Barriers to Timely Diagnosis and Treatment of Vector-Borne Diseases in a Changing Climate: A Case Report.

This case study examined current trends in the prevalence of vector-borne diseases and the impact of climate change on disease distribution. Our findings indicate that the dynamics of the Anopheles mosquito population in particular has changed dramatically in the past decade and now poses an increasing threat to human populations previously at low risk for malaria transmission. Given their geographic location and propensity for sustaining vector-borne disease outbreaks, southeastern states are particularly vulnerable to climate-induced changes in vector populations. We demonstrate the need to strengthen our hospital and laboratory infrastructure prior to further increases in the incidence of vector-borne diseases by discussing a case of uncomplicated malaria in a patient who arrived in one of our hospitals in Louisiana. This case exemplifies a delay in diagnosis and obtaining appropriate treatment in a timely manner, which suggests that our current health care infrastructure, especially in areas heavily affected by climate change, may not be adequately prepared to protect patients from vector-borne diseases. We conclude our discussion by examining current laboratory protocols in place with suggestions for future actions to combat this increasing threat to public health in the United States.

The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

Impact of New Orleans Saints Football Games on Internal Medicine Admissions.

Background: Various studies have reported a decrease in emergency department admissions in correlation with major sporting events. However, these studies limit the investigation of selected variables to the 24-hour periods on game days. For our study, we assessed the impact of New Orleans Saints football team games on medical admissions on game days and also on post-game days. Methods: We collected Saints game results from the 2013-2014 to 2019-2020 season and admissions data from 3 local hospitals during the same 7-year period. We compared the average daily census of game days vs non-game days as our control group using a 2-sample t test with unequal variances. Results: The results demonstrate a statistically significant reduction in the average number of internal medicine admissions on game days (19.6%, P=0.0001). This reduction in admissions was not observed on post-game days (5.84%, P>0.05). On post-game days following a Saints victory, we found a statistically significant increase in the average number of admissions compared to when the team lost the previous day (18.2%, P=0.0105). Conclusion: To our knowledge, the relationship between a recurring major sporting event and inpatient internal medicine admissions has not been previously quantified. Our study of the impact of the New Orleans Saints football games on internal medicine admissions provides insights into the relationship between social sporting events and health outcomes in the city. While our results may not be directly generalizable to other locations-particularly those that are not in a National Football League team market-we showed that during a 7-year period, Saints football games correlated with a 19.6% decrease in internal medicine admissions on the day of the game. This finding suggests that Saints games may serve as a protective factor associated with decreased negative health outcomes among residents in the city.

Relationship between Medical School Diversity and Participation in the US News and World Report Survey.

INTRODUCTION: Reporting in USNWR rankings may reveal unintended, but important, sources of disparities with implications for medical school admissions and the future physician workforce. MATERIALS AND METHODS: To investigate relationships between allopathic medical school's student body diversity and participation in the US News and World Report Survey, we analyzed diversity statistics as listed in the Medical School Admissions Requirements (MSAR) database. These were compared to the institution's participation in the US News and World Report Survey for 152 US medical schools as either Primary Care or Research ranking. RESULTS & DISCUSSION: When considering USNWR rankings of research schools of medicine, those schools not participating in the survey had a 44.8% increase in UIM students. There was a statistical increase in the percentage of Latino/Hispanic students in schools that did not participate in the US News and World report survey as compared with those that did. Percentages of African American and Latino/Hispanic students were inversely correlated with US News and World Report research rankings. We suggest that participation in current publicly available allopathic medical school ranking platforms may have unintended and adverse consequences in maintaining a diverse medical school class and may impact longer-term goal of developing a diverse physician workforce that resembles the constituent population.

How well did our students match? A peer-validated quantitative assessment of medical school match success: the match quality score.

Background: Assessment of an individual medical school's performance in the match is an important outcome of the educational program. Unfortunately, student rank lists are not public. A method to objectively gauge the quality of an institution's match regardless of student preference has not been described in the literature.Objective: This manuscript serves to determine the relative weights of included variables and derive a statistically valid Match Quality Score (MQS).Design: Between 2016 and 2018, student affairs experts derived from a national cohort validated the MQS by scoring factitious mini-match lists that covered three variables: student's Match Status, specialty Competitiveness, and residency program Reputation.Results: Of the variables assessed, only Match Status and Competitiveness were found to be significant. We derived the resulting coefficients for the Match Quality Score (MQS) as: [3.74A (# students successfully matched) + 2.34B (# students matching into their initial specialty in the SOAP process) + 1.77C (# students who secured a SOAP position in another specialty) + 0.26D (# students matching into a specialty where there are more applicants than spots)]/Total # students.Conclusions: The MQS is a potentially useful educational outcome measurement for US medical schools and may be considered as an outcome measure for continuous quality improvement to tailor future institutional changes to training, mentoring, and student-advising programs.

