 percentage points. CONCLUSIONS: Reexamination revealed that the evidence does not warrant the strong, disturbing conclusion that empathy declines during medical education. Results show a very weak decline in mean ratings, and even the weak decline is questionable because of the low and varying response rates. Moreover, the empathy instruments are self-reports, and it isn't clear what they measure-or whether what they measure is indicative of patients' perceptions and the effectiveness of patient care.

B cell depletion therapy for new-onset opsoclonus-myoclonus.

Twelve immunotherapy-naïve children with opsoclonus-myoclonus syndrome and CSF B cell expansion received rituximab, adrenocorticotropic hormone (ACTH), and IVIg. Motor severity lessened 73% by 6 mo and 81% at 1 yr (P < 0.0001). Opsoclonus and action myoclonus disappeared rapidly, whereas gait ataxia and some other motor components improved more slowly. ACTH dose was tapered by 87%. Reduction in total CSF B cells was profound at 6 mo (-93%). By study end, peripheral B cells returned to 53% of baseline and serum IgM levels to 63%. Overall clinical response trailed peripheral B cell and IgM depletion, but improvement continued after their levels recovered. All but one non-ambulatory subject became ambulatory without additional chemotherapy; two relapsed and remitted; four had rituximab-related or possibly related adverse events; and two had low-titer human anti-chimeric antibody. Combination of rituximab with conventional agents as initial therapy was effective and safe. A controlled trial with long-term safety monitoring is indicated.

Peer assessment of professionalism: a five-year experience in medical clerkship.

INTRODUCTION: Faculty assessment of students' professionalism is often based upon sporadic exposure to students. Peers are in a unique position to provide valid judgments of these behaviors. AIMS: (1) To learn if peer assessments of professional conduct correlate with traditional performance measures; (2) to determine if peer assessments of professionalism influence the designation of honors, and (3) to explore student and faculty opinions regarding peer assessment. SETTING: Internal Medicine Clerkship at Southern Illinois University. PROGRAM DESCRIPTION: Since 2001 anonymous student peer assessments of professionalism have been used in assigning clerkship grades. PROGRAM EVALUATION: Peer assessments of professionalism had weak, though significant, correlations with faculty ratings (r = 0.29), performance on the NBME subject test (r = 0.28), and performance on a cumulative performance assessment (r = 0.30), and did not change the total number of honors awarded. A majority of students (71%) felt comfortable evaluating their peers, and 77% would keep the peer evaluation procedure in place. A majority of faculty (83%) indicated that peer assessments added valuable information. DISCUSSION: Peer assessments of professional conduct have little correlation with other performance measures, are more likely to have a positive influence on final clerkship grades, and have little impact on awarding honors.

Decreased mortality associated with prompt Gram staining of blood cultures.

Gram stains of positive blood cultures are the most important factor influencing appropriate therapy. The sooner appropriate therapy is initiated, the better. Therefore, it is reasonable to expect that the sooner Gram stains are performed, the better. To determine the value of timely Gram stains and whether improvement in Gram stain turnaround time (TAT) is feasible, we compared data for matched pairs of patients with cultures processed promptly (<1 hour TAT) with data for patients with cultures not processed promptly (> or =1 hour TAT) and then monitored TAT by control charting.In 99 matched pairs, average difference in time to detection of positive blood cultures within a pair of patients was less than 0.1 hour. For the less than 1 hour TAT group, the average TAT and crude mortality were 0.1 hour and 10.1%, respectively; for the 1 hour or longer TAT group, they were 3.3 hours and 19.2%, respectively (P < .0001 and P = .0389, respectively). After multifaceted efforts, we achieved significant improvement in the TAT for Gram stains.