Medical Students' Exposure to the Humanities Correlates with Positive Personal Qualities and Reduced Burnout: A Multi-Institutional U.S. Survey.

BACKGROUND: Literature, music, theater, and visual arts play an uncertain and limited role in medical education. One of the arguments often advanced in favor of teaching the humanities refers to their capacity to foster traits that not only improve practice, but might also reduce physician burnout-an increasing scourge in today's medicine. Yet, research remains limited. OBJECTIVE: To test the hypothesis that medical students with higher exposure to the humanities would report higher levels of positive physician qualities (e.g., wisdom, empathy, self-efficacy, emotional appraisal, spatial skills), while reporting lower levels of negative qualities that are detrimental to physician well-being (e.g., intolerance of ambiguity, physical fatigue, emotional exhaustion, and cognitive weariness). DESIGN: An online survey. PARTICIPANTS: All students enrolled at five U.S. medical schools during the 2014-2015 academic year were invited by email to take part in our online survey. MAIN MEASURES: Students reported their exposure to the humanities (e.g., music, literature, theater, visual arts) and completed rating scales measuring selected personal qualities. KEY RESULTS: In all, 739/3107 medical students completed the survey (23.8%). Regression analyses revealed that exposure to the humanities was significantly correlated with positive personal qualities, including empathy (p < 0.001), tolerance for ambiguity (p < 0.001), wisdom (p < 0.001), emotional appraisal (p = 0.01), self-efficacy (p = 0.02), and spatial skills (p = 0.02), while it was significantly and inversely correlated with some components of burnout (p = 0.01). Thus, all hypotheses were statistically significant, with effect sizes ranging from 0.2 to 0.59. CONCLUSIONS: This study confirms the association between exposure to the humanities and both a higher level of students' positive qualities and a lower level of adverse traits. These findings may carry implications for medical school recruitment and curriculum design. "[Science and humanities are] twin berries on one stem, grievous damage has been done to both in regarding [them]... in any other light than complemental." (William Osler, Br Med J. 1919;2:1-7).

Social Contexts in Medicine: A Patient-Centered Curriculum Empowering Medical Students to Provide Contextualized Care.

INTRODUCTION: Social Contexts in Medicine (SCIM) is an 18-month program that connects medical students, patients, and physicians for a longitudinal learning experience. SCIM was developed for first- and second-year medical students and seeks to supplement students' biomedical education with practical experiences built around community and continuity. The program increases students' awareness of, and skills to address, social determinants of health via a seminar series, a home visit program, and a mentoring component. METHODS: The program begins with a seminar series covering communication skills and the basics of social determinants of health, providing the foundation for successful home visits. Students are then paired with a patient for home visits to learn firsthand about the complex social factors that affect health and illness, patient participation in health care systems, and the doctor-patient relationship. In conjunction with the home visits, students obtain guidance from a physician mentor. RESULTS: The SCIM program has been successful during its first 3 years at our institution. Analysis of changes in student attitudes using Crandall's Medical Student Attitudes Toward the Underserved survey has shown that SCIM students develop more positive attitudes toward the underserved than do their peers completing traditional clinic-based preceptorships. Additionally, in student surveys, the average response to the statement "I learned something valuable I would not have otherwise learned in my classes" has been 4.5 out of 5. DISCUSSION: These findings suggest that the SCIM model contributes to medical education by broadening students' understanding about the influence of social factors on health and disease.

Chagas Cardiomyopathy in New Orleans and the Southeastern United States.

BACKGROUND: Chagas disease (CD), caused by Trypanosoma cruzi, affects 6-7 million people worldwide annually, primarily in Central and South America, and >300,000 people in the United States. CD consists of acute and chronic stages. Hallmarks of acute CD include fever, myalgia, diaphoresis, hepatosplenomegaly, and myocarditis. Symptoms of chronic CD include pathologic involvement of the heart, esophagus, and colon. Myocardial involvement is identifiable by electrocardiogram and cardiac magnetic resonance imaging showing inflammation and left ventricular wall functional abnormalities. CASE REPORTS: We present two cases of CD identified in a single hospital in the Southeastern United States. Case 1 presents a patient with symptoms of anginal chest pain and associated shortness of breath with myocardial involvement suggestive of ischemic infarction but normal coronary arteries. Case 2 describes a patient with no physical symptoms and echocardiogram with ejection fraction of 50% with posterolateral and anterolateral wall hypokinesis but normal coronary arteries. CONCLUSION: With a growing number of immigrants from Central and South America in the United States, it is imperative for clinicians to include CD as part of the differential diagnosis for patients presenting with heart disease who have a history of exposure to T. cruzi endemic areas.

Features of successful academic hospitalist programs: Insights from the SCHOLAR (SuCcessful HOspitaLists in academics and research) project.

BACKGROUND: As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important. OBJECTIVE: To develop and validate a quantifiable definition of academic success for AHPs. METHODS: A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey. RESULTS: Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6-18 years) and mean size of 36 faculty (range, 18-95). The mean total grant funding/program was $4 million (range, $0-$15 million), with mean funding/FTE of $364,000 (range, $0-$1.4 million); both were significantly higher than the comparison sample. The majority of SCHOLAR faculty (82%) were junior, a lower percentage than the comparison sample. The mean number of research abstracts presented over 2 years was 10.8 (range, 9-23). DISCUSSION: Our approach effectively identified a subset of successful AHPs. Despite the relative maturity and large size of the programs in the SCHOLAR cohort, they were comprised of relatively few senior faculty members and varied widely in the quantity of funded research and scholarship. Journal of Hospital Medicine 2016;11:708-713. © 2016 Society of Hospital Medicine.

Effects of implementing a protocol for arterial blood gas use on ordering practices and diagnostic yield.

BACKGROUND: The arterial blood gas (ABG) is a valuable and commonly used laboratory test. This prospective cohort study examined the variability of ABG ordering through the implementation of an evidence-based protocol. METHODS: The study consisted of two 6-week periods. The protocol consisted of evidence-based and consensus opinion based indications for ABGs. In the first phase (initial 6 weeks), respiratory therapists recorded the indications for ABGs ordered by clinicians. In the second phase, all medical and surgical physicians were trained on the clinical rationale behind the protocol and were instructed to write the indication for each ABG with the order. Rates of ABGs/patient/day were measured in aggregate and per indication. Multivariate regression was used for adjusted comparisons between indications within the protocol. RESULTS: After protocol implementation, there was a significant decrease in ABGs from 2158 to 1674 (p=0.001), and after adjusting for daily census, there was a significant decrease from 35.3 ABGs/100 patients/day to 26.5 ABGs/100 patients/day (p<0.001), with no change in mortality or demographic characteristics between the populations. The percent of ABGs with normal range values for pH, PaCO2, and PaO2 decreased from 13.3% to 9.6% after implementation (p<0.001). Multivariate analysis revealed a 14% decrease in daily ABGs (p=0.001), a 15% decrease in weaning trial ABGs (p=0.039), and a 15% increase in ABGs ordered following a change in minute ventilation (p=0.004). Cost minimization analysis estimated annual institutional savings to be $87,565. CONCLUSIONS: Implementation of an evidence based protocol for ABG use resulted in fewer ABGs/patient/day largely from reduction of routine, daily ABGs. Ordering patterns for ABGs appeared to shift towards more clinically appropriate/relevant indications. LEVEL OF EVIDENCE: 2b.

Chest pains--a formal risk assessment of acute coronary syndrome.

Two patients presented on the same day with similar stories of chest pain, physical exams, laboratory results, and ECG findings. Applying formal risk assessment provided validation of the initial impression that one patient had a higher likelihood of acute coronary syndrome than the other patient. Using pre-test probabilities of coronary artery disease, likelihood ratios of symptoms, and diagnostic tests, we demonstrate how to calculate a post-test probability for acute coronary syndrome (ACS). We discuss the importance of knowing disease prevalence and recognizing powerful tests. We also explore the variables for early risk stratification of ACS listed in the American College of Cardiology/American Heart Association guidelines. This demonstrates how the application of formal risk assessment can be used to teach clinical reasoning and improve clinical practice.

Diagnosis and management of delayed hemoperitoneum following therapeutic paracentesis.

Abdominal paracentesis is a frequently employed diagnostic and therapeutic procedure for patients with refractory ascites, typically in patients with cirrhosis. It is generally regarded as a safe procedure with significant complications occurring in <1% of cases. Most hemorrhagic complications are due to abdominal wall trauma, during which clear evidence of active bleeding is usually visualized during the procedure. Delayed hemoperitoneum is a rare complication of large-volume paracentesis in which clinical evidence of active bleeding is typically absent until substantial blood loss has taken place (often several days to a week later), leading to an exceedingly high mortality rate. Herein we describe a case of delayed hemoperitoneum in a 55-year-old man with heart failure. This case emphasizes the importance of identifying patients who are at high risk for delayed hemoperitoneum as well as the need to closely monitor complete blood counts in the days following a large-volume paracentesis.

Integrating Lesbian, Gay, Bisexual, and Transgender (LGBT) Content Into Undergraduate Medical School Curricula: A Qualitative Study.

BACKGROUND: The lesbian, gay, bisexual, and transgender (LGBT) community is a diverse, underserved, and often stigmatized group that faces many barriers to accessing quality healthcare. Not only are few practicing physicians knowledgeable about and sensitive to the needs of LGBT patients, but medical school curricula include limited LGBT-related content. Our goals were to use LGBT-related educational sessions to gauge undergraduate medical students' interest and their perceptions of relevance and to eventually incorporate this topic into the curriculum. METHODS: We provided 4 educational sessions to preclinical medical students at the Tulane University School of Medicine: 3 optional, 1-hour didactic sessions and 1 standardized patient encounter. Following sessions 1-3, students completed electronic feedback forms; we then analyzed their responses thematically. RESULTS: THE THEMATIC ANALYSIS OF STUDENT RESPONSES IDENTIFIED KEY THEMES: a current lack of exposure to LGBT content, agreement that LGBT material is applicable to students' work as future physicians, and the relevance of including such information in the medical school curriculum. CONCLUSION: The study validated the underlying assumption that LGBT educational sessions are meaningful to and valued by medical students.

Corticosteroids in the treatment of alcohol-induced rhabdomyolysis.

Rhabdomyolysis is a common condition with potentially devastating complications, including acute renal failure, arrhythmias, and death. The standard of care is to use supportive measures such as aggressive fluid repletion to prevent kidney injury and attenuate clinical symptoms. Besides fluid management, few therapeutic options are available for the treatment of acute rhabdomyolysis. As a result, acute and refractory cases remain difficult to manage. We report a case of alcohol-induced rhabdomyolysis that responded dramatically to high-dose corticosteroids. A 55-year-old man presented to the emergency department for evaluation of diffuse muscle pain, weakness, and darkening urine. On admission, his creatine kinase (CK) level was 50,022 U/L. Despite aggressive fluid repletion, his CK level continued to increase, peaking at 401,280 U/L with a concomitant increase in muscle pain and urine darkening. On administration of high-dose corticosteroids, clinical symptoms and CK levels improved dramatically, and the patient was discharged 36 hours later with complete resolution of muscle pain and weakness. Given their low toxicity profile, short-term high-dose corticosteroids may be a valid treatment option for recurrent rhabdomyolysis unresponsive to fluid repletion.

Sensitivity of superficial cultures in lower extremity wounds.

BACKGROUND: Superficial wound cultures are routinely used to guide therapy, despite a lack of clear supporting evidence. PURPOSE: To conduct a systematic review of the correlation between superficial wound cultures and the etiology of skin and soft tissue infections. DATA SOURCES: Medline, EMBASE, CINAHL, Scopus. STUDY SELECTION: Articles published between January 1960 and August 2009 involving superficial wound cultures and deeper comparison cultures. DATA EXTRACTION: Two reviewers independently searched for abstracted information pertaining to the microbiology of lower extremity wounds sufficient to calculate the sensitivity and specificity of superficial wound cultures versus comparison cultures. DATA SYNTHESIS: Data pooled using a random-effects meta-analysis model. RESULTS: Of 9032 unique citations, 8 studies met all inclusion criteria. Inter-rater reliability was substantial (Kappa = 0.78). Pooled test sensitivity for superficial wound swabs was 49% (95% confidence interval [CI], 37-61%], and specificity was 62% (95% CI, 51-74%). The pooled positive and negative likelihood ratios (LRs) were 1.1 (95% CI, 0.71-1.5) and 0.67 (95% CI, 0.52-0.82). The median number of isolates for surface cultures (2.7, interquartile range [IQR] 1.8-3.2) was not significantly different than that for comparison cultures, (2.2, IQR 1.7-2.9) (P = 0.75). CONCLUSION: Few studies show a strong relationship between superficial wound swabs and deep tissue cultures, and the current data demonstrate poor overall sensitivity and specificity. The positive and negative LRs were found to provide minimal utility in influencing pretest probabilities. Results of this analysis show that wound cultures should not be used in lieu of local antibiograms to guide initial antibiotic therapies.